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Specialist Surgery (North-West Kent)

1 pm

Dr. Howard Stoate (Dartford): Last month, the Government announced an expansion in day surgery in the national health service, a welcome decision given the lengthy waiting times for most elective operations.

In 2000-01, according to the Audit Commission, the average wait for day-case patients needing cataract operations was 163 days, for hernia operations 84 days and for varicose vein operations, 154 days. Furthermore, critics of the NHS often do not recognise that the demand for operations continues to increase. The United Kingdom has an ageing population, which is reflected in the increasing amount of resources that the NHS must set aside each year for treating and managing chronic conditions and performing elective surgery.

More operations than ever before are being performed; for example, in 1994 there were 145,000 cataract operations, in 1999 there were 200,000 and about 250,000 are expected to be performed next year. However, unless we are prepared to carry out a far-reaching overhaul of the way in which surgery is carried, demand will continue greatly to outstrip supply.

A report by consultants from Moorfields eye hospital, published in the British Journal of Ophthalmology in the year 2000, warned of the escalating problem of visual impairment in the UK. The report concluded that by the beginning of this year the number of people with impaired vision needing some form of surgical intervention would reach 2.5 million and many of them would die before they had the operation. That is especially regrettable given the reduction in the quality of life caused by impaired vision, especially in elderly people.

Unfortunately, the UK is not the only country facing this problem; hundreds of thousands of patients in France and Germany are in a similar position, and even their much-vaunted health systems leave thousands of patients untreated each year. Indeed, no health system, however generously resourced or efficient it is, will ever eliminate the problem of unmet need. A constituent who came to see me recently mentioned the German system, which we hear is well resourced and has no waiting list, yet her sister had waited eight months for a hip replacement in the private sector. It is not only a problem in the UK; other countries have similar problems.

Nevertheless, there is no doubt that the way that elective surgery is managed in this country can and should be improved, as the Government have said. Too many patients wait too long for treatment. For example, last year a quarter of patients in north-west Kent waiting for an ophthalmology appointment had to wait in excess of six months to be seen. Several patients, having eventually been given a date for cataract surgery, had their operations cancelled at the last moment because their bed or theatre space was needed for an emergency.

For an elderly and often vulnerable patient, such a scenario is stressful and confusing. It is also extremely frustrating for the patient's family, who have to prepare their mother or father once again to face an operation, having already had to deal with the problems caused by their impaired vision, perhaps for many months.

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Patients and their families ask why they should have to wait so long for what is in most cases a routine and relatively straightforward procedure. They also ask why there are such glaring local variations in the way that elective surgery is managed. Why do some trusts have measures to ensure that day surgery cases and planned operations are not cancelled for emergency cases and others not?

Plans by Darent Valley hospital in my constituency to begin 24-hour surgery, with six beds specifically ring-fenced for patients requiring routine operations such as hernias, varicose veins and urological procedures, are an example of innovative thinking, which needs to be more widely replicated in the NHS. The new service, which is being supported by a dedicated nursing team, is being funded for 12 months by the winter emergency services team, and will allow 30 extra patients each week to receive treatment. Darent Valley hospital is the first hospital in Kent to provide a dedicated, stand-alone unit for intermediate and elective surgery. That is welcome and essential. I have been in touch with the hospital over the past few months, and I have recent figures about its latest situation.

The Minister will know that Darent Valley hospital was zero-rated and has faced significant problems. However, I am pleased to tell those in the Chamber that there have already been noticeable improvements. The number of patients waiting more than 26 weeks for an out-patient appointment has reduced from 501 to 117 in the past four months. The total number of patients waiting for more than 13 weeks for an out-patient appointment dropped dramatically from 2,160 in March 2001 to 654. That is a huge and welcome improvement in waiting times for out-patient appointments.

The worst problem faced by the hospital is the waiting list for in-patient procedures. The total number of patients waiting for an in-patient appointment is still 3,500 and has not dropped significantly over the past year, despite the trust's best efforts. The hospital has successfully reduced the wait for an out-patient appointment, but there are still huge backlogs on in-patient appointments, which is causing it great difficulties.

