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House of Commons
Tuesday 16 May 1995
The House met at half-past Two o'clock
PRAYERS
[ Madam Speaker-- in the Chair ]
Oral Answers to Questions
HEALTH
Hospital Provision (South-west London)
1. Dr. Goodson-Wickes: To ask the Secretary of State for Health what recent consultations she has had concerning the provision of hospitals in south-west London. [22851]
The Minister for Health (Mr. Gerald Malone): Local health authorities, national health service trusts and general practitioners in south-west London are considering the future provision of hospital services in the area.
Dr. Goodson-Wickes: Does my hon. Friend accept that although the London borough of Merton does not have a general hospital within its boundaries, thanks to Government reforms it already has unrivalled access to three excellent national health service hospitals, St. George's hospital, St. Helier hospital and Kingston hospital? Does he agree that the picture would be completed by the exciting new plans to rebuild the Nelson hospital in Wimbledon, so that my constituents can have access to the highest quality day surgery and out-patient care?
Mr. Malone: My hon. Friend has been a staunch advocate of that proposal. It is intended that the review of specialist services, which is under way, will improve services across the area that serves my hon. Friend's constituency. I am sure that his points will be borne in mind by all concerned.
Mr. Nicholas Brown: As London has half the number of health centres per person of other major cities in England and fewer GPs, health visitors and district nurses than it had in 1990, and as there has been a decrease of 2 per cent. in the number of GPs per head of the population in inner London in the past decade, how can the Minister claim to be presiding over a shift from hospital services to primary care? Surely he is getting rid of beds without providing alternative services.
Mr. Malone: As it is essential to provide excellent health care in London, combine specialist services, improve primary care and continue the Government's investment in primary care, such as the £210 million investment in the London implementation zone scheme, why do the hon. Gentleman and his party want to stop all that in its tracks and call for yet another review?
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Consultant Specialties
2. Rev. Martin Smyth: To ask the Secretary of State for Health if she will make a statement on the shortage of staff in consultant specialties in the health service. [22852]
The Secretary of State for Health (Mrs. Virginia Bottomley): In the five years to 1993, the number of hospital consultants in England increased by an average of 3 per cent. a year, well above the target of 2 per cent. set in 1987. Over the same period, the number of consultants in Northern Ireland increased by 12 per cent. The Government have established effective mechanisms to ensure that consultant numbers continue to expand to meet demand.
Rev. Martin Smyth: If the Government are controlling numbers to meet demand, why are there continuing shortages, particularly among anaesthetists and paediatricians, which mean that operations have been cancelled? Is someone in the Department using new maths and not counting correctly? Is it job protectionism, or are hospitals saving money at the cost of patient care?
Mrs. Bottomley: I explained that there has been a substantial increase in the number of consultants, but there are always times when there is particular pressure on certain categories. That is why we have set up a working arrangement with the professions, whereby one committee can monitor and anticipate where there is particular pressure. The hon. Gentleman will be pleased to know that, for example, in paediatrics there was a 5.5 per cent. increase in consultants and in accident and emergency there was a 6.7 per cent. increase. The increase has been above average in both those specialisms.
Mrs. Roe: Will my right hon. Friend confirm that the Government are committed to increasing the number of medical students and have taken on board the recommendations to that effect by the Medical Workforce Standing Advisory Committee? Will she also comment on the training of doctors? Can she say anything further about the implementation of the Calman changes?
Mrs. Bottomley: I can indeed inform my hon. Friend that, having not only published the first report of the Medical Workforce Standing Advisory Committee but acted on it, we shall shortly produce the second standing advisory committee report. We train about 500 more medical students a year than we did 10 years ago and we anticipate further increases. My hon. Friend referred to the important Calman proposals to improve and accelerate specialist training. We are working on their detailed implementation, from which future generations of consultants will greatly benefit.
Mrs. Bridget Prentice: Is the Secretary of State aware of public alarm at the number of casualty departments being temporarily closed-- including at least five in London? Is she further aware of concern that--
Madam Speaker: Order. The question has already been widened.
