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Health Services (Finance)

Volume 976: debated on Tuesday 18 December 1979

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1.20 am

After the long debate on the textile industry, I return the attention of the House to Class XI, Vote 1 of the Supplementary Estimates, which deals with the financial resources of the health and personal social services. On many occasions I have drawn the attention of the House to the desperate situation in the National Health Service, particularly in my constituency. I offer no apology for taking the time of the House to highlight the deplorable situation which faces my constituents.

The principal factor is the failure to provide sufficient funding to maintain an adequate service commensurate with changing needs. The Department has failed to appreciate the shifting age pattern in the population, particularly in areas such as mine. The changing pattern is imposing a great demand on the National Health Service. If there were a planned growth in the money available, it would be possible to attempt to match the demand, but the money available in real terms has, at best, stood still. In many cases it has been reduced.

It is no good the Government wringing their hands and saying that they appreciate the problem but that it is up to the health authorities to decide their own prorities. The health authorities have little choice. When the Government strangle the money supply, the authorities can only reduce the share of resources given to acute medicine and transfer money to geriatric services.

How can the Government justify a choice between the desperately sick person and the elderly geriatric patient? The Health Services Bill, which is due to be debated shortly, proposes to redress the balance by providing that those who can pay for their sickness will be able to apply for treatment. Where does that leave the bulk of my constituents who are at the lower end of the income bracket? According to the Government, they are expendable.

In a letter to me, the Prime Minister said:
"I am especially conscious that some health authorities, particularly those in central London, need to make some reduction in service in addition to those economies possible through good housekeeping."
However, under clauses 7, 8 and 9 of the Health Services Bill it will be possible to buy better treatment. That will mean good health for the lucky people with money but a knacker's yard for the rest. What chance will there be of developing services for the mentally ill and mentally handicapped? How can the primary health services be developed and strengthened to provide preventative medicine—a cost-effective process?

The Prime Minister continued in her letter:
"The RHA Chairman has stressed to you his concern for the NHS and his Authority's intentions to provide the best service possible within the present financial constraints. I appreciate the efforts the City and East London AHA(T) are making in what is an invidious though necessary task. I understand that the decisions taken represent what, in the Authority's view, were the necessary temporary adjustments in the level of services provided which will have the least impact on patient care."
If we translate that into actions, it means closing every hospital in my constituency. Two hospitals have gone already, one is in the process of closure and a fourth is planned. That is happening in the full knowledge that the primary care service is almost non-existent and that the general practice service is chronically sick.

If we combine all that with the effects of inflation, plus the 15 per cent. VAT and the pay awards, none of which had been fully met by the Department of Health and Social Security—and which together will probably cost the North-East Thames regional health authority somewhere in the region of £8 million to £9 million—it is easy for the House to appreciate why I speak of the total destruction of the Health Service in my constituency.

The area health authority is totally lacking in ability to cope with the problems. To give them credit, the chairman of the AHA and the equally hapless chairman of the regional health authority decided at long last to make representations to the Minister, but my view is that they had no credibility left. It would be of great advantage if both these chairmen were put out to grass and fresh chairmen were appointed to grapple with the problem—chairmen who are sensitive to the needs of the people and who believe in consultation.

I will give an example of the area health authority's view of consultation. Together with some of my constituents, I attended the area health authority's meeting last week. At that meeting some very profound decisions were being made which, according to the district administrator, would be a catastrophe for my constituents. There we were in the public gallery, trying to follow these important decisions. I was trying to see how they would affect my constituents. We did not even have an agenda. We sat there with no papers of any description, listening to the proceedings at a meeting which had obviously started in private in the morning.

I thought that the objects of area health authorities were such that they would meet in public. The authority had obviously met earlier in private, and was dealing with these matters publicly in a shorthand way in the afternoon, with the public—including the local Member of Parliament—unable to follow the proceedings. Yet decisions were being taken which were of profound importance to my constituents.