The new unit will allow the hospital to fast-track elective surgery cases and to ensure that all patients are seen within the year. Some 5 per cent. of patients have to wait more than 12 months. The new unit will also ensure that more patients are treated within the Government's target period of six months, which the hospital is finding challenging. The scheme is welcome and will significantly improve the situation. The drawback of the scheme is that it is only a temporary measure. The trust does not yet have funding to keep the unit open beyond next year, and has no resources permanently to operate its theatres around the clock. Although the winter and emergency services team funding is valuable, it underlines this country's ad hoc and inconsistent approach to elective surgery.

Occasional batches of funding for individual trusts are not the answer. Every trust in the country must look closely at the way in which it conducts elective and intermediate surgery, and must work hard to identify new ways of ensuring that patients do not wait as long, and get a better overall quality of service. Just as important, the Department of Health and the

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NHS Modernisation Agency must ensure that trusts are given the necessary resources and support. After all, what bothers patients who are waiting for elective operations is that under the current system they are made to feel like third-class patients. The quality of care that they get may be good, but naturally they feel aggrieved because it is made clear to them that their condition is of low priority, and that their treatment will be fitted in as and when circumstances permit. Their condition may not be life threatening, but it precludes them from enjoying quality of life, so why should they always be sent to the back of the queue?

There is no question of blame, and I am not attacking anyone. My point is simply that patients who are on routine waiting lists are often made to feel that their case must wait for the more urgent ones. They ask, quite reasonably, why that must always be so. This is why dedicated, stand-alone elective surgery units are a way forward. They ensure that patients awaiting elective operations enjoy the same access to health care as any other NHS patient does.

Dedicated units have operated effectively in the United States of America for many years. According to one US surgeon writing in the British Medical Journal, they have become such a fixture of the US health care system that in some cases they are threatening the viability of neighbouring general hospital units. One surgeon said that the dedicated unit was remarkably efficient. Its four theatres and fluoroscopy room performed 250 surgical and 200 interventional pain management procedures each month without operating at weekends or evenings, and without running at maximum capacity. The range of its care included orthopaedics, such as joint arthroscopy, cruciate ligament, shoulder reconstructions and extensive arm surgery. It also included general surgery, such as "lumps and bumps" and hernia repair, cosmetic surgery and invasive pain management. A neighbouring facility catered for common ear, nose and throat conditions and for ophthalmologic surgery.

Of course, specialist fast-track units are not suited to the needs of every patient. Patients with multiple health problems who need treatment from a range of services and specialisms will still need to be treated under the current system. Nevertheless, there is no doubt that for most patients, dedicated fast-track units are a viable option. Specialist units can operate throughout the week, at weekends as well as nights, provided they have proper support and are well integrated with other hospital facilities so that all the relevant services can be accessed easily and quickly at all times. They would cut swathes through our waiting lists in a short time.

The Royal College of Surgeons is backing the idea. The ex-president of the college—Sir Barry Jackson—said that the idea of ring-fencing elective beds and adopting more flexible working patterns should be embraced by the profession and promoted, providing there is an adequate number of surgeons and support staff to make it possible.

The British Medical Association also said that the concept of dedicated fast-track units was a welcome contribution to the debate about reducing time spent by patients waiting for elective surgery. I am therefore pleased that the Government announced last year their intention to build 26 fast-track units by 2006 as part of their latest hospital building programme. Will 26 units

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be enough to make a difference, given the rapidly increasing demand for elective surgery? There is a good case to be made for a dedicated unit of that sort to be built in north-west Kent, which is a fast-growing area where there is already a high demand for elective procedures. What will we do while we wait for the programme of elective units to come on stream, supposedly in 2006?

