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Earl Howe: My Lords, I am most grateful to the Minister for repeating the Statement. This is long awaited news and, to the extent that decisions have been taken to resolve some major uncertainties, it is news which is decidedly welcome. As the Minister said, our thanks are due to the Turnberg Committee for its careful and diligent consideration of these difficult issues. For the most part, too, the content of the Statement should be welcomed. However, I am a good deal less sanguine about one aspect of the announcement. I feel that the decision to reinvent Bart's as a specialist tertiary referral centre, attractive as that option may appear, requires very careful explaining indeed as regards its cost-effectiveness.

I should like to return to the question of Bart's in a moment, but perhaps I may come, first, to the main thrust of the announcement. It is fair to say that the problems being faced and the decisions to be taken as regards healthcare in London are absolutely no different from those currently being addressed in a number of big cities around the world. Acute hospital services need to be concentrated in fewer sites to maximise the benefits which patients can receive from specialist skills and expensive equipment. Accident and emergency departments need to be positioned next-door to intensive care and other specialist services and, not to be forgotten, medical and nursing staff need the best possible environment for training.

There is no argument about London's importance as an international centre of excellence both in treatment and in teaching. Whatever is done to change the nature and structure of London's hospitals, nothing must be allowed to place that excellence in jeopardy.

At the same time the thrust of Turnberg has been to acknowledge that, with the decline in London's population and with the huge advances in diagnostic and surgical techniques, the status quo is simply not an option. Londoners themselves need a different hospital service and indeed a change in the balance of health services as between those provided by GPs, by hospitals and in the community. The detailed decisions which the Government have taken have no doubt been complex.

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I do not think we should underestimate their considerable emotive aspect for Londoners all over the capital. No doubt Londoners, like Members of these Benches, will need time to digest what has been announced in terms of the scope and coverage of local hospital care.

The Minister has said that the presumption that London is over-provided with acute beds is to be abandoned. I think that that is a perfectly fair conclusion. Indeed, I believe we should welcome it. It was always said by Tomlinson in his report that if the rate of emergency admissions should increase, more beds would be needed. Professor Jarman was right in the views that he advanced consistently on this issue. It makes sense for Guy's to meet some of the need, as the Minister indicated that it will.

I turn to the issue which has perhaps aroused the greatest degree of interest in London, that of Bart's. The Statement refers to that noble hospital having been saved. I wonder whether that description is entirely appropriate. Of course we can only welcome the tertiary referral centre in terms of the services that it will provide. I have absolutely no doubt that the standards of care for cancer and cardiac patients from all over the country will be second to none. But the point that will not be lost on Londoners is that Bart's will no longer provide any of the local services normally provided by a district general hospital. Can the Minister say whether the boards of the Royal Hospitals Trust and East London and City Health Authority agree with the decision on Bart's? Did they believe that it would be more efficient to maintain split sites rather than transferring all services to a new hospital on the Royal London site? Do they agree with the decision to split hospital services and reduce the size of the new hospital which is being built with private funding?

I repeat that the standards of care to be offered at Bart's are not in question, and nor should they be. However, does not the Minister agree that such specialist hospitals--as Bart's is now apparently to be--run contrary to most expert opinion? Do not the Government believe that there is real advantage in having all specialist services grouped together on a single site? Equally important is the budgetary aspect. What estimate has been made of the additional cost of this decision as compared with the alternative which was to close Bart's altogether? I understand that the local health authority is already running a sizeable deficit. The question needs to be asked as to how it will be reimbursed for the additional costs to be incurred.

It looks very much as though before the election Labour exploited the save Bart's campaign, but now that Labour is in office it is not prepared to give local people what they want, which is a local district general hospital service on the Bart's site. What is being offered is a tertiary facility which could just as easily--and less expensively--have been provided as part of the new Royal London. It looks very much as though the people of East London will have to pay for that expensive decision. Will the Government publish the cost estimates of the two alternatives? Does the Minister agree that what is needed in East London is really better primary care, and that there are surely knock-on effects

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of the Bart's decision in that regard? Will she confirm that the extra costs arising from these decisions will reduce the budgets for local services, including primary care services, and that the people of East London will not gain much advantage from these tertiary services at Bart's, although they will be excellent in their own way? I feel that there is much in this Statement which is good news for London but much that needs to be explained. I look forward to hearing what the Minister has to say.