I can understand now why the area health authority should want to play it like that. The area administrator was kind enough to let me have a copy of the agenda. There was one item that I failed to understand when it was being debated, but when I received the agenda I could understand it. It was about a project that began life less than two years ago and of which, at the end of last year, the projected cost was about £230,000. Moneys were made available for that project, and at that meeting last week it was apparently being reported that this very same project, which less than a year before was to cost £230,000, was now to cost £630,000. Following in that document is a most trite comment by the officials of the way in which this appalling mismanagement came about

What is even more important is how the authority is intending to recoup the money. From that agenda I discovered that the authority is to take money that was identified by the Minister's predecessor in the last Administration and which that Minister gave me a categorical assurance in this House would be spent on St. Leonard's hospital. The authority is taking that money and giving it to this appallingly managed project and closing St. Leonard's hospital instead.

It seems to me that there are no medical factors involved in the closure of these hospitals. In effect, it is all due to bad management and financial jiggery-pokery. Let me illustrate how a hospital is closed without any consultation. We start off, as the Prime Minister put it in a letter to me, with the concept that it is a "temporary closure". I now read from the documents of the area health authority itself. I do not get many of them, but when I do I read them carefully, and they are useful. It begins by stating:
"The four general surgical wards at St. Leonard's Hospital have been selected for temporary closure."
By saying that, it means that there is no consultation. All consultation is wiped out, and it is done. The next paragraph states that
"The problems arising from the temporary closures affect two activities in particular—orthopaedic surgery and Accident and Emergency services".
Having closed the four general wards temporarily, the health authority now says that
"Without facilities and staff in general surgery it is dangerous to allow ambulance cases into the hospital. This cuts off the supply of trauma cases to the orthopaedic department who are now left with their elective cases, mostly joint replacements. These patients may prove insufficient to fill the orthopaedic wards and the DMT may have to consider closing one of them rather than staff and service an unoccupied ward".
Therefore, one begins by closing four wards temporarily, so that the matter is not discussed, yet before that takes place another ward is already closed. The health authority goes on to say that
"Other problems which may arise in orthopaedics are a loss of staff. Although other orthopaedics hospitals…are recognised for training it is possible that the College of Surgeons recognition may be withdrawn from the registrar post in orthopaedics at St. Leonard's."
Therefore, a whole department will be closed because it will not be recognised. What began as the closure of four wards without consultation ends with the elimination of an orthopaedics department, first because it is not worth while continuing it and, secondly, because the College of Surgeons will withdraw recognition.

We then come to the accident and emergency service. The document goes on to say that
"Once general surgery ceases it becomes dangerous not only to admit ambulance cases but also to operate a 'walk-in' service after normal working hours. At night time there is a real danger that there will not be available a doctor with the experience needed to diagnose serious illness. It is important for the safety of the local residents that they be diverted to Bart's or Hackney and not be deluded into thinking that St. Leonard's offers a satisfactory alternative".
All that stems from an allegation that four wards are to be closed temporarily and that as soon as the economy picks up and the money becomes available all will be well. But the hospital has now been closed, and terminology such as the word "temporary" is fraudulent.

The authority went on to discuss the hours of closing and argued that it should be between 8 o'clock in the morning to 8 o'clock at night. The ink on the paper was not even dry before it had changed that. It will now be between 9 o'clock and 5 o'clock. All that stems from an argument that the ward closures will be temporary and that it will be put right some time in the future.

The Minister for Health was kind enough to visit my constituency, and he will confirm all that I have said, but I should like an assurance tonight that the business of temporary closure, in the way that I have described St. Leonard's hospital, is regarded as a disgrace and that the Minister will intervene to stop it.

I know that the Secretary of State has seen the chairmen of the area and regional health authorities. Nevertheless, there is a gap in communication. The same words are used by us and by those gentlemen yet they appear to have different meanings. The Secretary of State is aware that the disgraceful situation cannot be maintained. I understand that a Mr. J. C. C. Smith, the permanent secretary with particular responsibility for London, was asked by the Secretary of State to explain the Department's policy. That is egalitarian if anything is—for a Minister to ask a civil servant to explain his policy. Mr. Smith confirmed that it was the Government's intention in April 1980 to make good the deficits in the 1979–80 cash limits caused by inflation, increases in VAT and oil prices and that the Government proposed a real growth of the NHS of 0·5 per cent.