Mrs. Prentice: Is the Secretary of State aware that those closures might be due to staff shortages or, more
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likely, to the Government's policy of permanently closing casualty departments? What guarantee can she give London in particular that such closures will not recur?Mrs. Bottomley: The hon. Lady identifies an area of special focus-- accident and emergency departments--in which there has been an 11.1 per cent. increase in consultant appointments because it is moving towards a consultant-led service. That is precisely what underpins the move to larger A and E departments associated with minor injury centres. Junior doctors will increasingly want to staff areas that offer an A and E service according to best practice--well staffed, well equipped and of significant size.
I am sure that the hon. Lady is aware that the Royal College of Surgeons commented recently that placement in an A and E department is not necessary for training. As a result, we are holding discussions with professional groups to ensure that those jobs continue to be attractive. Our job must be to ensure top quality, well-staffed, well-equipped A and E departments for the people of this country.
Mr. Heald: Does my right hon. Friend agree that consultant numbers have increased well ahead of target? Will she join me in congratulating North Hertfordshire NHS trust based at Lister hospital on the appointment of a new audiology consultant in September which, together with the new magnetic resonance imaging scanner later this month, will make a huge contribution to improved patient care for my constituents?
Mrs. Bottomley: I join my hon. Friend in congratulating his trust, which is a classic example of how trusts have used the opportunities of their status to improve patient services and make them more responsive. I confirm that there have been an extra 300 consultants a year for the last four years. We intend to maintain and improve that impressive record.
Hospitals
3. Mr. Turner: To ask the Secretary of State for Health how many hospitals there were in England in 1979, April 1991 and December 1994. [22853]
Mr. Malone: In 1979 there were 2,023 hospitals in England, and in 1991 there were 1,624. For 1994, NHS Estates, using a different basis of calculation, has estimated the number at 1,440.
Mr. Turner: Have not 245 hospitals closed since 1990--one per week since Conservative health reforms were introduced? Does the Minister agree that as a result of record waiting lists, hospital closures and bed losses, the NHS is at breaking point in many parts of the country? Operations have been cancelled, specialist beds have been unavailable and there has been the unholy sight of many people on trolleys waiting hours in casualty departments.
Mr. Malone: If the hon. Gentleman were to look at his own constituency, he would see a different picture from that which he painted. In 1989-90, there were 560 waiters over two years; in 1995, there is none. In 1989-90, there were 214 two-year waiters; in 1995 there is none. Investment projects totalling £17 million are under way in the hon. Gentleman's constituency. Of course there have been a number of closures, but substantially better
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facilities have been put in their place. Why does not the hon. Gentleman recognise that when it is happening in his constituency?Mr. Rowe: Is my hon. Friend aware that people in my constituency have warmly welcomed the closure--regrettable though it is in some respects --of the oldest hospital in Britain, St. Bart's, and of All Saints hospital, the former workhouse? It is shortly to close, almost entirely owing to the large investment put into the Medway hospitals complex, which will provide unrivalled modern facilities. Does he agree that this counting of hospitals is meaningless?
Mr. Malone: My hon. Friend is quite right. The purpose of the health service reforms was to allow services to be provided closer to people. That is precisely what my hon. Friend points out in respect of the reconfiguration of services in his constituency.
Mrs. Beckett: Does the Minister accept that we are pleased to learn that he has found out some facts about hospitals, as it is not long since he told us that he did not know how to define one. I hope that that means that the questions that we table will in future be answered. Does he nevertheless accept that there is considerable concern in many parts of the country about the pace of change, and that when Ministers say, as they repeatedly do, that they do not know what is happening in terms of the provision of hospitals and do not know which hospitals or A and E departments are at risk, they add to that concern?
The Secretary of State said a moment ago that Ministers are concerned about standards of hospital care and of accident and emergency provision. How can they know that standards are being met if they do not even know what is happening on the ground?
Mr. Malone: The right hon. Lady is well aware that these matters are decided locally. When they are disputed or objected to by community health councils, they come to Ministers for decision. Hence a tremendous amount of reconfiguration of service and change is going on around the country by local agreement.
It is not good enough to be obsessed with old buildings; it is far better to look at the new investment going into the health service. More than 700 schemes costing more than £1 million each have been completed in the course of the past decade. That is the measure of the Government's commitment to an improved health service. I do not understand why the right hon. Lady is obsessed with the past.
