HC Deb 28 July 1989 vol 157 cc1430-9 10.15 am
Mr. Keith Vaz (Leicester, East)

I am grateful for the opportunity to raise this important subject on the Floor of the House and I am grateful to the Minister for his attendance this morning. The crisis in the occupational therapy service affects thousands of my constituents and tens of thousands of people throughout the country. I believe that hon. Members share my enormous sense of frustration at the policy towards occupational therapy services. I have received complaints from the disabled and elderly whose lives are limited and restricted because of the grave difficulties in the service. Many are in agony and are prisoners in their own homes.

I begin by commending the work of occupational therapists. The overwhelming number—as many as 95 per cent.—are women and they work under enormous pressure. I also commend the following for bringing to my attention, and therefore allowing me to bring to the attention of the House, information of great relevance: the College of Occupational Therapists; the editor and staff of Therapy Weekly; Mr. Mick Welles, the deputy director of the social services for Leicestershire county council; Councillor Valerie Vaz of the London borough of Ealing and Mr. Ian Buchanan who is one of her officials. I thank them all for their efforts.

Social services departments the length and breadth of the country are only too aware of the severe delays experienced by disabled people in receiving a service from occupational therapists. Many of the departments have considered detailed reports on the problems in their areas. The problems have been compounded by the fact that many more people are becoming aware of what might be available to them and are going directly to the social services departments or going through their doctors. The service has expanded in many areas, but the real problem lies in the recruitment and retention of qualified staff.

The current vacancy level for occupational therapists in Leicestershire is running at 37 per cent. The national average is just below that. A survey by the Association of Directors of Social Services from January to April 1988 revealed a 35 per cent. vacancy rate and that 18 per cent. of posts were vacant for more than six months. The shortage has become critical. The association estimated that nationally it was short of 250 occupational therapists.

The Minister must acknowledge the fact that the Government's policies of reducing the number of patients in hospital have contributed to the problem. Those difficulties have been exacerbated by the provisions of the Disabled Persons (Services, Consultation and Representation) Act 1986 in relation to the assessment and provision of services to disabled people. That Act will create even greater demands for the services and skills of occupational therapists.

About a year ago, on 26 July 1988, the Association of County Councils social services committee met to discuss this subject and endorsed its members' grave concern at the increasing demand for and limited supply of occupational therapists. In a meeting with the Department of Health and Social Security on 27 June 1988 and in previous meetings with the College of Occupational Therapists and the National Association of Health Authorities in England and Wales, it identified the loss of staff, the need to increase training places and the increased need for sponsorship for training as key elements in the strategy to overcome problems. Because of demand, local authorities such as mine in Leicestershire have had to prioritise work.

Local authorities have agreed that the resources of the occupational therapy service should be concentrated as much as possible on two categories of need as defined by the Department. Category A includes the very severely handicapped—persons who consistently need night care such as help with toileting or turning in bed and who, in addition to night care, need help with basic feeding, washing, dressing and daytime toileting. They are all situations in which handicapped people are unable to care for themselves, as many are bed or wheelchair-bound. Category B includes severely or appreciably handicapped persons who do not need consistent night time care but who may need considerable help from another person in order to cope with at least one essential activity of daily living—dressing or undressing, feeding, bathing or toileting.

Leicestershire and other authorities decided that the resources of the occupational therapy service would be best deployed in accordance with a scale of priorities. Priority 1 was to be acute cases, or referrals showing that, without immediate action by the occupational therapy service, the client's health could be seriously impaired. Included in this priority are those who are chronically ill—referrals showing that action by the occupational therapy service is required immediately to prevent the client's circumstances from rapidly deteriorating, with the possibility of hospital admission.

Priority 2 included urgent cases, or referrals which showed that the client was unable to sustain independence without further support or that informal carers could no longer cope without assistance.

Priority 3 included referrals that showed that the client was unable to sustain independence without further assistance but where support systems were available via informal carers and/or other support services that could at least help in the short term.

As the first call on the resources available to the occupational therapy service was to be for acute cases in priority 1, or the urgent cases in priority 2, the waiting list has built up for the other priority categories.