Why has that intention not been stated publicly? Why has the hospital been destroyed on the basis that the district is overspending? Permanent closure will result, yet, in April—three months from now—more than sufficient money, between £8 million and £9 million, will be available. What is the sense of that? We are playing not with bricks and mortar but with sick people. The Government know that they will fund the enormous under-funding that has been experienced in the district, yet the statement is made privately. The two gentlemen to whom the statement was made have ensured that my constituents will suffer badly because of a decision that was taken on the spurious argument that insufficient money was available.

The Minister should make a statement today about his proposals to ensure that the area health authority will be stopped from making the closures. The reasons for the closures are spurious and cheating. The closures are called temporary when it is well known that they are permanent. The authority should be brought to the Department and asked to explain why it is causing chaos on the argument that there is insufficient money when it knows there will be full funding which will cover all the under-funding that existed in the past year.

I have criticised the authority's draft district plans, which were issued in August and October. The district's financial position for 1979–80 is clearly stated in the October plan:
"unless current expenditure patterns are curtailed, the City and East London Area Health Authority forecasts an overspending of some £3,983,000, of which some £1,133,000 is required to be a permanent saving arising as it does from the under-funding of wage awards".
How can that position be stated when the assurance of the Minister's permanent secretary has been given that the under-funding will not persist and that, on the contrary, within three months it will be covered? The document continues:
"a brought forward overspending from 1978–9 in the sum of £675,000. The balance of £2,850,000 is made up of a shortfall in the funding for inflation on non-pay items (£1,200,000), the increased cost of VAT announced in the budget (£950,000), and the rise in fuel prices (£700,000)."
The Minister has already indicated from his meetings with the chairmen that he would fund it, but, notwithstanding that assurance from the Government, they go ahead and continue to destroy the health services in my constituency.

I believe that the matter has gone too far. These gentlemen should be asked to resign immediately. I ask the hon. Gentleman if he will today make a categorical statement that all this under-funding in the area will, in accordance with the statement of his right hon. Friend's permanent secretary, be reinstated by April 1980.

I know, and the Minister knows, that a ½per cent. growth means a step backwards. We are both London Members, and know that in any other Thames authority a minimum growth of 1 per cent. is necessary to stand still. Nevertheless, the refunding of the other moneys, which has fallen heavily on the inner city areas, will be of great importance, as the Minister's right hon. Friend the Prime Minister rightly said. The burden falling on central London is very heavy indeed, and I hope that the Minister is in a position to give an assurance tonight that the authority will be instructed to change this behavioural pattern.

I turn now to another matter that is causing concern. I have a letter from Mr. Birnstingl, an eminent surgeon in my constituency, who operates at St. Bartholomew's hospital. He drew to my attention his experience with a constituent of mine. The document that begins the issue is an inter-office communication from a patient services officer to Mr. Birnstingl, which says:
"When the above named presented with a doctor's letter for a Surgical outpatient appointment I was not happy about her eligibility for NHS treatment. I contacted, therefore, the DHSS who in turn have obtained the following information from the Home Office. I did, in the meantime, ask the Appointments Department to make her an appointment but told Miss X that I would check and let her know our decision. She is due to attend your OPD on Monday 19 November."
Information was then telephoned through from the DHSS that this Miss X had arrived in the United Kingdom in 1974, had been given extensions for temporary stay until September 1975, and had then been told to return to her country of origin. She appealed against the decision, but the appeal was dismissed and she was told to embark by 7 August 1979.

The patient services officer was told that the DHSS had alerted the immigration authorities to the fact that Miss X was still here, and the Department gave her authority to tell Miss X that she could not be treated, although if Mr. Birnstingl considered her condition to be an emergency she could be treated on a paying patient basis only. The patient services officer went on:
"whichever way I am to alert the DHSS. Presumably if she does require emergency treatment it is intended that she return to"—
her country of origin—
"as soon as it is physically possible. Can you please let me know whether you are prepared to see her initially."
As Mr. Birnstingl said, since when have the National Health Service and its employees been used as policemen on behalf of the Home Office? What has happened to confidentiality between a person and his or her doctor? I think that it is a scandal that the Health Service is being used in this way. Within one hour of a telephone call from the appointments section of the hospital, the DHSS was apparently able to interrogate the Home Office computer in order to ascertain the facts affecting this person. The DHSS did not bother to argue whether the person concerned was fitted for treatment; it was more concerned that she should be apprehended.