Residential and Nursing Home Care
4. Mr. Sims: To ask the Secretary of State for Health what guidance she offers to local authorities in assessing the means of persons in need of residential and nursing home care; and what plans she has to amend the figures on which such calculations are based. [22854]
The Parliamentary Under-Secretary of State for Health (Mr. John Bowis): Comprehensive guidance was issued to local authorities in December 1992 and is regularly updated.
Mr. Sims: At present, anyone with capital of more than £3,000 is expected to contribute towards the cost of his care, and anyone with more than £8,000 has to pay in full. Will my hon. Friend confirm that the figures were
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inherited in 1993 from the income support system and have not been altered since? In fact, they date back to 1990. Does he agree that they are perhaps due for review?Will my hon. Friend consider clarifying the guidance that he gives local authorities, which take into account the full occupational pension of a person in a residential nursing home? This often means that the spouse left in the family home has no income whatever and may have to resort to income support.
Mr. Bowis: My hon. Friend's statement of the figures is correct. They were brought into line with income support figures in 1993, when the threshold was raised from £1,200 to £3,000. We do indeed keep the figures under review and will continue to do so.
As for the occupational pension, local authorities have a discretion to enable a spouse to remain at home with the same standard of living to which he or she has been accustomed. My noble Friend Lord Mackay asked in another place for any evidence that this discretion was not being used properly to be brought to the Government's attention. I repeat that request today; to date we have received no such evidence. We shall, however, consider the matter, as we promised to do, in another place.
Mrs. Dunwoody: Is the Minister aware that literally thousands of people are terrified that they will become so frail that they will be removed--forcibly, if need be--from an NHS bed and sent to a private home, leaving their families unable to make up the difference between the fees and the amounts available? That not only frightens large numbers of people but implies that the system is on the verge of breaking down.
Mr. Bowis: I refer the hon. Lady to the guidance that we recently issued on continuing care and on discharge; and to one of the conditions of the special transitional grant--that there should be agreement between the social services and hospitals. There has been no change to the system for charging introduced in 1948 by the then Labour Government. This Government introduced the discretion and the requirement that the value of the house be ignored for spouses and other members of a family who may remain at home.
Mr. Wilkinson: Will my hon. Friend publish the results of his review? As my hon. Friend the Member for Chislehurst (Mr. Sims) has made clear, in parts of outer London, such as my constituency of Ruislip- Northwood, a place in a residential nursing home can cost several hundred pounds a week, which can lead to a spouse eventually having to sell the family home, causing great distress over and above that of looking after the sick patient. Will my hon. Friend publish the review and re-examine the criteria?
Mr. Bowis: There is no review as such. I said that we kept the matter under review. If we decide to make a change, we shall announce it. However, I can reassure my hon. Friend that, where a spouse remains at home, there is no question under this Government of that spouse being turned out of the family home. That is precisely the requirement that we put into law which was not there under the previous Labour Government. We have also
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given the discretion to enable that spouse to remain in the family home according to the standard of living to which he or she has been accustomed.Mr. Wigley: Does the Minister accept that people with on-going medical needs are being pressurised to move from hospitals into private nursing homes because of the in-built financial structure of the health care authority and its lack of beds? Surely anyone with an on-going medical need should be able to stay on in an NHS hospital.
Mr. Bowis: The hon. Gentleman is correct. If someone is deemed by a doctor to have a continuing in-patient health care need, that should be provided by the NHS, whether in a hospital or a bed purchased by the NHS. It is only if doctors decide that there is no longer an in-patient health need that a patient will be discharged into the community where the community health services will continue to be free to that individual. However, as has been the case since 1948, the social care needs would be paid for by the individual unless that individual's income warrants support by previously the benefit and now the community care system.
Mr. Sumberg: Does my hon. Friend recognise that there is considerable concern among elderly people and their relatives that the family home, for which they have saved over many years, may well have to be sold? Will my hon. Friend urgently and radically consider proposals to exempt such homes?
Mr. Bowis: My hon. Friend is correct to raise the concern of his constituents. I am happy to give him the assurance that we will continue to review the situation to ensure that the family is looked after. We already have in place assurances that we can give to families, and to spouses in particular, and now we must consider whether the figures that are in place are still adequate to meet the needs.