The waiting lists have become a damning indictment of the present system. According to the latest figures for Leicestershire, from March to April 1989, in the first category 245 cases were dealt with and 315 cases were being progressed. There were no waiting times for those in the acute or chronic category. The priority 2 category was for urgent cases. I remind the House of the terms of reference: referrals which show that the client is unable to sustain independence without further support or if informal carers can no longer cope without assistance. The current waiting time in the Leicester city east division is 36 weeks, or nine months. From March to April 1989, 249 cases were dealt with, 332 cases were ongoing, 450 new cases arrived on the desk of the director of social services, and a staggering 1,680 cases were awaiting allocation or assessment.

Priority 3 cases were clients to be visited as soon as possible. Again I remind the House of the terms of reference: referrals which show that the client is unable to sustain independence without further assistance but where support systems are available via informal carers and other support services, but only in the short term.

The waiting time is more than 35 weeks. From March to April 1989, 111 cases were closed, 115 cases were progressed, 219 new cases arrived, and 727 cases were awaiting allocation or assessment.

Those are the statistics. They do not tell us about the human misery behind them. For example, I refer to the case of Mrs. Jean Wilson of 3 Frisby road, Leicester, who wrote: I am writing to you in regards to my situation. I am severely disabled…with a serious heart condition winch means I can hardly walk and I cannot climb stairs…I have now been in the position of not being able to have a bath or sleep in a proper bed or be able to move around in my house for almost six years now. And I am virtually condemned to one room. There is also the case of Mrs. Patel of 18 Coles close, Leicester. Her son wrote: I have a mother, 60 years old, virtually disabled due to severe Rheumatoid Arthritis and can hardly walk without help. She has had three sets of complete knee replacement operations; two on one knee and one on the other. All her joints are gradually degenerating and deforming…The very first day she moved into this new house, she fell down on the staircase after having been to the toilet. She was hurt on the forehead and legs and taken to the Casualty department…Few days before my mother moved in this new house … I spoke to the Social Services regarding the Staircase Lift." They said that there was 'a long waiting list' for this facility. They could not visit within a short period of time.

There is also the case of Mr. and Mrs. Cunningham, of 50 Croyland Green, Leicester whose granddaughter wrote: My grandmother cannot work any longer due to health problems, she has recently suffered a very stressful colostomy operation. My grandfather is 63 years of age and is on the sick at the moment and is expected to be for some time. He suffers from asthma and he is due to go into hospital for an operation on his left leg. Their problems are made much worse because they are in desperate need of a new bath. I briefly explained when we last met, but things have not improved. My grandmother needs to keep herself clean because she is not immune to catch infection with a colostomy and my grandfather has not got the strength to lift her in and out of the bath due to his health deterioration and vast loss of weight. The same applies to Mrs. Jean George, who lives in Maplin road in Humberstone. She has been waiting for a chairlift. On behalf of Mr. and Mrs. Spring who live on Bath street in Leicester, I wrote on 10 July to the director of social services, stating that I had been consulted by Mr. Spring who has told me of the terrible delays that are recurring with regards to the assessment of his home for, in particular, a lift and a shower. As you know, Mr. Spring's wife has a serious disability, and he is having to carry her upstairs. Visits have been made, and promises have been given concerning putting this matter right, but I am sorry to see that there has been very little progress. Mr. Spring himself is in difficulties, because of course this constant activity is putting his own health at risk. This is a very serious matter, and I have written to you about these delays in the past. Indeed, I am minded to raise this matter in Parliament. I have taken up all those cases and have written to the director of social services, Mr. Brian Waller, who seems as angry and frustrated about the delays as I am. He tells me that there is simply nothing that he can do to ensure that the delays are removed.

It is not all gloom, because I have figures showing that up to the end of the last financial year Leicestershire was ensuring that more home adaptation cases were being processed than almost every other county. It wants to ensure that it can provide a better service.

Within the past month, we have had the findings of the Blom-Cooper independent commission, which was established by the College of Occupational Therapists at the end of 1987. The commission recommended a movement into the community and an expansion of the College of Occupational Therapists. It revealed that in 1988, 549 National Health Service occupational therapists left the profession.