The fact that the appointments clerk did not seem to see that what she was doing was wrong is not relevant in itself. Rather, Mr. Birnstingl feels that the serious breach of confidence in an entirely medical matter is likely to lead to poorer medical care, because people will now be very careful about going for treatment. This whole incident needs to be examined most carefully. I asked Mr. Birnstingl whether he minded my mentioning this case on his behalf today, and he replied that he felt that it was important so to do.

St. Bartholomew's hospital is under threat from the area health authority, which is now closing beds. It is closing the out-patient department as well. One of the arguments for closing St. Leonard's hospital was that the patients could be redirected to Bart's. Yet one of the arguments put forward only last week was that Bart's can now claim that it has reduced substantially the number of its out-patients. That means that my constituents who are being redirected there obviously cannot get in, because the number of out-patients is being reduced.

Thus we have three fraudulent claims. The first is that the hospital is being closed temporarily when its own documents confirm that that is not the case, and the spin-off from that will make it permanent. The second is that when people go from that hospital to Bart's they will be unable to get in because the out-patient department is being run down as a matter of cost saving. The third is the assurance given by the Minister that the money obtained from the sale of the Metropolitan hospital would be directed towards St. Leonard's hospital. That was supposed to be an important factor in the decision to close the Metropolitan hospital. Yet the money has been used for some other purpose.

It is no good the Minister giving a platitudinous reply tonight about the difficulties involved and the fact that it is not his Government's fault. I am not interested in party politics, I am talking about the health and welfare of my constituents. I do not want any claptrap about who is responsible. I challenge whether the Minister has the right to continue to agree to the absurdity of the resource allocation working party. We have given up £1 million to Essex. Therefore, my constituency has less and less money for more and more patients, while Essex has more and more money for the same number of patients.

I am told that the Chancellor of the Duchy of Lancaster was rather concerned that one of his constituents had to travel to hospital in London because the peripatetic consultants who normally travelled out to Essex had stopped doing so as part of the Government's savings programme. I understand that the Chancellor of the Duchy of Lancaster was rather annoyed and that he wrote to the Secretary of State for Social Services, who has been in touch with the regional health authority to discover what is happening. This is an extraordinary situation. The Secretary of State starts the exercise and forces a contraction of services but the Chancellor of the Duchy of Lancaster then wants to know why his constituent is suffering because a consultant is not travelling out to Essex to provide a service.

On one hand, the Government are closing a hospital in my constituency and my constituents are unable to get service. On the other hand, they want sums of money provided to allow peripatetic consultants to travel out to Essex for the convenience of the right hon. Gentleman's constituents. The Chancellor of the Duchy of Lancaster and the Secretary of State should get together to explain that one of the spin-offs of this appalling progress is that people get hurt.

The Chancellor of the Duchy of Lancaster is right to take up the case of his constituent. I am taking up the case of my constituents. I hope for an assurance from the Minister that will enable me to tell my constituents that the National Health Service will continue to operate in Hackney.

1.51 am

I shall not detain the House for long. I congratulate my hon. Friend the Member for Hackney, South and Shoreditch (Mr. Brown) on raising this subject and casting it in such wide and generous terms. It would be valuable for the Minister and my hon. Friend to hear about the position elsewhere in the country.

I must tell my hon. Friend that complaints about London by Londoners, although no doubt justified in London terms, sometimes look different viewed from one of the under-funded regions of the country. Those of us who live in the Trent Valley, in the region of the Trent regional health authority, think that there is considerable difference between the Thames Valley and the Trent Valley. On funding, the previous Government and, so far as I know, the present Government became committed to the idea of a progressive and slow transfer of resources to the under-funded regions. Among those principally affected was the Trent region.

It is the question of resources for the Trent RHA and, particularly, the Derbyshire area health authority that I wish to raise with the Minister. I shall be as brief and explicit as possible.

Three issues concern us in the East Midlands and within the area of the Trent RHA. There is the question of the scaling down of medical skills available in some hospitals. There is the question of the waiting lists, a matter to which my hon. Friend has already referred so eloquently. There is the question of the severe. drastic and immediate hospital closures—a large number of them.