Mr. Hinchliffe: Does the Minister recall that one of the key objectives of the assessment process was the avoidance of unnecessary institutional care? Is it not a fact that many people are still being placed unnecessarily in care homes because of the requirement to spend the bulk of the community care grant in the private sector? Will the Minister make it clear which is more important--the proper assessment of individual needs or propping up the private care market?
Mr. Bowis: Yet again, we see the naked hostility to the private sector that has been so apparent from the Labour party ever since we introduced the community care policy. It is clear that the assessment of the individual is central to community care. The individual takes part in that assessment and the individual and the individual's carers take part in discussions on how to meet the needs of that assessment.
It is then a question of whether it is possible to enable the individual to stay at home with a package of care or whether it is better to place the person in residential care. That is a matter for the assessment, which should involve the appropriate medical input. We have no dogmatic view on whether someone should stay at home or go into residential care. We want the individual to receive the best care, irrespective of from which sector that care comes.
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Elective Surgery
5. Mr. Ottaway: To ask the Secretary of State for Health what proportion of elective surgery is now carried out on a day-case basis. [22855]
The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville): Half of all elective surgery is done on a day-care basis.
Mr. Ottaway: In the light of that excellent answer, will my hon. Friend pay tribute to Croydon's Mayday healthcare trust? More than half its non-urgent surgery is carried out on a day-care basis, and it has just opened a brand-new paediatric day-case unit. Does my hon. Friend realise that, if he had listened to the Opposition last week, all that would have been put in jeopardy? Is it not the Conservative party that is looking forward, and the Labour party that is looking backward?
Mr. Sackville: I can confirm that 90 per cent. of cataract operations carried out at the Mayday hospital, 73 per cent of arthroscopies and 54 per cent. of laparoscopies are performed on a day-case basis. That is good news for patients in my hon. Friend's constituency, and I am glad that he has endorsed and paid tribute to what has been a central policy in my Department.
Mrs. Mahon: When the Minister gives figures showing an increase in day-case surgery, does he take into account the extra work load for nurses? Does he not feel just a little ashamed of the fact that those who have made that increase possible are now balloting on whether to take industrial action?
Is it not time that the Minister stopped insulting nurses, and started to pay them a proper rate for the job? At present, nurses are scrabbling about with trusts which do not care, and which are not--as the Minister claimed-- offering them a 3 per cent. pay increase: they are offering 1 per cent., or 3 per cent. if extra elements are taken into account. That involves altering nurses' working conditions.
Mr. Sackville: Nurses do a wonderful job in day-case units, and it is right and fitting for their pay to reflect that.
Night Services (General Practitioners)
6. Mr. Simon Coombs: To ask the Secretary of State for Health if she will make a statement on the provision of night time services by general practitioners. [22856]
Mr. Malone: Night-time services provided by family doctors are integral to British general practice. On 20 April, after discussions with general practitioner leaders, we proposed changes to strengthen services by increasing the support for local GPs working together to offer high-quality care to patients in their area.
Mr. Coombs: No doubt my hon. Friend is aware that the number of night visits by GPs has more than doubled in the four years to last year. Is he fully satisfied that the proposals that the Department has put to the BMA--on which it will vote in the next few days--reflect that fact? How satisfied is he that the BMA will accept what is, on the face of it, a very reasonable proposition?
Mr. Malone: It is perhaps not surprising that, when the hours of night cover were extended some years ago, night
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fees and the number of night visits increased. About 50 per cent. of the increase in visits is attributable to that increase in hours of cover.As GPs across the country decide whether to accept the proposal, I ask them to bear two points in mind. First, it is fair to them; secondly, it is fair to their patients. It will encourage the sort of co-operative arrangement that I saw in Reading, which serves my hon. Friend's constituency. That is certainly one of the possible ways forward, providing first-class out-of- hours cover for patients.
Mr. Bryan Davies: If the services are satisfactory, will the Minister condemn, and take steps to stamp out, the practice of hotels charging their residents for night-time visits when they are taken ill on the ground that national health service provision is inadequate and private doctors must be called in?
Mr. Malone: There is nothing to prevent anyone who is resident in either a hotel or private premises from making his or her own arrangements to seek emergency care.
