Westminster Hall
Wednesday 21 March 2007
[Hugh Bayley in the Chair]
Specialist Orthopaedic Hospitals and Services
Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Watts.]
9.30 am
Mr. Andrew Smith (Oxford, East) (Lab): I am pleased to have the opportunity to open this debate and to be able to do so with you in the Chair, Mr. Bayley.
I begin by underlining that we are fortunate to have in this country outstanding orthopaedic hospitals and services, with expert and dedicated consultants, doctors, nurses and staff at all levels. They are rightly held in high regard by patients and the public at large.
What is more, thanks to the additional resources that our Government have put in, there has been remarkable progress in orthopaedic provision during the past 10 years. Waiting lists are down, staffing levels are up, and new facilities are taking shape at many orthopaedic hospitals across the country.
In my constituency, the Nuffield orthopaedic centre is moving into a new £42 million state-of-the-art hospital, which will replace outdated facilities and buildings. The wonderful new facilities include a room-sized open MRI scanner, the first of its kind in the world, a best-in-class hydrotherapy pool, a specialist gait laboratory and expanded sports injury and medicine services. All that is alongside the hospital’s Oxford Centre for Enablement, with its specialist services and equipment for long-term conditions, disability and rehabilitation, and the Oxford university Botnar research centre, which is home to the Institute of Musculoskeletal Sciences, and the Tebbit centre.
The hospital and its staff and patients have benefited from substantially increased Government health expenditure and spending on the private finance initiative project that is providing the new building and its servicing, but the fact that the hospital has received significant charitable support from generous donors large and small is also crucial, and reflects the esteem and affection in which it is held locally and throughout the world. During the past 15 years, the Nuffield orthopaedic centre charity has contributed £15 million to the hospital for new buildings, facilities and equipment, including £6.6 million towards the PFI development and £4.5 million for the Botnar research centre.
So we have a remarkable hospital with remarkable staff and remarkable public support. Similar stories can be told about the UK’s other specialist orthopaedic hospitals; for example: the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, which came out as one of the top trusts nationwide for standards of care and professionalism; the Royal Orthopaedic hospital in Birmingham, which is an internationally renowned centre of excellence for the diagnosis and treatment of bone and soft tissue cancers; the Royal National Orthopaedic hospital in Stanmore, another great centre of excellence, which trains 20 per
cent. of the UK’s orthopaedic surgeons, and the Wrightington hospital, which serves the Minister’s area and is now merged with the Wigan and Leigh NHS trust.
Those first-rate hospitals, which are committed to providing the best orthopaedic services through the NHS, are at the leading edge of best practice in medicine. We must ensure that they are sustained and developed for the future. I know that the Minister and the Government as a whole want that, but it is such a tragedy, with so much happening that is good, and with such committed staff and public support, that a dark shadow of financial uncertainty still hangs over those centres of excellence because of the failure, over a number of years, to resolve the national tariff question and fairly pay hospitals for the specialist and complex work that they do.
We were able to touch on the issue briefly in a Westminster Hall debate two weeks ago that was initiated by the hon. Member for Wyre Forest (Dr. Taylor), in which my hon. Friend the Minister stated:
“I understand the situation in which those providers find themselves and the argument that they make about the costs of providing specialist orthopaedic work not being adequately reimbursed through the tariff. I understand that point. The process of payment-by-results will refine and improve as we progress so that there can be a further differentiation between high-value work and work that can be provided at a lower cost. I recognise the need for a sustainable solution.”—[Official Report, Westminster Hall, 7 March 2007; Vol. 457, c. 496WH.]
My hon. Friend referred to a recent meeting that he and the Secretary of State for Health had with the trusts concerned, and their commitment to work towards finding a solution. I know that he subsequently initiated a consultation on the development of payment by results, including fair payment for specialist services. I welcome that commitment and the consultation, but I want to take this opportunity to underline just how imperative it is, for both the care of patients and fairness to the hospitals concerned, that a solution is found as soon as humanly possible.
The existing top-up funding from the Department of Health, with additional funding for 2007-08 from primary care trusts and strategic health authorities, has provided some respite, but the hospitals are still left grappling with uncertainty about future finances, which is debilitating, demoralising and damaging. I would like to stress some of the key dimensions of that. The exact impacts vary from trust to trust, depending on their combination of standard, specialised and highly specialist work, but common pressures and uncertainties are at work. What is particularly galling for all who care about the hospitals is that the difficulties are not of their own making but arise from the incomplete policy framework within which they must operate.
First, all trusts are obliged to seek foundation status. However, because the specialist tariff question is unresolved, those with a high proportion of specialist work cannot demonstrate future financial stability to meet the criteria. They have been placed in a classic Catch-22 position. The Robert Jones and Agnes Hunt trust has had to delay its foundation application because of that, and the Nuffield orthopaedic centre was turned down in wave 1 of foundation applications for that reason alone.
Secondly, much-needed facilities and service improvements are being delayed. For example, at the Royal National Orthopaedic hospital, the business case for replacing its outdated Nissen hut accommodation has been turned down by the strategic health authority—again, because of financial uncertainty arising from the tariff problem.