Plans by Dartford and Gravesham NHS trust to ring-fence beds for elective surgery and to explore the viability of 24-hour surgery is one way of ensuring that patients awaiting elective procedures are seen more quickly. Another possible approach would be to employ surgical teams from abroad on short-term NHS contracts. I know that it is extremely controversial but only last week I received a letter from a German health association that said it could provide the NHS with a complete surgical team able to carry out a wide range of elective and intermediate procedures. Clearly there would be all sorts of issues but they would be working in NHS hospitals, with NHS staff and NHS equipment, on NHS patients. It is worthy of consideration. Currently there are not enough surgeons and nurses to cut through the backlog of waiting lists as fast as we would like. It might be a way of reducing some of the problems.

As many of our operating theatres are not capable of operating round the clock because of manpower and resource restrictions, it would seem sensible to examine such ideas as a means of clearing our surgical backlog at regular intervals. After all, most patients would much prefer to be treated in an NHS hospital, which is close to home and a familiar environment, than to have to fly abroad for treatment. While I am pleased to see real and tangible efforts being made to cut elective surgery waiting lists, we can and need to go further. With the demand for elective procedures likely only to increase in the next few years, we have to ensure now that we have the right sort of surgical regime in place so that the NHS has the capacity to deal with the problems effectively.

I have worked in the NHS for a long time. I believe that I am the only MP who currently carries on any medical practice. I therefore have a lot of experience with the way that patients deal with the NHS and the way that they handle their care. Patients, generally speaking, do not complain about the care once they receive it. People who have heart attacks or get pneumonia go to hospital and are treated very quickly and generally are extremely appreciative. Patients complain not about emergency care, but about the length of time that they have to wait for non-emergency care. That is the biggest problem that the NHS faces.

There are currently three problems. One is increasing demand. We call it a problem but I am not sure that it is. People are living longer and the population is ageing. It has been shown that men in particular will spend the last 15 years of their life with a chronic or disabling illness. That is a long time. Many of those chronic and disabling illnesses are amenable to surgical intervention. If we could reduce the number of people waiting, we could improve the quality of life for millions of people by operating on them when they need it. I see it not as a problem, but as an opportunity. People are living longer: they are coming forward with more illnesses and they have more treatable conditions. It is up to us to ensure that they get that treatment.

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The second problem that the NHS faces is its inability to predict accurately how long people must wait. They are told that they will have to wait six or nine months for their operation but cannot be given an accurate figure. The hospital cannot predict how many operations it will carry out in a given week because it cannot predict how many emergencies it might have to deal with that would eat into that list.

The third problem is the low priority given to routine cases. Hospitals have to make emergencies their priority, but the corollary is that people who are not emergencies see themselves as a nuisance and insufficiently ill to merit the treatment that they want. That is unnecessary and unhelpful. Operations are postponed for very good reasons but it causes huge disruption for families. The Government should look at the overall picture of the disruption not only to the family, but to the staff and the patient and the overall costs. Someone needing a hip replacement will be virtually incapacitated. If they had a hip replacement they could become productive members of society. If we examined the overall cost to society of a patient on a waiting list, we might discover some interesting figures.

In conclusion, we have to change the culture and move towards an NHS that is seen to view people as a high priority, seen to provide the right treatment and seen to predict when an operation should take place. If we can produce a culture in which people no longer view themselves as a nuisance, but as part of a system to provide treatment in response to their needs in a timely fashion, everyone will be more satisfied. I urge the Minister to reflect carefully on the plans that I outlined and assess whether any mileage can be gained in progressing them further. I look forward to hearing her response.

1.15 pm

The Parliamentary Under-Secretary of State for Health (Yvette Cooper) : I congratulate my hon. Friend the Member for Dartford (Dr. Stoate) on securing this debate and on his thoughtful speech about the direction of reform for the NHS. Much is happening, but more progress remains to be made. My hon. Friend clearly speaks with great authority and commitment. He is right that this subject does not always secure the most attention from the public or the media, yet it is a vital issue for many thousands of people every day.

