DOMICILIARY PHYSIOTHERAPY SERVICES (Hansard, 4 December 1950)

§ Mr. Kenneth Thompson (Liverpool, Walton)
I want to raise a matter which concerns not a large number of people and not a large sum of money, but which to those who are concerned is a matter of very great importance. Under the National Health Service, regional hospital boards are required to provide satisfactory physiotherapy services. I understand that those services are very satisfactory, despite difficulties in the early stages, but that there are some people, such as sufferers from cardiac complications, heart disease, old age and advancing infirmity, for whom the treatment is prescribed but who cannot go to the hospitals and clinics. To meet the needs of those people a domiciliary service is needed. Several regions have worked out contractual arrangements with outside agencies, such as district nursing associations and private practitioners, to take the service to these patients.
Such arrangements appear to have had the blessing of the Ministry of Health. I have a letter dated July, 1948, from the Ministry to the secretary of the Liverpool Queen Victoria District Nursing Association stating that if the regional board think it is necessary to make such an arrangement to supplement the resources of the hospital, they might do so. A large number of such arrangements have been in operation during the last 12 months. They vary in their quality from place to place, but I am assured that most of them have worked extremely well in the view of the boards which set the standard and in the view of the patients.
To mention the service I know best, I would refer the Parliamentary Secretary to one which is extremely good. It is one of the first, if not the first, of the domiciliary services, and it was organised by the Liverpool Queen Victoria District Nursing Association four or five years ago, before the Health Service began. It is not without significance that it was this organisation that pioneered in the field of domiciliary nursing of any kind about 100 years ago, and for a large number 162 of years it has provided physiotherapy. No fewer than 26 district nursing associations are operating a mobile service of this kind, many of them under some form of contract with the regional boards. All these regions appear to have received instructions now which they are interpreting as a direction to terminate their contracts and arrangements with the district nursing associations.
The first question I want to address to the Parliamentary Secretary is this. In view of the fact that, after all, it is the region which is responsible for conducting this service as well as all the services for which it is responsible, were the regional boards consulted before they were instructed to cancel the contract? Were they asked whether they had an alternative arrangement to put into operation or whether they considered that the contract was an advantageous one from the point of view of either the board or the patient? After all, it is with the regional board that the responsibility lies. The House will want to know why the instruction was given at all and what it is proposed to put in the place of the present arrangement.
It is more than a little difficult to follow the reasons set out in the circulars and letters from the Ministry. I have here a circular which was presented to me as being the circular upon which the regional boards were to take action in this matter. Paragraph 2 includes this sentence: The shortage of adequately trained personnel, which will continue for an indefinite period, makes it imperative to concentrate them in hospital departments. Tonight is not the occasion for me to dwell on the ominous ring in the phrase "concentrate them." I am not sure whether this is a veiled introduction to a new form of direction of labour, but I am sure that the trained personnel would have a good deal to say about it if they thought there was any proposal to direct them into hospital departments. I shall refer to this aspect of the matter later, because it is germane to the whole argument.
Paragraph 5 of the same circular—conveniently over the page—includes this sentence: In the Minister's view it would be found more effective as well as more economical to employ additional physiotherapists … than to seek to continue contractual arrangements. … 163 One paragraph speaks of a shortage which is being experienced now and which is expected to continue and another paragraph contains the bland assumption that it is possible to go on employing additional trained physiotherapists at the present time.
In a very careful examination of the relevant papers which I have been able to obtain, I have found no very clear statement of what it is that the Minister is seeking to do by this instruction to cancel the present arrangements; whether it is to secure the best and the fullest use of a kind of skill which is in short supply, whether it is to ensure that the patient receives adequate and proper treatment, or whether the thing is being done on the grounds of economy.
As to making sure that we are securing the best and fullest use of the personnel available, I would point out that 26 district nursing associations at least are operating their own domiciliary service and employing physiotherapists in the performance of these duties in the ordinary course of the activities of those associations. Those physiotherapists will in all probability continue in the service of those associations whether there is a contract agreement between the association and the board or not. At any rate, these physiotherapists will be used less rather than more under the conditions which will obtain after this instruction is put into operation. I am sure that that cannot result in the best and fullest use of the physiotherapists.
If there is any suggestion that boards can solve the residual problem which will be theirs after this instruction is carried out by setting up their own mobile unit, it will have an equally disadvantageous effect on any ambitions to use the personnel more fully or more adequately. There will be competition between the various boards for these scarce services and between the boards and the present employers, whether private practitioners or nursing associations, of the physiotherapists at present in operation.
Nor can I find any grounds anywhere for believing that the present service is anything but very satisfactory. I have a letter from the secretary of the Liverpool Regional Hospital Board in which he sets out the terms on which the board does 164 business with the district nursing association. There could not be a clearer definition of the limitations on the service to be used, and how the quality of that service is to be watched to the satisfaction of the Board. The letter says: … the treatment for which the Board will accept financial responsibility would be restricted to those exceptional cases where the service was necessary in the patient's own interest because it would be harmful to convey the patient to the nearest hospital or clinic, and on the recommendation of the Hospital Consultant after either hospital investigation or domiciliary consultation. If the service proved to be less than satisfactory, the hospital consultant would be in a position to bring it to an end, and if it were satisfactory, then the board would wish to have the service continued and perhaps extended. So far as I am able to discover, there have been no complaints yet of the quality of the service rendered by the District Nursing Association with their mobile physiotherapy services. So the effect of this order cannot be to improve the service available to the patient.
Above all else, the Ministry appears to be particularly ill-informed on the costs of the different systems. In a letter sent to the secretary of the Liverpool Queen Victoria District Nursing Association from the Ministry of Health, which I understand is typical of those that have gone to other people, appears the following sentence: The system of contracting with other agencies … has proved to be expensive. The Parliamentary Secretary ought to be prepared to support that statement with some figures. I apologise for repeatedly referring to the instance I know best, but, so far as the Liverpool area is concerned, it results in a cost to the board of not more than 9s. per treatment. There are other arrangements in different parts of the country; in one case the cost to the board is 11s. and in another 14s.
Is the Parliamentary Secretary going to ask the House to believe that any system which he can conceive and establish, with all the resources at his disposal, will result in treatment being available to the patient at a lower cost than that? It cannot be done if it is proposed, as might be possible in certain cases, to bring the patient to the hospital at grave inconvenience, disturbance and disadvantage to the patient. The cost of transport alone, taking the average for the country, is about 20s. a trip in 165 the ambulance. On grounds of economy, then, there is nothing whatever to be said in favour of the instruction issued by the Minister.
This matter, almost more than any other, is one which ought to rest with the regions concerned and responsible for the treatment. They should be entitled, within the exercise of their normal duties of the day-to-day running of the health services, to decide a matter like this themselves; and where they can find and arrange an efficient and inexpensive service, they should not be subjected to this kind of blanket instruction.
In response to my initial inquiry, I received a letter from the Ministry of Health explaining what was happening, and finishing with this alarmingly casual sentence: Where in exceptional cases, patients for whom physiotherapy has been prescribed cannot attend a hospital or local clinic arrangements can usually he made for them to be treated at home.

