The hon. Gentleman is right, they do not add up. The problem with the report is that it talks of London as a whole. None the less, it says that there are 8 per cent. more available acute beds per capita in London than there are in England as a whole. What is more significant is that 40 per cent. of those beds are in inner London. There is a preponderance of beds in inner London. We also know that the length of stay in teaching hospitals in London is 15 per cent. above the average for the provinces.
The right hon. Member for Derby, South made great play of the fact that, in a sudden surge of inspiration, she had managed to determine that somehow the figures for London were not valid, because London was no better off than comparable cities up and down the country. Yet we knew that, because it was clearly stated in the original King's Fund report, which preceded the Tomlinson report and "Making London Better".
Therefore, we are not debating London only, because the situation in London is comparable to that in other cities that also have to get to grips with problems. However, that does not negate the need to make progress in London. Despite all those figures—possibly because of the apparent over-provision—London has poorer primary care.
I shall address some other aspects of health care in London. I was very pleased that the hon. Member for Southwark and Bermondsey (Mr. Hughes) mentioned the funding formula, because I think that it is important. Again, it was interesting that the right hon. Member for Derby, South did not remind the House that the original changes to funding, which have affected London so seriously, go back an awful long time, to the doctor who was a Minister of State for Health, Lord Owen. He introduced the resource allocation working party formula, which took funds away from London. Certainly Croydon has suffered from that ever since.
There have also been recent changes to the funding formula which benefit Croydon. Whereas, before, the borough was about on target, it is now £6 million under target. However, I was somewhat disconcerted to learn from figures that I received only today from the South Thames regional health authority that the South East London health authority, which was apparently £5 million under target, is now £4 million over target.
I urge Ministers to look again at the funding formula. I know that they have relied heavily on work done by York university, but there is still concern that too much weight in the formula is given to the age profile of the population and the number of elderly people, rather than to deprivation factors, which clearly have a significant impact on health spending.
We are well aware of the other pressures for change. The switch from secondary to primary care is leading each purchaser to reduce the percentage of funding it spends on secondary care. There is a welcome trend of more patients being treated near home. I know that my hon. Friends who represent constituencies outside London welcome the fact that their constituents do not have to travel to London for care, and that they can receive such treatment at their local district general hospitals.
We have also heard about the significant switch to day surgery. It is obvious that beds are not needed for day surgery. At my local hospital, the Mayday University hospital, 90 per cent. of cataract operations are now carried out on a day basis, much to the benefit of the patient. Micro-techniques have led to much less invasive surgery, which also means shorter stays in hospital. All those pressures justify the general strategic direction that the reforms and changes are taking in London.
I mentioned earlier the King's Fund, the Tomlinson report and "Making London Better". It was significant that "Making London Better" scaled down the figures for bed losses as outlined in the Tomlinson report.
Although it was not really a target, "Making London Better" refers to a bed loss of between 2,000 and 2,500 beds in inner London in comparison with the 1990–91 figure. In last October's debate, I drew attention to the fact that, if London could improve its efficiency of bed usage to the level of other areas in England, that target could be achieved easily. If London could reach the level of 14 beds per 1,000 in terms of the population in inner London, 2,700 beds could he taken out of the system.
That is not the end of the story. There is clearly a serious dichotomy between the strategic direction and analysis of the situation in London and what is happening on the ground today. I castigated Opposition Members earlier for over-exaggerating the problem. I believe that they do that, but it would be foolish to deny that there is pressure on beds in London.
One need only visit accident and emergency departments to witness the pressure that they are working under. I visited the A and E department at Mayday hospital recently. I did not visit at its busiest time, but it was very cramped. I am pleased that major redevelopment is going on at the moment to provide proper facilities. When facilities are cramped and there are problems with getting people into beds in hospitals, there is the dreadful phenomenon of people having to spend time on trolleys. That is clearly unacceptable.
The picture with regard to health in London is confusing, because it is rapidly changing. Reference has already been made to the report entitled "Hospital Services for Londoners" by the inner London purchasers. The report makes several points. Interestingly, it refers to the fact that accident and emergency attendances had not changed significantly. That is surprising, because, from anecdotal evidence, some people had felt that A and E attendances had increased.
It is noteworthy that emergency admissions, whether via an ambulance on a 999 call, or via an ambulance bringing in an urgent case from a GP, have increased significantly. One of the difficulties that I have found with the inner London purchasers' report is that it does not provide the figures. It does not give the scale of the increase.
I am aware that my district general hospital, Mayday in Croydon, has seen an increase of 25 per cent. in emergency and urgent admissions in comparison to January last year. We have had a very mild winter this year. As far as I am aware, there has been no great spread of illnesses, such as a large epidemic of influenza, which would have had a significant impact on such admissions.