In the city of Derby, part of which I have the honour to represent, the Derbyshire Royal infirmary is threatened with the loss of a number of facilities, including its facilities for neurology and neurosurgery. The idea is that these facilities might be rationalised within Nottingham hospitals. If that happened, I must inform the Minister that it would be hard to maintain the standards of treatment and the range of skills that have existed at the Derbyshire Royal infirmary. That is part of the problem with which we were dealing under the previous Labour Government.

On the issue of radiotherapy, we got several concessions from the former Secretary of State, my right hon. Friend the Member for Norwich, North (Mr. Ennals), but there appears now to be an additional threat. I mention this because it is one of the sources of neurosis and demoralisation spreading across the entire hospital service in Derbyshire and because the Minister knows of my interest in some of the areas that I shall be discussing.

In Derbyshire and in the Trent region, there is now as serious and chronic a shortage of beds—a problem of waiting lists—asanywhere in the country, certainly as bad as anywhere in London. The Minister knows that the national figures are in excess of 850,000 and rising. The position is so bad in some parts of Derbyshire that patients have to wait years for critical operations.

A constituent of mine has a young teenage daughter who has severe curvature of the spine. That condition needs an operation in adolescence if it is to be successful. She had to wait not months but years for that operation. After the intervention of the Department and the RHA, the operation was finally carried out—we pray successfully—on 14 November. For critical operations of that kind it should not be necessary to have to approach the Member of Parliament and the DHSS to get satisfactory surgical treatment within the National Health Service.

For non-critical operations the position is much worse. The Minister will probably have seen one of the cases quoted in the Sunday Mirror last weekend. I refer to the North Derbyshire district, again within the Derbyshire AHA. Dr. McConachie, the chairman of the local medical advisory committee, told that newspaper that
"The area is the worst in the country. If you need surgery for some minor operation, varicose veins for instance, you could wait up to 30 years."
That is an appalling indictment of our National Health Service. I do not want to play party politics. These matters have long been coming to the boil. They are a disgrace to any country that pretends to have a comprehensive National Health Service.

The position in Derbyshire will be made still worse by the progressive closures of hospitals upon which the area health authority has now embarked. This is a fairly narrow point, relating to Derbyshire, but it may be appropriate to make it in this debate rather than attempt to make it on the wider issues tomorrow when the hon. Member for Belper (Mrs. Faith) hopes to raise the case of one hospital on the Adjournment. We can then go into even more detail.

The Derbyshire area health authority, being now £.1½ million overspent, proposes to close not just one but seven hospitals within the county—almost all of the smaller, well-established, highly regarded hospitals that deal with recuperative treatment and non-acute cases.

The Minister knows of my interest in, for example, multiple sclerosis. The only place to which someone can go for rehabilitative treatment for multiple sclerosis, if he lives in the city of Derby, with the enormous pressure on beds for operations and post-operative cases in the Derbyshire Royal infirmary and the City hospital, is one of the small hospitals on the outskirts of Derby, such as Etwall or Draycott. If one goes to the Etwall hospital, as I frequently do, to see multiple sclerosis patients and others, one sees the remarkable treatment that these patients have been getting from highly skilled staff.

There is no question of these hospitals being out of date, incompetent or degenerating in themselves, but we are now told that they are all to be closed. It may be that they are to be closed only temporarily, but "temporarily" in the first instance means until 1981, and that may mean for ever. The record of the AHA reopening hospitals is not good. That would mean, inevitably, that the waiting lists would be longer and some people would not receive hospital treatment at all.

For many, the difference between resuming some sort of active life and a helpless vegetable existence at home comes from the recuperative treatment in the smaller hospital, where there is not the rush and throughput of a larger hospital that is mostly concerned with postoperative cases. That has been the position of the smaller hospitals in Derbyshire. All who have had relatives treated in those hospitals, as I have, have reason to be grateful. Now, the person who has a stroke or amputation or is suffering from a degenerative disease and who has been greatly helped by the smaller hospitals in the past will have nowhere to turn. It would not be possible, within the National Health Service, to receive the treatment that that person needs.