4.6 p.m.

Lord Newby: My Lords, we on these Benches are also grateful to the Minister for repeating the Statement and also for the extraordinary amount of work which the Turnberg Committee has undertaken in producing a comprehensive report in such a short time. We should ideally have liked to see the report at the time the Government received it so that we could have studied it at the same time as Ministers. We cannot see any particularly strong reason why that should not have been the case. It is, of course, much more difficult to influence decision-making at the point when Ministers have not only had the report but have had several months to chew it over before anyone else has seen it, and then produce firm proposals.

That having been said, we find much in the report to welcome. We also welcome the Government's commitment to a strategic review of the provision of health services in London. We are therefore slightly surprised to read the weasel words that the report proposes as a medium-term aim the establishment of an NHS regional office in London. We find the words "medium term" somewhat worrying as regards what appears to be a relatively modest institutional change within the NHS. Can the Minister help us by explaining what kind of timescale she envisages as medium term? Much as we enjoy discussing these issues in this House, as do our colleagues in another place, we believe that the correct place primarily to discuss the strategic needs of London health services is within a strategic authority for London and Londoners. Does the Minister believe that strategic healthcare is a matter that could sensibly be added to the powers of the proposed GLA? We would welcome the Minister's views on that.

We wish that the Statement had included what most strategic documents mention; namely, overall figures on beds, doctors, nurses and those other matters that concern Londoners when they consider healthcare. I raise that matter because we believe that when new hospitals are built under the PFI there is an inexorable pressure to reduce the number of beds. We have seen that in the proposals before us today in respect of the Royal London Hospital where it is proposed that 200 fewer beds are now provided than was originally proposed, at a time when some estimates at least suggest that the 1,100 that were originally provided might be insufficient. We wonder therefore whether Bart's might face a slightly odd fate, even when the Royal London is open, in that there will simply not be enough acute beds elsewhere in East London and Bart's will be required to continue to provide that kind of facility well beyond the medium-term, however that is defined.

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Your Lordships will be relieved to know that I do not propose to discuss the individual proposals in detail. However, I raise a general point with regard to Queen Mary's at Roehampton. In many cases what we are talking about here is replacing one provision with another. We are moving from one static position to another. We are concerned about what happens in the meantime.

I welcome an assurance that the provisions of Kingston--they need to be enhanced to match the increased demand which will arise as Queen Mary's services are transferred--will come on stream before they are required rather than months afterwards, and after patients have faced additional difficulties during the transitional period.

Two overriding issues are dealt with in the Statement. The first is a proper strategic framework for decision making in London. We feel that the Government have made some progress on that. Some of the progress is to be welcomed, but we believe that there is need to go further. The next key question relates to whether the Statement is satisfactory in terms of the overall level of resourcing of the special health needs of London. We are pleased to hear confirmed the additional funding for primary services, mental health, intermediate care and community services. Those funds are desperately needed. There must be more cases of acute under-provision in London than anywhere else in the country. Those of us who live in south London have in mind, for example, the horrendous murder in Tulse Hill a couple of weeks ago by a patient with severe mental health problems. That patient was not receiving the care in the community required. We can only welcome any action to improve and increase the level of funding for those Cinderella services. It is desperately needed, in particular in London. We are unconvinced that the proposals will be enough to provide the first-rate health services that Londoners need and deserve.

If we were confident that an NHS body, or the GLA, would discuss the issues at a strategic level, we might allow the matter to rest there. However, those bodies are unlikely to be in position for some considerable time. I hope that after an appropriate period the Minister will report again to the House on the progress made towards achieving the ambitious goals set out in the Statement. At the same time I hope that the noble Baroness will come forward with any further proposals necessary for funding or structural arrangements to meet those goals.

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