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8.14 p.m.

Lord Rea: My Lords, my noble friend has revealed a sad and serious catalogue of errors. It is hard to believe that a management team could have miscalculated so often, and gone against professional advice. It has been said, with some justification, that one possible beneficial effect of the Government's NHS legislation has been to remove decision-making power from the vested interests of the hospital consultants and move it to managers

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acting on behalf of patients and communities. But in South Birmingham that policy seems to have misfired totally.

What has happened is the equivalent of a ship dropping its pilot while it is still going through a dangerous passage, full of rocks and dangerous currents, and handing the wheel to the purser who is more skilled in financial calculation than navigation. However, even in financial terms, the Birmingham managers have managed to run the ship aground.

A further example of that, which was given to me by an orthopaedic surgeon, is the decision of the managers to ignore a carefully costed plan put forward by the clinicians concerned accepting that the famous Birmingham Accident Hospital had to be closed but proposing that the Selly Oak Hospital be the site of a new burns and trauma unit. However, that plan was rejected. The general hospital was chosen as the site for the accident and burns service which was created there at a cost of some £4 million. However, after less than two years the decision has been taken to resite the unit at Selly Oak, as originally proposed by the professional staff involved, at a cost of some £6 million.

While the bulldozers are now pulling down the old accident hospital, and patients are being treated at a new unit at Birmingham General Hospital, contractors are building yet another new unit at Selly Oak. That has meant a loss of £4 million of taxpayers' money. That is at a time when the grave shortages, redundancies and bed closures which my noble friend described are taking place. The situation has become so uncertain that, as my noble friend pointed out, a number of senior clinical staff have resigned or taken early retirement. Among those are two general surgeons, Mr. Geoffrey Oates and Mr. John Harman, who have been re-employed in a private hospital which receives patients who cannot be accommodated at the acute unit. Despite that, as my noble friend pointed out, South Birmingham has a waiting list which has been increasing steadily.

I turn now to primary care which, as the Minister knows, is my own field. One of the key features of the RHAs Looking Forward ... Moving Ahead strategy was the development of primary care. That involved, in particular, improving practice premises and increasing the number of nurses. But funds are needed for that, some of which were to come from the savings being made in the acute unit. However, as my noble friend pointed out, so rapid has been the run down of beds, and so great has been the disruption of services as a result, that money has had to be diverted to the private sector to contain the increasing size of the waiting list.

As a result, improvements in primary care have hardly been noticeable, except perhaps in fundholding general practices. Incidentally, in creating multi-fund administrative units of a rather luxurious nature, they seem to have no shortage of funds. Fundholders' patients are partially cushioned from the results of the administrative bungles which have been described--a further example, if one were needed, of the two-tier system that the fundholder scheme has created. Sadly that is a case of "to he that hath shall more be given", since poorer districts with the greatest health needs have the lowest proportion of GP fundholders.

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In South Birmingham £500,000 has also been taken from the allocation for the psychiatric services--an area in need of more, not less funds--to buttress the acute unit in its difficulties. One answer often proffered by the Government --I have heard this from the Minister--when it is said that there has been too great an increase in the numbers of managerial staff, is that the NHS was previously undermanaged. The South Birmingham story shows, however, that far from improving services for patients these new managers have made them worse and wasted huge sums of public money in the process.

8.20 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I am grateful to the noble Lord, Lord Howell, for this opportunity to debate with the select group here tonight the health services in South Birmingham. Although the Chamber is not crowded, I recognise that the subject is of enormous concern to the people of Birmingham. There has been room for misunderstanding and therefore I welcome the opportunity to go into some of the issues tonight.

As your Lordships will be aware, South Birmingham has been dogged with financial problems since its inception in 1991 when it was created out of the merger of the old Central and South Birmingham Health Authorities. I do not wish to retread old ground as to why the financial problems occurred or why it took so long for them to be rectified. As the noble Lord said, this has been thoroughly investigated by the Public Accounts Committee and was covered in detail in its 36th report, which was published last July and to which the Government responded via a Treasury Minute on 18th October 1994.

The Department of Health and West Midlands Regional Health Authority have accepted that senior managers failed to resolve the financial problems within South Birmingham Health Authority in the prescribed timescales.

New senior management teams for both the South Birmingham Acute Unit and South Birmingham Health Authority have been recruited and together they will work to resolve the immediate financial problems and ensure that the acute unit achieves a balanced income and expenditure position by October 1995. It will be announced tomorrow that John Boyak will be appointed chief executive of the acute unit and therefore both teams are fully appointed.