We are not talking simply of some facilities being closed down or the long waiting lists within existing hospitals. We are talking of the whole problem being made more acute by the closures of the seven hospitals to which I have referred. I should like to hear tonight from the DHSS an assurance that it will look at the problem in terms of the first charge upon it being that of patient care and the maintenance of the hospital services that we have every right to expect and for which we have paid our taxes. Does the DHSS accept that the Trent AHA, over the years, has been under-funded and that there should have been a progressive transfer of resources to health authorities of that sort? Does it accept that it is a foolish and short-sighted step to close hospitals in such a wanton fashion? Does it further accept that the under-funding of the AHA—it is a general under-funding, not incompetence or extravagance in other areas on the part of the AHA—can be remedied only by an infusion of additional money? More funds are needed, especially for the Derbyshire AHA.

I hope that the Minister does not tell the House that it will all be solved by the axing of the AHAs. It may well be. I thought in the past that a layer of bureaucracy should be removed. However, the eventual overall saving from the axing of the AHAs would be about £30 million at its most optimistic, and that would be spread over 60 or more authorities. Clearly, that would not mean much, even in terms of the one year's over-spending in Derbyshire.

One of the issues of the Bill is that the very hospitals that are to be emptied will become establishments for private practice. The funds are being set out to allow private practice to take place, and those who are able to afford treatment will continue to receive it, while my constituents are unable to afford it.

I agree entirely with my hon. Friend. The partisan note that he has injected is one that I must echo If one drives out of Derby, one passes the site of a new luxury hospital being built with private cash by a consortium of consultants and financial friends. It will offer a great range of recuperative services, if one is prepared to pay large sums to receive them.

I am concerned that we should even consider reaching a position in which the patient is told that if he needs a non-urgent operation or recuperative treatment he must go to the private sector. It is clear that many people will not be in a position to afford that. It is absolutely clear, for example, that many elderly people, stricken down with disease, a stroke, or something of that sort, will not be able to go to the luxury hospitals set up in the private sector and buy the treatment they need.

The principle of the National Health Service, set out by its founding fathers—Dr. Stark Murray, and people like that—was that we should have a comprehensive service from the cradle to the grave. Well, we do not have it from the cradle to the grave, and people get to the grave a good deal earlier without the service that they need. Many people will meet an untimely end and many more will be condemned to a period of misery and immobility as a result of the kind of closures of which we are talking.

The Minister is a compassionate man. I want from him a commitment to the principle of a National Health Service for all—for the non-acute as well as the acute cases, and for the recuperative as well as the operative cases. I want him to say loud and clear that the Department will look at the closures now being proposed in Derbyshire and will consider the alternatives, both in terms of the funding that the authority already has and the funding that we contend it ought to have in order to maintain the level of patient care in the region that we believe any well-intentioned and properly funded Health Service should provide.

2.6 am

This has been an interesting debate. I think that the contributions by the hon. Members for Hackney, South and Shoreditch (Mr. Brown) and Derby, North (Mr. Whitehead) have counterbalanced each other. The first hon. Member spoke on behalf of an "over-provided" London area. His contribution was balanced by that of his hon. Friend, who was speaking for an "under-provided" area outside London. They have posed very well the problem that faces the Government in allocating resources to the National Health Service.

The hon. Member for Hackney, South and Shoreditch has a deep interest in and knowledge of the National Health Service, but his language was Somewhat extravagant. When he reads his words in the cold light of dawn, I hope that he will agree to moderate his remarks. He said that we were embarking upon "the total destruction of health services" in his constituency. That is an emotive and hysterical remark, which bears no relation to what is happening in his constituency. As a member of a regional health authority, he knows that.

He and his hon. Friend trespassed to some extent on a debate that will take place in just over 12 hours' time on the Health Services Bill. I do not want also to trespass on that territory. The hon. Member spoke of closures. His Government's record was hardly one to inspire confidence. During their period in office about 280 hospitals were closed or approved for closure. On 31 March this year proposals were made for the closure of a further 31 hospitals.

The hon. Member began by saying that there was a shifting age pattern in his constituency, and he is right The RAWP formula, as set out in the document "Sharing resources for health in England" makes it quite clear that age is one of the factors that has to be taken into account. Paragraph 2.4 relates to the need for measuring the demand for non-psychiatric inpatient services to take account of age and sex. The same point is made in paragraph 1.7, which considers the population make-up. I concede what the hon. Gentleman says. The formula for allocating resources should take that into account. But on pages 132 and 128 of the document, bearing in mind the contrast between the region in which the constituency of the hon. Member for Hackney, South and Shoreditch is located and that in which the constituency of the hon. Member for Derby, North is located, one can see a tremendous discrepancy in the amount of resources per head. On page 128 the document states that
"The North East Thames Region has £13·54 excess over the average per head of weighted population whereas the Trent Region has a shortfall of £7·72."
That is an example of the disparity in provision which this Government and our predecessors have been determined to do something about.