I do not know whether the increase in Mayday's emergency and urgent admissions is mirrored across London. I would be surprised if it was, because the figure is extraordinary and it cannot be explained by straightforward demographic factors. I urge my hon. Friend the Minister to ensure that that aspect is considered.
I wonder whether all A and E departments in London are pulling their weight and taking their share of cases that come their way. I wonder whether some are closing their doors from time to time, putting pressure on other hospitals. If that is the case, it would clearly be unacceptable.
While we are right to press on with the strategic drift of the changes in London, we must be cautious about losing further acute beds too quickly in London. I have received figures only today—today seems to be my lucky day—which show the bed position in London until March 1994. It would obviously be helpful if there were more up-to-date figures.
I was particularly interested in the bed loss figures in inner London. Compared with "Making London Better" and Tomlinson, and the target of 2,000 to 2,500 bed losses in five years, 1,400 beds have been lost in inner London. It is interesting that, between 1991–92 and 1992–93, the bed loss was comparatively small, but it accelerated between 1992–93 and 1993–94. It is possible that that, in conjunction with the implementation of care in the community, in respect of which we know that there is a problem in getting elderly people out of hospital quickly enough because of problems with discharge, is a factor in influencing the pressure on admissions to hospitals in London.
From talking to my district general hospital, my impression is that it is quite possible to reduce surgical beds even further, because of the advances in medical technology to which I referred earlier. However, it is difficult to reduce medical beds which tend to be used mainly by the elderly. Indeed, my hospital has had to open additional medical beds to cope with the demand, and I urge my hon. Friend the Minister to consider that aspect in more detail.
In addition to the inner London purchasers' report, the clinical studies advisory group has produced a very useful report into A and E admissions and how A and E departments should be organised. I refer to those two reports because they make important recommendations.
There is no doubt that there is a need to improve the management of A and E departments and to ensure that they have proper observation wards and, perhaps even more importantly, admission wards, so that people do not spend time on trolleys. The inner London purchasers' report states that some hospitals are operating to too tight a margin.
If there is very high demand in a hospital, particularly on the emergency admissions side, the inner London purchasers' report makes it clear that the occupancy level of beds must be lower than would otherwise be the case if the level of emergency admissions was lower. That stands to reason, because if a hospital caters primarily for elective surgery, with very few emergency admissions, it can plan for that, and it does not need the slack for emergencies. However, if a hospital has a very high percentage of emergencies, there could be a sudden surge, which could completely disrupt the hospital. That hospital therefore needs greater spare capacity.
The inner London purchasers' report states that hospitals should operate at a level of about 85 per cent. I do not know whether that is a good suggestion or a bad one, but it must be borne very carefully in mind. The report also suggests that, in assessing bed requirements, one particular formula to be applied across London is not necessarily the correct approach. The health authority should assess the needs in its area before reaching a conclusion about bed requirements.
The report makes another important point. We know that London has more acute beds per 1,000 of the population than elsewhere. Interestingly, it has fewer nursing home places. That causes more pressure on medical beds, and that is why we must proceed with caution before reducing those beds further.
The report by the clinical studies advisory group is interesting, covering issues such as bed management. That issue is crucial in any hospital. Too often, there are problems in getting patients on to wards. However, sometimes beds are being kept vacant by consultants. Hospitals must manage beds properly.
It is also important to ensure proper consultant cover in A and E. Too often, patients turn up in A and E and find that the more junior doctors are on duty.
The NHS does an excellent job catering for most people when they are ill. If one is seriously ill or in a major road accident, generally speaking one will be treated very well indeed. But it is not acceptable to have the main entrance to the NHS in A and E departments which are often not staffed by senior consultants and which are often short of facilities for getting patients out of A and E and into the main part of the hospital. That aspect of health care is critical, and it must be given priority.
I shall say a couple of brief words about some specific changes in London, of which great play has been made. There has been concern about the closure of Bart's A and E department,. but I am hound to say that, given that it catered for only 30,000 attendances a year, it was right to centralise facilities elsewhere. Indeed, those facilities have been expanded. I welcome also investments in A and E at various centres within London, including King's, the Homerton, and the Mayday in Croydon.
I do not think that there is a crisis in the health service in London. The changes that have been set in train are proceeding in the right direction. However, I agree with the hon. Member for Southwark and Bermondsey, who made the plea that responsibility for bringing about those changes in the configuration of particular trusts should be left to them, rather than be determined by the center—but with the one key reservation that I have mentioned.
I hope that my hon. Friend the Minister will not agree to massive capital injections where they are not necessary. I urge my hon. Friend to be cautious in relation to further acute bed reductions, given the evident pressures on beds at present. I am happy to support the amendment.