Some initiatives can be taken in the short term. There is a need to increase the number of occupational therapists being trained. The number of training places must be increased, with the ever-increasing number of elderly people. It is imperative that urgent action is taken on training.

We must consider how occupational therapists are being recruited, even if it is on a part-time or sessional basis. For example, because many occupational therapists are women we must consider job shares, the establishment of creche facilities, better pay, refresher courses, and overall changes in the structure of their gradings. Sponsorship for training is another option.

The Government must realise that only quick, firm and effective action can resolve the problem. Every minute of every day someone is suffering because of the delays and the backlog. It is impossible for able-bodied persons to imagine the social and physical pain of those who wait month after month for assessment. In some cases, they are unable to move beyond a bed, a chair or a room.

Twenty years later, we are celebrating the technology of placing a man on the moon. Surely something can be done for those ordinary, helpless citizens. The answer, and the active lives of many people, rest inevitably in the Minister's hands.

10.32 am
The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

I very much welcome the opportunity to debate the occupational therapy profession and the challenges facing it. It is a most important subject and the House is indebted to the hon. Member for Leicester, East (Mr. Vaz) for raising it this morning.

The House has been sitting all night, and we are grateful for the fact that the Chamber is air-conditioned. Hon. Members present will wish to place on record our thanks for and recognition of not only the Chair but the Clerks and all those who work in the House. Their hard work often goes unrecognised and taken for granted, but I am sure that the hon. Member for Leicester, East and my hon. Friends the Members for Solihull (Mr. Taylor) and for Beckenham (Sir P. Goodhart) will join me in wishing all the House's staff a restful recess.

I join the hon. Member for Leicester, East in thanking the profession for its hard work, which the hon. Gentleman rightly acknowledged in his speech. I unreservedly congratulate the profession on dealing with ever-increasing demand, for reasons that were accurately cited, in a professional way.

The occupational therapy profession has experienced a tremendous increase in demand for its services. As the hon. Member for Leicester, East said, that is because of the Health Service policy of discharging patients who no longer need medical attention but who may need sustenance and support in their homes, the ageing population, greater rights for disabled people and their increased determination, quite properly, to seek assistance from occupational therapists employed by the Health Service or local authorities.

In the face of that increased demand, the supply of occupational therapists has undoubtedly increased. The problem is that that increase has not been sufficient. There are substantial shortages, and I shall explain some of the ways in which the Health Service is dealing with vacancies.

Although I am the Under-Secretary of State for Health, I am not responsible for Leicestershire county council. I am ultimately responsible for the quality of service delivered, which is monitored and inspected by the social services inspectorate. In the final analysis, local authority occupational therapy services are a matter for the local authority. We are aware of the increased demand for those local authority services. Each year, we discuss their resource implications with local authorities. We have made more resources available through the rate support grant, but no one denies that demand is increasing.

I shall concentrate my remarks on the national picture and mention some of the issues that the hon. Member for Leicester, East raised about vacancies and the supply of more occupational therapists in the future. I understand the problems in Leicester, particularly in the hon. Gentleman's constituency. Leicester is an extreme microcosm of the national position. There is a much higher proportion of vacancies in the hon. Gentleman's constituency for occupational therapists, who work not only for the Health Service but for the local authority.

The subject of the debate is the occupational therapy service nationally. There is more than one service, as occupational therapists, uniquely among professional staff groups, are employed by the National Health Service and local authorities. A common and widely accepted definition of occupational therapy, made by the College of Occupational Therapists, is that it is the treatment of physical and psychiatric conditions through specific activities in order to help people reach their maximum level of function and independence in all aspects of daily life. In practice in the National Health Service, occupational therapists work with people of all ages who may have physical disabilities, including the elderly, the elderly confused, those with learning difficulties and mental health problems, substance abusers or other forms of disability.

Occupational therapy developed in social service departments largely as a response to the statutory obligations placed on local authorities by the Chronically Sick and Disabled Persons Act 1970 to provide certain services for people registered as chronically sick or disabled, such as the prescription and provision of disability equipment—mobility aids, bathing aids and hoists—and the assessment and recommendation of adaptions to the person's home. This role is developing to become more of an enabler, aimed at helping the disabled person to maximise his independence and quality of life.