Only 15 per cent.—two years ago it was 13 per cent.—of the people using St. Bartholomew's, the teaching hospital in my constituency, come from my constituency. The rest come from other parts of the country, including the Trent region.

The hon. Gentleman is right, but this comprehensive document indicates that part of the formula takes account of the fact that people move from one region to another and that some regions have a teaching responsibility that others do not.

The hon. Gentleman raised detailed points about St. Leonard's hospital. I should like to look into them. The hon. Gentleman will not expect me to have at my finger-tips the agenda of the meeting that took place recently, though I hope the the members of the authority who are taking the decisions have the agenda and relevant papers. I shall write to the hon. Gentleman after looking into the matters that he has raised.

On consultation, the hon. Gentleman may not know that my hon. Friend the Minister for Health has recently given fresh guidance to health authorities on the procedure for consultation, particularly where temporary closures are proposed. If the hon. Gentleman has not seen that guidance, I shall certainly send him a copy.

Claiming that the term "temporary closure" is fraudulent is another exaggeration.

Last week I answered an Adjournment debate initiated by the right hon. Member for Bermondsey (Mr. Mellish) about the temporary closure of a hospital—a closure that was clearly a temporary one. A working party had been set up to make plans available for bringing the hospital back into action. I do not accept what the hon. Member for Hackney, South and Shoreditch says about the use of the term "temporary closure" being fraudulent.

The hon. Member for Derby, North made a much more reasoned contribution. I assure him that we have a commitment to the NHS. My right hon. Friend the Secretary of State will be making that even clearer in his speech later today. I also confirm that the hon. Gentleman's region is under-funded and that there ought to be a switch towards it.

The hon. Gentleman said that there are seven proposed closures in his region, and he added that some are only temporary. There is a procedure that must be gone through before permanent closures can take place. There is to be another debate today on problems in Derbyshire. I shall look in more detail at the problems raised by the hon. Gentleman and write to him. I do not accept the hon. Gentleman's conclusion that it is hospital closures that will add to waiting lists. The problem is one of resources rather than closures. The waiting list in December 1974 was 517,000 and in March this year it was 752,422. There is not much in the record of the previous Administration that affords comfort there.

I know the deep concern of the hon. Member for Derby, North about problems in Derbyshire. I shall consider what he has said and will write to him. I do not think that he would expect me to have at my finger-tips hte answers to all the matters that he raised.

I turn to what the hon. Member for Hackney, South and Shoreditch said about Mr. Birnstingl. The Minister for Health issued a press statement a few days ago rebutting the allegations made in some national papers. No information was given to the Home Office that it did not already have. My Department does not pass information on to the Home Office to enable it to chase illegal immigrants. It has a responsibility to see that the NHS is not abused, and we try to minimise gate-crashers. I see the hon. Gentleman nodding in assent. That is the extent of our responsibility, and we do not pass to the Home Office confidential information that it may need for a totally different purpose.

Behind the remarks of both hon. Members is the debate about redistributing resources. It is important to understand that redistributing resources on a more equitable basis is a long-term strategy. The aim is one that has existed from the birth of the National Health Service and has been part of its basic philosophy, but it is only in recent years that an objective measure has been developed and applied to effect and monitor the process.

The first step was the development of the formula that was applied from 1971–72 to non-teaching hospital services. After the 1974 reorganisation, this was refined and developed for application to the hospital and community health services as a whole, in the shape of the resource allocation working party recommendations published in 1976. This process is colloquially known as RAWP.

The working party's formula for assessing target allocations takes account of age and sex structure of the population and other selected indicators of need for health care such as standardised mortality ratios, which are included as a proxy for morbidity. Account is also taken of the numbers of in-patients that cross administrative boundaries, of London weighting payments and of the additional costs that arise from the provision of facilities for undergraduate medical education.