Last year, more than 6.5 million elective operations in NUS trusts took place in England and nearly half were day case operations. As my hon. Friend said, these operations matter immensely to people's quality of life and the effective delivery of elective surgery is crucial to delivering the in-patient waiting time target set out in the NHS plan and rightly so. We all want top quality emergency care when we need it, but we also want to know that routine treatment for quality of life and our ability to carry on living our lives to the full is delivered as speedily as possible.

My hon. Friend is right to raise issues about the separation of elective and emergency care as part of the modernisation of services. Equally important is the role of the Modernisation Agency in improving the delivery of care at trust level and spreading good practice

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throughout the NHS. The success of the national booked admissions programme is also important. By 2005, it will allow GPs to book hospital appointments at times convenient to the patient. It is not just about better management of elective surgery and patient treatment throughout the NHS, but about addressing the frustration of patients who do not know when their appointment for needed surgery will take place. Shaping the services around the needs of patients as well as more efficient care is necessary.

In north-west Kent, some measures are already under way to increase the optimum use of bed capacity and ease the pressures placed on elective surgery by emergency care. The new Darent Valley hospital, opened by my right hon. Friend the Secretary of State in December 2000, was linked closely to the development and implementation of new models of care around a "closer to home" strategy, which supports additional capacity in the non-acute setting.

In the past year, the trust and primary care trust rolled out initiatives to support these new ways of working with an increasing emphasis on that strategy. For example, the stroke rehabilitation team reduced the length of stay of rehabilitative patients from an average of 21 days to an average of seven. The intermediate care team worked to prevent the need for hospital admission by working directly with the medical assessment unit and accident and emergency departments. Additional intermediate care capacity was freed up at the Livingstone hospital and the orthopaedic bridging team in the acute trust allowed the team to treat around 10 per cent. of total orthopaedic admissions, thus reducing the average length of stay of patients in the acute setting. Of course more remains to be done, but it is important to recognise progress.

My hon. Friend spoke about elective centres, but I want to speak about the national position on diagnostic and treatment centres before I deal with his points about north-west Kent. Diagnostic and treatment centres are a new, more appropriate way of delivering elective care. They can carry out a wide range of elective work and, by moving elective patients out of acute centres and into dedicated units, they free valuable emergency and critical care beds. They are separate units, not disrupted by other parts of the hospital, so patients can be treated quickly and efficiently and in an appropriate environment. Often, the centres are on the hospital site and so appropriate treatment in emergency or critical care units is available. However, as my hon. Friend said, there are a variety of DTCs in other countries and we need to learn from their experience, too.

A diagnostic and treatment centre is defined as a dedicated unit providing safe, high-volume, elective diagnostic and treatment services, with its work separated and protected from emergency pressures. DTCs are capable of delivering a wide range of services. How they develop in an individual hospital trust will be influenced by a variety of factors, including the potential impact and reliance on other hospital services. Careful consideration must be given to those factors in each individual instance, but there are some core elements that we expect all DTCs to provide.

First, elective or scheduled care must be separated from emergency care, with both diagnosis and treatment usually provided. Secondly, the centres must focus on effective work processes for maximum efficiency to

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make possible the speedy treatment of as many patients as possible. Care must be co-ordinated among medical and surgical specialities, and across all disciplines. Fourthly, they must provide a service focused around the patient, with prompt and convenient access and reliable booked appointments. As my hon. Friend made clear, patients' concerns and experiences must be addressed when considering the routine surgery that they need.

The booked admissions programme is a crucial part of the DTCs. It should mean the abolition of waiting lists for hospital appointments and admissions. Patients should receive a choice of convenient times within a guaranteed maximum waiting time. If the current trend in the growth of GP referrals continues, it will halve the maximum waiting time for a routine appointment, with the average waiting time for out-patient appointments also falling in line with the targets in the NHS plan.

The DTCs and the booked admissions programme will have a major impact on elective surgery throughout the NHS. The DTCs also have an important part to play in achieving the targets in the NHS plan. As my hon. Friend said, we have already announced a series of diagnostic and treatment centres. A target of 20 was set out in the NHS plan, with eight fully operational and treating 200,000 patients a year by 2004. The plan states:

My right hon. Friend the Secretary of State announced plans for 26 DTCs in February 2001. That announcement put us well on course to exceed the target that I mentioned a moment ago. Work is progressing to ensure that those deliver, through tight project management and, where necessary, intense and early process redesign. They will work with the NHS Modernisation Agency as part of its programme.