Mr. Budgen: Is my hon. Friend aware that there is, in general, great satisfaction in Wolverhampton about the way in which GPs provide night-time services? Will he pay a sincere compliment to the hon. Member for Wolverhampton, South-East (Mr. Turner)? For 20 years, in all his observations about matters connected with the health service, the hon. Gentleman has screamed that there is a crisis, and has said that the best way of dealing with that crisis is to spend a large amount of someone else's money. Is he not to be commended for the splendid consistency of his views?
Mr. Malone: His consistency is the equivalent of others who cry wolf too often and eventually get ignored. My hon. Friend makes a good, substantive point--that care in his constituency is good. The proposals for GP out-of-hours cover are designed to improve on that, to reduce the burden on medical practitioners who wish to undertake fewer night visits and to ensure that the quality of care for patients is improved during that important period when they need to call on medical services.
GP Fundholding
7. Mr. Gunnell: To ask the Secretary of State for Health what research her Department has undertaken into the administrative costs of general practitioner fundholding; and if she will make a statement. [22857]
Mrs. Virginia Bottomley: The management costs of general practitioner fundholding are kept under regular review. In the first three years of the scheme, general practitioner management costs were about 2 per cent. of budgets, which represents excellent value for money for the very real benefits to patients resulting from the scheme.
Mr. Gunnell: I am sure that the Secretary of State is aware that the magazine Fundholding , which can hardly be said to be unsympathetic to fundholders, has estimated that the amount spent on setting up the scheme and on administration was £98 million, and that the average cost per fundholding practice is more than £80,000. There is also plenty of research to show that this is a much more expensive way of purchasing for district health
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authorities. Does not she think that the money should have been put into patient care and not into creating an expensive administrative system?Mrs. Bottomley: I do not agree with the hon. Gentleman. I believe, as does the King's Fund, that fundholding has been one of the most exciting aspects of our health service reforms. I recommend to the hon. Gentleman the words of the National Audit Office, the Organisation for Economic Co- operation and Development and Professor Howard Glennerster. They have all confirmed that fundholding has made care much more responsive to patients. The amount spent on management is modest compared with the substantial improvements in patient care and the better value for money that has been achieved by the scheme.
Mr. Quentin Davies: Is my right hon. Friend aware that in Lincolnshire well over 50 per cent. of patients are now treated by fundholding general practitioners? Is not that a remarkable tribute to the popularity of fundholding among GPs and patients, and does not it vindicate the Government's decision to go ahead with this proposal despite the consistent opposition of the Labour party?
Mrs. Bottomley: I commend the example of Lincolnshire, but perhaps the most interesting example is to be found in Derbyshire. In Derby, South, 78 per cent. of the population have fundholders. That shows how persuasive is the Opposition spokesman on health with her local general practitioners, all of whom totally disregarded her words and decided that there were benefits for their patients by taking up the fundholding option.
Mrs. Beckett: Is the Secretary of State aware that managers in some parts of the country are said to be insisting that general practitioners become fundholders and are refusing to provide financial or administrative support to groups of GPs who want to become commissioning GPs although that is a much less expensive and more effective system? Those managers claim to be acting on instructions from the Department of Health. Why?
Mrs. Bottomley: Let me make it clear that fundholding is and will remain voluntary. Undoubtedly, fundholding offers much more direct control to the general practitioner for securing, commissioning and monitoring services than joint commissioning. Joint commissioning clearly has a part to play, but in our view it is not as effective as proper GP fundholding. As the right hon. Lady will know, we have now set up 51 total fundholding projects which are being carefully evaluated to see what further lessons can be learned.
Mr. Evennett: Does my right hon. Friend agree that GP fundholders are delivering a clear benefit to all patients in their areas? Does she further agree that the waiting time for the patients of GP fundholders tends to be shorter and that the opportunity for a better and more varied service in the surgery is greater?
Mrs. Bottomley: I very much agree with my hon. Friend. I hope that he agrees that waiting time for all patients is shorter. Before the reforms there were 200,000 one-year waiters and he will know that there are now only 31,000. That affects all patients, irrespective of whether they have GP fundholders. It is right to say that the
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Opposition do not care. They do not want to know the facts because they might get in the way of the rhetoric. I agree not only with my hon. Friend but with the OECD that GP fundholders have been more prepared to challenge hospital practices and demand improvements. The National Audit Office states:"the direct involvement of general practitioner fundholders in health care purchasing has led to improvements in the service provided for their patients".