Even before these yardsticks had been developed, however, successive Governments had gone some way to reducing the gross inequities that the National Health Service had inherited in the provision of health care across the country. But the actual process of shifting resources relied mainly on building new hospitals where they were judged to be most needed and providing the necessary resources to run them. There are obvious dangers in such a haphazard approach. Special pleading and other subjective considerations are likely to have an undue influence, hence the strong advantage of the sort of objective measure that RAWP provides.

However, even with a formula to guide us, equity cannot be achieved overnight. RAWP can help on what share of available resources a region ought to have, but how quickly that target can he achieved is still amatter of political judgment. The overriding regulator will always be the additional resources available nationally in any one year coupled with the judgment of Ministers about the maximum restraint that can realistically be imposed on the relatively better-off regions, such as North-East Thames.

It has always been an unenviable task to have to decide the fairest way of allocating new resources, particularly, as in present times, when they are so scarce. Not only is it impossible to satisfy everyone; it is scarcely possible to satisfy anyone. It has come as no surprise to hear of the difficulties of the better-off regions in making ends meet from a position of virtually nil growth in the past, and from the less well-endowed regions about the need from their point of view for a much faster redistribution of resources.

For next year, the recent White Paper gives only½per cent. growth nationally for the health services—the level of growth planned by the previous Administration—after restoring what has been lost in this year's squeeze on resources. That is what we allocate to the National Health Service as a whole. It has to be redistributed among the regional health authorities, from them to the area health authorities, and from them to the districts. It does not follow that each area health authority will get an additional ½ per cent.

Much play has been made of the effects of cash limits on health authorities. There has been a considerable effect. Health authorities' revenue allocations have been squeezed by about 3 per cent.—between £125 million and £130 million—and the effects of such a reduction are bound to be considerable. We have discussed this matter during two Supply day debates and on a number of Adjournment debates. I do not want to belittle either those effects or the concern felt by hon. Members. However, we must set the record straight. The Labour Government set cash limits at a woefully low level. They were guilty of setting cash limits at the level that they would have liked to see for pay and prices rather than taking realistic account of what was likely. When the limits were announced in April, they were already far too low.

Health authorities were told that there would be no increases for excess inflation and that the first £23·4 million of excess pay costs would not be met. There was the undertaking to pay the excess costs of approved pay settlements above £23·4 million, but no financial provision was made for that. This was a classic postdated cheque drawn on somebody else's bank account. We have honoured that undertaking and we have increased the cash limits by £250 million-plus as a consequence. One more major sum remains to be added for the costs of the Clegg Commission award to nurses. By the time that we have honoured the commitment on that award, the increase in the cash limits is likely to be in excess of £300 million, or about 8 per cent. above the original cash limit.

I do not detract from the squeeze that has taken place, but it is important to recognise that, at a time when the Government's fiscal and economic policies demand a reduction in public spending and that the PSBR be held down, we have nevertheless found for the NHS substantial sums previously unbudgeted for.

The effects of the squeeze that have occurred this year have attracted much attention. The hon. Gentleman himself mentioned this. The Government believe that the NHS should do everything in its power to absorb the effects of the squeeze as far as possible without cutting or harming direct patient services. We have been heartened by the way in which authorities generally have set about this task. I am sure that they will continue to tackle it well. A good treasurer knows of many ways of cutting corners which do not affect patients, and I pay tribute to the treasurers who have done all in their power. But in some places economies of this sort have not been enough, and cuts in the planned levels of services have had to happen—new developments have had to be delayed and existing hospitals and wards have had to be closed, some of them temporarily.

I regret each and every one of these decisions, and I appreciate the impact that they have had on the patients who would have used those services and the dedicated staff who would have worked there, but in the last resort the necessity of those measures has to be recognised. I do not for a moment suppose that it was any easier for the authorities concerned to decide on those measures than it was for those of us seeing them from a greater distance. The plain fact is that this country can have only the services—education, housing and personal social services, as well as the NHS—which our economy can sustain.

Finally, I shall say a word about next year's cash limits. It will be some time before the cash limits themselves can be announced, although we have set out in the White Paper our general expectations. But I can say that we have no intention of repeating our predecessors' error. We shall be setting cash limits that we judge to be realistic, and we shall stick to them. Health authorities will be able to plan with more certainty and to be arbiters of their own fates.