I know that the hon. Member for Leicester, East is active in looking after the interests of all his constituents. In my constituency in Northamptonshire—not a million miles away—I have visited many residential homes for the elderly and many of my elderly and disabled constituents in their own homes. I have seen for myself what can and should be done. There is no doubt that the services of occupational therapists, particularly those working in the community visiting elderly people, can make a tremendous difference to the quality of their lives.

The focus of occupational therapy on the practical resettlement and integration of a whole range of people is closely linked to the Government's care in the community policy. The emphasis on resettlement and integration has seen a substantial increase in demand for occupational therapy services. This is due to a number of factors, including the reduction of the long-stay hospital populations, reduced length of stay in acute hospitals and improved survival rates for people with often very severe disabilities. Demographic changes, such as the increasing number of elderly people in our population, many of whom have physical or mental difficulties, have also generated increased demand for occupational therapy.

Occupational therapists are often the key to the continued independence of the many people who are now rightly living in the community rather than in the various forms of institutional care.

The hon. Member for Leicester, East has implicitly endorsed the Government's policy of seeking to care for as many people as possible in their own homes and the community if they do not require medical attention in hospital. That is a fair statement of a commonly agreed policy and aim.

NHS expenditure on occupational therapy services in England increased from £23 million in 1978–79 to £135 million in 1987–88, which represents a real-terms increase of 102 per cent. Expenditure on community occupational therapy services provided by the NHS, although still a small proportion of the total, has grown at an even greater rate than expenditure on the service as a whole. The real-terms increase in that sector since 1978–79 is 543 per cent.

The increased expenditure has led to more occupational therapists being employed. The number has doubled in 10 years—I am now giving NHS figures—from 2,500 whole-time equivalents in 1979 to about 5,000 whole-time equivalents at present. Of course, some are employed on a part-time or temporary basis. There has also been a rapid growth in the number of helpers and technical instructors employed in the NHS. The total number is about 3,500 whole-time equivalents.

Although the local authority occupational therapy service is much smaller than the NHS service, it has grown significantly since 1979. The number of qualified occupational therapists employed by social services departments in England has about doubled from 550 whole-time equivalents in 1979 to more than 1,100 whole-time equivalents now. The hon. Member for Leicester, East might be interested in the figures for Leicestershire social services department. I am informed that in June 1988 there were 57 whole-time qualified occupational therapists in post and in April 1989—I am sorry that I do not have a more up-to-date figure—there were 71 whole-time equivalent qualified occupational therapists. The comparative figures for non-professional qualified staff were 18 in June 1988 and 59 in April 1989. That is a welcome increase in about a year.

Unfortunately, the NHS and local authorities are affected by shortages of qualified occupational therapists. The hon. Gentleman was right to underline the basic problem, which is that we cannot fill the posts available. The NHS has about a 17 per cent. vacancy factor, and the hon. Gentleman mentioned the much higher figure for local authorities. I assure him that we are not complacent about that because we know that it affects the service to patients and results in some people waiting far too long to see an occupational therapist. We know that that causes particular problems in the local authority service when people are unable to receive the equipment that they need because they are waiting for an assessment by the occupational therapist.

The Department has taken several initiatives to resolve the problem. First, the hon. Member for Leicester, East may be aware that the fees and bursaries for occupational therapy students in England and Wales are currently centrally funded through the Department of Health at a cost of some £8 million. Training to become an occupational therapist can be undertaken in a number of ways. Most of the 17 schools in England and Wales offer the three-year, full-time diploma course, and four-year, day release in-service courses for helpers and technical instructors. In the forthcoming academic year, 1989–90, 60 additional places have been funded. We are therefore on target for a total of at least 160 extra places, funded by us centrally, by 1990–91. We are currently supporting 740 entrants into training each year.