Thirdly, relations with independent sector treatment centres risk being damaged. The specialist orthopaedic centres have gone along with the introduction of ISTCs and the extra capacity that they have brought on stream, but they now find themselves in the galling position of being paid below cost for complex treatments, which ISTCS cannot undertake, while ISTCs are guaranteed premium payments for routine work that, in some cases, is transferred from specialist hospitals.
I and, indeed, the medical staff at the Nuffield have defended the contribution that pluralism in provision can make, notably to increasing capacity and cutting waiting lists, but there must be a level playing field, and an absolute requirement for parcelling out the more routine work is fair remuneration for the complex work that only specialist centres can undertake. Neither of those conditions has been satisfied at present.
Fourthly, there is a worry that the vital training and education that the specialist centres provide will be damaged unless their financial and operational viability is properly secured. That concern is compounded by the challenge of retaining a sufficiently wide mix of work, particularly the routine and specialist work of the orthopaedic centres, in the volumes that are vital to train surgeons and specialist nursing and support staff properly. Any consultant at an orthopaedic centre will say how worried they are about that issue and its implications for the future.
Several other issues have a bearing on patient care and the economics of health provision, which are relevant to this debate. Specialist orthopaedic hospitals are at the forefront of good practice in limiting infection rates in hospital and reducing unnecessary lengths of stay, which are crucial to patient care and the wise use of resources. We need more of that expertise, not less. Infection rates for knee replacements across the UK as a whole are about 3 per cent. and there are 1,800 such cases a year. As well as the human cost to patients, each of those cases costs about £80,000 to put right, which has a financial cost to the NHS of £146 million a year. If we could get that infection rate down to the average in the specialist orthopaedic hospitals, where it is 0.2 per cent., there would be 120 infected knees a year at a financial cost of £9.6 million, which is a potential saving of £146 million a year. That would also have benefits for patients.
Similarly, the specialist hospitals have a remarkable record on lengths of stay, especially considering that the complex nature of much of their work might be expected to lead to longer than average stays. However, across 18 procedures monitored by the Specialist Orthopaedic Alliance, the percentage of procedures where the length of stay was less than the national average was 83 per cent. at the Robert Jones and Agnes Hunt trust, 78 per cent. at Wrightington, Wigan and Leigh NHS Trust, 72 per cent. at the Royal Orthopaedic Hospital NHS Foundation Trust and the
Nuffield Orthopaedic Centre NHS Trust, and 67 per cent. at the Royal National Orthopaedic Hospital NHS Trust. Those hospitals are all examples of good practice and provide real benefits to patients and the NHS.
Lastly, I warn against a merger with district general hospitals as a reaction to the financial uncertainties facing specialist orthopaedics. Such mergers are not a solution to the present shortcomings and financial problems created by the absence of a realistic tariff. A merger in those circumstances would mask rather than resolve the underlying problems. In the case of the Nuffield orthopaedic centre, a merger with the John Radcliffe hospital, which has difficult enough challenges of its own to deal with, would mean either cutting back on specialist orthopaedic treatments, or, given that much of the routine work is carried out by ISTCs, cross-subsidising specialist treatment from non-orthopaedic work. Neither cutbacks nor cross- subsidy would make any sense and would not be in patients’ interests. We need to tackle, sort out and get right the underlying challenge of fair remuneration for the specialist work itself.
Infection rates are significantly higher on average in district general hospitals and service integration between specialist orthopaedic centres and district hospitals would raise real worries about the risk of orthopaedic infection rates going up, which would damage patient care and add to NHS costs. If management teams only were merged, the savings would not amount to much as studies show that orthopaedic managements perform well in comparison with acute trusts.
It is conclusive that specialist orthopaedic hospitals play a vital and distinctive role in the NHS. They represent a precious national and local resource that is rightly held in high esteem by patients and the public. Such hospitals will have a crucial role in the future. With an ageing population, people are, wonderfully, able to live longer and healthier lives and are having hip, knee and other joint replacements. Such operations will have to be revised or replaced in the future. Pressure on orthopaedic services will increase, and we will need our specialist centres more than ever. We should value such centres in deed as well as in word, and act now to sort out the tariff, treat those excellent hospitals properly, and ensure that they and their dedicated staff are secure for the NHS and its future patients.
9.45 am
Mr. Richard Benyon (Newbury) (Con): I apologise for being unable to stay until the end of the debate, but I shall make a brief contribution. I congratulate the right hon. Member for Oxford, East (Mr. Smith) on securing the debate and on his fantastic work setting up the all-party group on specialist orthopaedic services and hospitals, of which I am a member.
The right hon. Gentleman spoke about the Nuffield orthopaedic centre in Oxford, which is a facility that serves my constituency in west Berkshire. It is of the highest standard and achieves fantastic outcomes for patients in my constituency and many others in the area, and I am speaking today in order to support it. I want to make one major point: we must resolve the issue of providing trusts with adequate recompense for the work and costs of caring for people with complex orthopaedic disorders. Under payment for results, there
was a simple nationally set tariff. It is clear that for specialist orthopaedic facilities, a nationally set tariff is a blunt weapon and provides a broad-brush approach that simply does not deliver the results necessary for such organisations to survive.