In parallel with these changes, new and exciting developments have also been taking place across Greater Birmingham. We should not lose sight of those. Your Lordships will appreciate that, as South Birmingham is an integral part of the city and comprises one of its two health authorities, anything that affects Birmingham as a whole has equally strong implications for health services in the South Birmingham conurbations.

Many cities throughout the country are becoming aware of the growing need to plan their health services so that they take account of today's rapidly changing demands and in doing so are in a strong position to carry

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them forward into the next century. As the noble Lord, Lord Rea, will know only too well, medical science and clinical practice do not stand still and we need to be aware of developments and harness them. That is good management and better quality care for patients.

Birmingham has recognised this need and accepted the challenge. On 9th December 1993 the health authorities in Greater Birmingham jointly published a discussion document called Looking Forward. This sets out broad proposals for reshaping health services in the city by recognising the important changes that are taking place. I assure the noble Lord, Lord Rea, that among those changes are plans to enhance and expand primary care.

I am well aware that in developing its health care services Birmingham has had many false starts. It is an enormous task and quite understandably local people have a right to be sceptical over this latest attempt. However, it was with this scepticism in mind that the Greater Birmingham purchasers ensured that Looking Forward was subject to as much public discussion and consultation as possible. They listened carefully to local people's views and amended the proposals to meet their concerns.

On 1st July the West Midlands RHA announced the outcome of these consultation exercises. None was formally opposed by the Birmingham Community Health Councils and this meant that the planned £100 million plus investment programme for Greater Birmingham could now begin.

In South Birmingham this involves investment of more than £70 million. It includes the planned transfer of the Children's Hospital from its present dilapidated location to a refurbished Birmingham General Hospital at a cost of more than £20 million; the development of a high quality accident and emergency service throughout the city and in particular a new £6.8 million accident and emergency department at South Birmingham Acute Unit; and the development of a new £8.5 million oncology centre for cancer sufferers at the South Birmingham Acute Unit.

During my visit to Birmingham yesterday I was told that Professor David Kerr, a leading cancer specialist of international renown based at the South Birmingham Acute Unit, has rejected the opportunity to move to a number of other leading cancer centres in this country because of the excellent facilities in South Birmingham and the encouragement and respect he has had from the management. Also planned is a new £6 million neurosciences centre, again at the acute unit; a £14 million refurbishment of Birmingham Women's Healthcare NHS Trust; a new health centre at Quinton as part of a £23 million investment in primary care across the city; and a major investment in the fabric of hospitals in South Birmingham, including £37 million on upgrading and improving facilities at Selly Oak Hospital, part of the South Birmingham Acute Unit.

Some of these initiatives are already under way and others are scheduled to take place over the next few years. In all, they represent a significant investment in local services across both the primary and secondary care sectors and all will considerably benefit the people of South Birmingham.

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The noble Lords, Lord Howell and Lord Rea, drew our attention to the bed closures taking place in particular at the South Birmingham Acute Unit. As I have already pointed out, improved medical technology and clinical practice means that more patients are being treated more quickly using fewer beds. Since 1987 the average length of stay in hospitals in the West Midlands has fallen substantially. For example, in the past six years the average length of stay for general surgery has fallen from 12 to eight days and for eye surgery the fall has been from five days to three.

Day case surgery has become a more common method of treatment. In South Birmingham since 1987 the number of day cases treated has risen by 234 per cent. In the West Midlands about 40 per cent. of cases are now treated on a day case basis. The West Midlands RHA believes that a target of 60 per cent. is reasonable. This is good news for local patients. Credit must go to those who planned, built and now work in the new £640,000, 18-bed day case unit which has recently opened at Selly Oak Hospital and which will benefit the people of South Birmingham.

However, in the midst of all this investment there is a complicating factor. In the past, many health authorities have sent their patients to the South Birmingham Acute Unit for treatment. These authorities are now developing services more locally and this means that fewer patients are being referred to Birmingham. This is better for patients but means that the acute unit has had to look at the various services it provides. It has had to match the changes in demand to the income that it now receives. This is one of the key issues underlying the acute unit's current financial situation.

The noble Lord quoted from a letter from the chief executive citing the importance of having a sound financial position. Every health authority must live within its means, and there is nothing more demoralising for staff or miserable for patients than having services that are expanded one moment and cut back the next. South Birmingham has to get its house in order and regain the stability which staff and patients so badly need.