Secondly, in addition to funding bursaries and fees, the Department has provided a great deal of capital—more than £2 million over the past three years—to a number of the schools of occupational therapy which has enabled them not only to increase their intake of students, but to improve their learning environment. That money has enabled two new schools to be opened, in Canterbury and Sheffield. Officials are also exploring possibilities of additional training schools to increase the number of available training places.

Thirdly, the Department has held discussions with local authority representatives about their contribution to the training of occupational therapists. They make a negligible contribution to the three-year diploma courses, although they take 20 per cent. of the available supply of qualified people. I understand that Leicestershire social services department is planning to sponsor two occupational therapy assistants on the proposed in-service course to be held in Derby plus one on the three-year diploma at Northampton. I welcome that and wish that more local authorities would take a positive attitude towards helping to meet the widespread national need for more students to be in training.

Mr. Vaz

Does not the Minister think it a little unfair to expect local authorities to make a larger contribution in view of the expenditure restrictions that have been placed on them by the Secretary of State for the Environment?

Mr. Freeman

I do not accept that argument. As the hon. Gentleman knows, each year there are discussions about centrally provided funds between the Department of the Environment and the local authority associations. The Department of Health is represented at those discussions and an assessment is made of revenue needs, including the cost of providing a local authority occupational therapy service and the cost of training. Training is part and parcel of the supply of services. The Government reach a determination of the central grant available, and it is then for the local authorities—in this case the county council—to decide specifically what the priorities are.

The fourth measure addressing the need to increase supply and reduce shortages is that the Department also recognises that imaginative ways are needed to enable suitable recruits to undertake training. While the profession should be congratulated on the work that it has done so far in this direction, it is felt that there are additional ways in which an increase in student numbers could be achieved. To assist innovative developments in this direction, the Department has provided a total of £135,000 in the current financial year, divided between five of the schools of occupational therapy as pump-priming money. They are to report back in the autumn with options on a variety of topics agreed with us. They include the progression through national vocational qualifications to state registration level, as well as refresher training for those returning to work after a career break.

It is important that we attract back into the NHS—I am now speaking in a slightly wider context—nurses and midwives, particularly women, who have taken a break for family reasons and who, perhaps in middle age, still have a good deal to offer. Refresher courses are clearly needed, particularly in occupational therapy, but there is no reason why those who leave the NHS in their twenties or early thirties to have a family should not plan to return. I am sure that the hon. Gentleman would join me in encouraging the breakdown of any prejudices that may remain, not only in the Health Service but in local authorities.

No doubt the hon. Gentleman expects me to mention rates of pay. He may be aware that NHS pay is determined each year following the recommendations of an independent review body for nursing staff, midwives, health visitors and professions allied to medicine. That includes occupational therapists. In making its recommendations, the review body takes full account of the duties and responsibilities of occupational therapists, reflected in evidence submitted by the health departments, trade unions and professional bodies representing the staff concerned. The Government are committed to implementing the recommendations of the review unless there are clear and compelling reasons not to do so.

I should mention that since the inception of the review body in 1983, the pay of occupational therapists in the NHS has been increased by 24 per cent. in real terms. The hon. Gentleman will know that my Department has no direct influence over the pay of occupational therapists in local authorities.

We recognise that it is very important for health and local authorities to retain qualified staff. That is clearly a more effective use of resources than undue reliance on recruiting new people into the profession. Equally important is the attraction of non-practising occupational therapists back into employment. We know that there are many of them, and some health authorities have been successful in identifying this hitherto largely untapped labour pool, providing refresher opportunities and then offering flexible working hours.

As part of the NHS manpower planning advisory group's national professional manpower initiative, we are currently collecting information about retention and returner patterns and the strategies adopted by authorities to attract people back to work in the NHS and local authority sectors. We intend to disseminate that information to employing authorities, and to use it as a basis for considering what further action can be taken by the Department, the NHS and local authorities to effect an improvement in retention and returner rates of qualified occupational therapists.

It must be recognised, however, that good retention reflects good management. Some authorities have paid notable attention to such issues, and have provided good management support with appropriate training and development opportunities for their staff. That has reaped benefits, and I am sure that some authorities with particularly acute staffing problems could learn from the practice of the best authorities. I am not passing judgment on Leicestershire county council, or on the specific problems of Leicester city; I am making a general point.