We were told by some of the organisations that we are trying to help today that
“an operation to save the limb of a patient with bone cancer may cost £7,600”,
but under the nationally set tariff that
“attracts a payment of only £1,700”.
When those figures are spread out across the country, the problems we are facing become clear. Such organisations have also said that an amputation, which costs around £8,500, is inadequately reimbursed under the tariff and that
“A patient with a history of hip dislocation work and corrective surgery, needing a hip replacement in her mid-40s may cost a hospital up to £14,000 for the hip operation but attract a payment of only £5,000.”
I hope that the Minister will respond to those points.
One of the consequences of the difficulties faced is that specialist orthopaedic hospitals are unable to plan for the future. Slow progress on resolving the tariff issue is preventing some trusts from making long-term plans to improve their service. We have already heard about the problems at Stanmore, where there are 1940s Nissen huts. There is great concern at the NOC in Oxford about where it will be in four or five years’ time. We all know where it wants to be, and as the right hon. Gentleman has pointed out, the services that it provides are of great long-term benefit to the national health service, because they reduce the costs of hospital-borne infections. The NOC is doing exactly the Government’s bidding by developing the NHS in specialist terms, and unless we can resolve the problems the uncertainly surrounding its future will not be resolved.
The way forward is to resolve the tariff situation. I know that the Specialist Orthopaedic Alliance is working with the Department of Health, but the negotiations are taking a long time. I hope that the Minister can demonstrate today that he is injecting some leadership into resolving the problem.
I conclude by making two vital points. The first, which was touched on by the right hon. Member for Oxford, East, is about hospital-borne infections. We have heard that the infection rates are much lower in orthopaedic facilities. If that rate can be achieved across the NHS, the Government will have done remarkably well.
The Minister of State, Department of Health (Andy Burnham): It is important to recognise that the hospitals that we are talking about today do not have accident and emergency departments, which is a crucial difference when it comes to managing infection in hospitals.
Mr. Benyon: I entirely accept that. However, unless the problem can be resolved—the future of some centres seems to be in doubt—where would those patients then go for treatment? They would have to go to the district general hospital. The vast majority would probably be treated very well, but the risk of infection would increase.
My final point is that resources have a major influence on the NHS in other respects. As a teaching hospital trust, the Nuffield orthopaedic centre in Oxford provides a large number of placements and fellowships for student doctors, nurses and other health care professionals in training, who benefit from the expertise and experience of some of the most skilled clinicians in the world. It would be a tragedy if a failure to resolve the problem were to result in the loss of that fantastic resource to the NHS.
9.51 am
Mr. Neil Turner (Wigan) (Lab): I congratulate my right hon. Friend the Member for Oxford, East (Mr. Smith) on securing this debate. He raises an important issue and I wholeheartedly support all that he said. He outlined exceptionally well the difficulties that face all such hospitals, especially their financial stability both now and in the future. I fully agree with all that he said.
I turn specifically to the problems at the Wrightington hospital in Wigan. It is somewhat different from the others in that it is the only specialist orthopaedic hospital attached to an acute hospital trust. I shall give a little background information about the hospital. It started as a TB sanatorium before becoming a specialist orthopaedic hospital in the 1950s. It was one of the pioneering orthopaedic hospitals. Indeed, the first ever hip replacement operation was carried out there by Dr. Charnley. For many years it was a stand-alone orthopaedic hospital.
In the late 1990s, the Department of Health made a move to merge the Wrightington hospital with the then Wigan and Leigh acute hospital trust. That was opposed by the clinicians and administrative staff at Wrightington, who felt that it would be better as a stand-alone hospital. The Wigan and Leigh hospital board thought that it was marginally okay to merge, and the hospitals eventually merged in 2001. I emphasise that the merger was made at the request of the Department of Health but that it was opposed by the Wrightington people, and that the Wigan and Leigh people acquiesced under pressure. That is an important point, and I shall give the reasons later.
In the past, the Department of Health expressed a number of concerns about the way in which the Wrightington hospital was being run—rightly so, because many of the hospital’s operational statistics were not good. The management and the clinicians sat down together and worked out exactly what they should do and how they should do it in order to ensure that the hospital improved.
The hospital now has additional operating theatres and wards, elective surgery is 16 per cent. better than a year ago, and non-elective surgery is 9 per cent. better. The 11-week out-patient target has been met; next year it will be reduced to nine weeks. The 20-week in-patient target will be achieved by the end of this year. Suspensions from lists—those taken off for non-medical reasons—are down by 75 per cent. A one-stop shop has been opened in the hospital to help ensure that people receive the proper treatment quickly. The wait for follow-up appointments has been dramatically reduced through the use of additional staff. The deficit at the hospital has been reduced from £3.4 million to £1.1 million.
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