Broadgreen Hospital
8. Mr. O'Hara: To ask the Secretary of State for Health if she will make it her policy that the accident and emergency department of Broadgreen hospital will not be closed until adequate alternative facilities are made available. [22858]
Mr. O'Hara: I am delighted to have that assurance. The Minister will be aware, however, that at the turn of the year the accident and emergency department has almost closed perforce due to lack of recruitment of qualified staff. He will also be aware of leaked reports that it was to be closed on 31 July when the contracts of staff recruited in crisis came to an end. Will he ensure that steps are in place to ensure that Broadgreen accident and emergency department is fully staffed to remain open after 31 July? Otherwise, my constituents in Knowsley, South will continue to live in fear and suspicion that the trust in which they have no trust is trying to engineer the closure of the department before adequate facilities are in place.
Mr. Bowis: The hon. Gentleman's constituents can have trust in the trust. One has to consider only the brand new A and E department at Fazakerley hospital, the largest and best equipped not only in this country but in Europe, the £2.7 million extension to the Royal Liverpool University hospital A and E department, and the new £9 million critical care unit at St. Helens and Knowsley hospital, to be completed in April 1996. The pledge is there that the A and E department at Broadgreen hospital will not be phased out until those facilities are in place.
National Blood Authority
9. Mr. Illsley: To ask the Secretary of State for Health when she last met the chairman of the National Blood Authority to discuss rationalisation proposals. [22859]
Mr. Sackville: Ministers meet the chairman of the National Blood Authority regularly.
Mr. Illsley: The Minister will be aware of the national blood transfusion service's continued difficulties consequent upon those rationalisation proposals, the latest of which is the purchase by the NBA of blood-testing kits which are regarded as inferior for HIV and hepatitis testing and are banned in many countries. In the past few months, the level of blood donations has decreased in this country, staff employed in the blood transfusion service have been completely demoralised, many skilled staff have left the service and, above all, there has been a
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complete loss of public confidence in that precious service. Will the Minister advise the chairman of the NBA to abandon the rationalisation proposals once and for all?Mr. Sackville: I am aware of a continuing attempt by the hon. Gentleman to make his political name by undermining the blood service-- [Interruption.] He has continually claimed that blood donations are down, when they are holding at the level of last year. Demand for blood has gone up by 4 per cent. and donations have gone up by 5 per cent. As he knows, the plans to rationalise the blood service are to do with that fact that it has always been run regionally, so there is too much processing and too much testing. We must reduce those overheads on the service.
Dame Elaine Kellett-Bowman: Does my hon. Friend agree that blood centres must be run for the benefit of the donors who give their blood freely and the teams who so devotedly serve them? Does he further agree that nothing whatever in the consultation document, or in anything that Sir Colin Walker has subsequently said, militates against that? Will he further emphasise his comment that the Opposition's political agitation is causing great dismay and is unnecessary?
Mr. Sackville: I confirm that, whatever happens, specialist services, such as the anti-D donors, are being retained in Lancaster. My hon. Friend is right: the allegations have been attempts to be undermine the confidence of donors, but they have failed.
Statistics
10. Mr. Win Griffiths: To ask the Secretary of State for Health what plans she has to change the way in which statistics are collected for publication on activities in the NHS. [22860]
Mr. Sackville: There are no specific major changes in prospect, but each statistical return is reviewed at least once every three years, and every item is subjected to rigorous examination.
Mr. Griffiths: Many people will be disappointed with that reply because a strong case exists for radically overhauling NHS statistics. For instance, does the Minister agree that we should publish statistics on the readmission of patients to hospital so that we can measure the quality of the care that they receive there, the success of the treatment and the availability of good quality community care?
Mr. Sackville: The hon. Gentleman is aware that in England we went over from deaths and discharges to a system of finished consultant episodes some years ago. Wales did not follow at that time, but it is now setting up a patient episode database which roughly mirrors our system. That is good news because the new Ko rner statistics are a proper measure of patient activity.
Mr. John Marshall: Does my hon. Friend accept that, however the figures are collated, there is strong evidence of a shortage of beds in London for the mentally ill, as was discussed in the Adjournment debate last Wednesday?
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