My hon. Friend asked us to go further and I agree that we need to do so. The Government are considering ways to extend the DTC programme to areas including the south-east and, if possible, bring it forward. We have an ambitious programme for centres throughout London and the south-east and we will consider any suitable proposals to benefit even more patients.

We are already working with the London and south-east regional offices to identify additional diagnostic and treatment centre sites. We aim to have at least four schemes up and running in London and the south-east by the end of this year. We will encourage all proposals if they offer an appropriate response to local needs and quality and value for money. We will look to the new strategic health authorities to oversee the strategy and development of diagnostic and treatment centre proposals. They will work with local project teams to establish when the proposals should move forward.

We are also developing a process for further proposals to receive approval. We shall consider future proposals, including those from the new Kent and Medway health authority, which will no doubt need to take a strategic view of the delivery of services for Kent and Medway as a whole. At the launch of the diagnostic and treatment centre programme on 6 February this year, further expressions of interest were sought from

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trusts that wish to participate in the second wave of diagnostic and treatment centre expansion. We expect more interest and we shall look to the Modernisation Agency to support applications.

It is only appropriate, of course, that the first decision about where DTC sites are located should come from the future strategic health authorities. Obviously, the Kent and Medway health authority will need to explore with all the acute trusts and the nine PCTs the current capacity constraints within the area. Strategic decisions will need to be taken about the future delivery of services, but I understand that a provision of a diagnostic and treatment centre to serve the population of Kent and Medway to increase elective capacity is one of the options that is being considered.

Discussions will need to take place on an area-wide basis to determine the most appropriate site and the most appropriate way forward. If developed, a diagnostic and treatment centre could relieve pressure on not only the Darent Valley hospital, but other providers. My hon. Friend asked what should happen while the development of diagnostic and treatment centres takes place. He mentioned the present work in his local hospital. He is right that, due to constraints on capacity as a result of an increase in emergency admissions and delayed discharges, the trust has reduced the number of cancelled operations by protecting six beds for intermediate dependency elective surgery. Those beds are being used for patients on the in-patient waiting list, whose operations require them to stay overnight.

Non-recurrent funding from WEST—the winter and emergency services team—will maintain that service for 10 months from the end of February this year and will allow 30 patients a week to access surgery. That amounts to 1,380 a year from a current waiting list of 3,500 patients. By targeting the patients with the greatest clinical need whose operations make them most suitable for such care, it will enable the trust to make considerable progress.

The trust is negotiating with the PCT to ensure that funding is provided on a recurrent basis for the remainder of the year and beyond. Clearly, it is for the local economy to decide how best its local targets should be met and the best way in which to provide the service. My hon. Friend is also right that we shall need to look at other innovative ways of improving elective surgery and reducing waiting times in the meantime, such as introducing the booked admissions programme and recruiting staff from different places, including abroad.

We are only too aware of the pressures on the NHS system. Perhaps too often, the media focuses on the accident and emergency programmes and emergency care. We have taken steps to deal with those pressures and to improve emergency care by making more money available and introducing reforms to improve the patient experience, whenever we can. We need also to keep high in our minds the work that is being done to improve the support for those who need routine treatment. We must look to how we use new methods of working and how to make the best use of modern, more sophisticated technology. That is clearly about expanding capacity and investing the additional resources, where needed, and also most crucially about reforming the way in which we provide services and ensuring that the additional resources are put to best

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use. We must use that work to make the greatest possible impact on people's lives and, especially, patients' lives.

I hope that my hon. Friend will feel that considerable progress is being made in diagnostic and treatment centres throughout the country and that there is the potential for a big difference for his constituents and those who use the specialist elective surgical services throughout north-west Kent.

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