Inevitably, the review of services has had an effect on the acute unit's organisation, although actual permanent bed closures at the unit have been minimal; a total of 42 since January this year. A significant number of these have been the result of major refurbishment taking place elsewhere in South Birmingham, necessitating short-term bed closures. Unfortunately, there have also been a number of temporary closures at the acute unit because of a shortage of nurses with the required specialist skills. An example is the cardiac unit, where 10 of the 62 beds are currently closed for this reason. This matter is being addressed by the health authority, which is seeking to recruit suitable staff as soon as possible. Interestingly, the situation at the Royal Orthopaedic Hospital and Birmingham Children's Hospital is the reverse, where there has been an increase in the number of beds available over this same period.

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Noble Lords have also drawn attention to the redundancies taking place. I wish to say, first, that it is always regrettable when redundancies are necessary but in this case it is essential in order to ensure that South Birmingham lives within its resources.

No significant redundancies have occurred at the Royal Orthopaedic Hospital or the Birmingham Children's Hospital; but, since the beginning of the year, 770 posts have gone at the South Birmingham Acute Unit. The vast majority have been administrative and clerical but some have been from the nursing and medical grades. Only 14 of those redundancies in total have so far been compulsory with the majority achieved through freezing of vacancies and voluntary early retirement.

Decisions on what posts should go is a matter for local managers, who must take account of local needs and the reductions in workload. It is certainly not the case that patients' lives are being put at risk because of those reductions. Posts go because the work is no longer there.

To help those whose jobs have been affected, South Birmingham Acute Unit has set up a staff commission which has been notified of some 400 nursing vacancies since June. In addition, there are plans to retrain about 60 acute nurses to work as community and practice nurses, reflecting the move towards greater care in the community.

Both noble Lords raised the question of waiting lists. The West Midlands Regional Health Authority is unique in that it has set all hospitals within the region a target of guaranteeing all patients who were on West Midlands waiting lists as at 1st July 1994 the offer of treatment by 31st March 1995--a maximum waiting time for treatment of no more than nine months. An additional £10 million region-wide has been made available to achieve that. South Birmingham is signed up to this target but to achieve it means an additional work load. I should explain to the noble Lord, Lord Rea, that that is a short-term initiative, over and above the normal workload. It will not be of a long duration once the backlog has been cleared. Therefore, it is a good idea to use other facilities in order to accommodate that increased workload.

The noble Lord mentioned the situation concerning the cancellation of operations. That is an area of great anxiety, which needs careful management. In that authority, the level of cancelled operations is high. That is partly attributable to the fact that the South Birmingham Acute Unit is heavily involved with treating emergencies and many cancelled operations are a direct result of unexpected surges in the emergency workload. That is particularly true of the cardiac services.

The noble Lord mentioned also intensive care beds. Currently in South Birmingham there are 25 intensive care beds but a further four will be opened in January 1995. Also, a new cardiac bed is due to be opened early next year. I hope that that will relieve the situation.

In his Question the noble Lord, Lord Howell, asked what action is proposed to ensure that South

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Birmingham provides adequate hospital services for patients. I have already outlined what is planned for the future, but let me also mention very briefly the excellent services already provided: the Birmingham Children's Hospital provides first-class patient care not only to the local community, but to patients elsewhere in the UK and overseas. Its expertise includes craniofacial surgery, oncology, cochlear implants, liver programme including liver and small bowel transplants, cardiac services; the Royal Orthopaedic Hospital, a single specialty orthopaedic hospital where outcome measures compare favourably with world standards; a women's hospital providing excellent maternity facilities and gynaecological care; strong community and mental health support from the local community and mental health trusts. Perhaps the most significant is the South Birmingham Acute Unit which offers one of the widest range of specialist leading edge services in the country including: one of the largest and most extensive transplant programmes in Europe; a quick and early diagnosis facility for the early detection of cancer; a major injuries intensive care unit for burns and trauma patients; one of the top national comprehensive cardiac programmes in the country; a direct access service for GPs to the day surgery programme; the most extensive renal programme in Europe; and a urology department which was a finalist in the national Hospital Doctor of the Year Awards for this year. Add those services to the planned £70 million plus investment in services in South Birmingham over the next four years and I believe that your Lordships will agree that that shows considerable commitment to providing excellent hospital services to

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the people of Birmingham in the future. Sadly, therefore, I cannot accede to the noble Lord's request for an inquiry.

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