The hon. Gentlemen concentrated on the difficulties in the local authority services particularly those that he has experienced in his constituency. As I think can be understood from my description of the profession's work, the operation of the local authority service cannot be seen in isolation from that of its NHS counterpart.

Mr. Vaz

Has my hon. Friend the Minister any more to tell us about his six-point plan? Assuming that he has not, may I question him on a point that he has raised?

Some of what he said will be welcome to those working in this profession; my concern, however, is with the backlog and delays in Leicestershire and other authorities. I realise that Leicestershire may be worse off than other areas. Although we have heard that the Minister is pledged to increase the number of training places, it will be three years before we have qualified occupational therapists. Can the Government do anything for local authorities such as Leicestershire in the short term?

Mr. Freeman

It may be convenient for the House and helpful to the hon. Gentleman if I now refer to my information concerning Leicestershire specifically. As I understand it, the hon. Gentleman's constituency covers the city east division of Leicestershire social services. That division has 1.5 occupational therapists in post, with 4.5 vacancies. Most are of more than six months' duration. Four occupational therapy assistants are in post, one of whom is to be sponsored for the three-year diploma course that I mentioned earlier.

Most waiting clients fall into what is described as priority category 2. Category 1 clients are seen within two to three weeks, while category 3 clients are invited to attend a clinic rather than receive a home visit: they are less disabled, and therefore able to travel. Category 2 clients wait for a long time. Most are awaiting assessment for home adaptation.

Leicestershire social services department is discussing with Leicester city council the idea of jointly funding a post just to assess for adaptations to homes. That innovative idea should help to clear much of the backlog. Leicestershire social services is also considering ways of introducing a self-assessment form for clients, so that it can determine who needs an occupational therapist to visit and who could be seen by an assistant. That is not a satisfactory or comprehensive solution; it is a means of satisfying as much demand as possible from the available resources.

Leicestershire social services' salary scales do not encourage occupational therapists to stay in post. If they wish to be promoted, they go back to the NHS. I understand that the division in the hon. Gentleman's constituency has lost two members of staff in that way recently. Recruitment to the NHS occupational therapy services has been good of late. Pay is clearly a factor in the problem in the hon. Gentleman's constituency. As a health Minister, I cannot either take direct action or directly advise the local authority concerned—the county council—on the action that it should take. At least the hon. Gentleman and I seem to agree on the diagnosis of the problem.

Clearly, initiatives can be taken jointly by the county and city councils: I have already referred to one. Management is all-important. I do not know the specific circumstances of Leicester, East or, indeed, the city of Leicester, but good management and good direction can help to improve retention, and can encourage staff who have left to return.

Mr. Vaz

The Minister is being very diplomatic. Perhaps I can tease an answer out of him. Does he consider that an authority—perhaps not Leicestershire county council, but a fictitious county council in exactly the same position—should pay its occupational therapists more than Leicestershire is currently paying?

Mr. Freeman

The hon. Gentleman, with his rapidly acquired parliamentary skill, cannot draw me on that.

Let me emphasise that our policy for care in the community—that is, caring for more elderly people in their own homes if they do not need medical attention in hospital—is one with which I hope all hon. Members agree. The independent Blom-Cooper commission, to which the hon. Gentleman referred, has put valuable effort into looking at the future of the profession. Although its report is not expected until October, I understand that its central theme is likely to be the need for the profession to direct more of its energies, planning and resources towards care in the community, as opposed to care in hospitals or institutions. I fully support that.

I remind the hon. Gentleman and the House that our proposals for the reform of funding for care in the community will mean that local authorities—that includes the social services department of Leicestershire county council—will in future have resources transferred from central Government. The portion of income support which is the care element will go to the local authorities so that they can make the correct decisions about how to provide support for the elderly in their own homes. That includes occupational therapy services and the provision of a wide range of domiciliary services to enable elderly people to stay in their own homes. The local authority will have continued responsibility and enhanced resources to achieve the laudable aim of providing for disabled people who wish to remain in the community.