§ Mr. Collick (Birkenhead)
Is the hon. Member going to allow the Minister time to reply?

§ Mr. Thompson
I hope to do so. A sentence of that kind will strike alarm in the mind of any person who is receiving this kind of treatment and knows that arrangements have been made to cancel it. I hope the Minister will reconsider the circular instruction and will avoid prejudicing the well-being of the patient and the good repute of his Service.

§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
It is, of course, with the welfare of the patients that both we in the Ministry and hon. Members must be chiefly concerned. I should like first to give the assurance that, with regard to individual patients, whether in Liverpool or elsewhere, we shall of course ensure that those who require physiotherapy treatment in their homes on medical grounds shall continue to receive it; that must be our intention. We should, however, always insist that physiotherapy provided in the home is a very poor second best to that which is provided in the better medical surroundings of a hospital or clinic properly fitted out for the purpose.
I was a little alarmed by the categories of cases which the hon. Member for 166 Walton (Mr. K. Thompson) listed as the sort that would naturally require physiotherapy treatment at home. He included, for example, old people. The requirements depend very much on the individual case, and we would regard it as a very exceptional case that should be treated at home. With old people, as with others, the important question is to give active treatment, and not tend to provide treatment on a sort of permanent basis, nor to let it be regarded as a natural part of the life of the patient. That is the great danger with domiciliary treatment of this kind.
I have a certain amount of personal interest in physiotherapy services, as I believe I have declared before. My wife is a physiotherapist, although no longer actively practising, and I am brought face to face with physiotherapy problems comparatively frequently. I appreciate very much the value of the work that can be done.
Let me give some of the arguments which we think are reasonable arguments why we should do our utmost to ensure that treatment should be taken other than in the home. First, as I have already said, there is the very grave tendency that treatment may become no more than a palliative, and that we must avoid. The whole trend of modern medical treatment is to try to ensure the active participation of the patient, as well as of the practitioner and specialist concerned; otherwise the best results cannot be hoped for. It is obvious that the amount of equipment that can be provided with a domiciliary team, even a well organised one, which, I fully accept, is provided in Liverpool, is very limited as compared with the provision in a hospital. Furthermore, it is certainly not economical of trained staff that they should be wandering about the countryside, as it were, giving individual treatment instead of being able to provide treatment for several patients together in a clinic, whether part of a hospital premises or outside it.

§ Mr. K. Thompson
I am concerned, of course, only with those who simply cannot be treated except at home. Perhaps my definition of the cases was rafther broader than that given by the Minister.

§ Mr. Blenkinsop
I agree that it is very difficult to establish a proper definition. Our experience, not necessarily only in 167 Liverpool, but elsewhere, has been that where contracts of this sort are entered into, whether with an organisation of the kind which has been mentioned or, in some extreme cases, with individual physiotherapists, the danger has been of a gradual growth of demand which cannot properly be regarded as a medical demand.
This is not only a problem of the initial control of the cases that are to be dealt with. I think the hon. Member will appreciate that we are concerned not merely with sifting out those which could properly be regarded in the initial stages as medical cases, but with some method of assuring that we have a reasonably proper control over how long the treatment should be continued. The difficulty with domiciliary treatment is that it tends to become permanent instead of being, in the very exceptional cases which we would regard as requiring domiciliary treatment, rather a method of ensuring that patients can at some later date go to the hospital for treatment that will be very much better for them.
The important thing, therefore, is not merely to have control of the initiation of the scheme, but also to have a direct control over its continuation and to be able to decide at what point the domiciliary treatment should stop and treatment at the hospital or clinic should commence. It has been our experience that it is extremely difficult to achieve that when contracts of this kind are made with the nursing associations or, in some exceptional cases, with physiotherapists themselves. We insisted from the start in paying very great regard to ensuring that the treatment was provided in hospitals. That was laid down very clearly in the earlier circulars which we issued. We did say that for exceptional cases treatment should be provided in the different ways which have been mentioned, if it was indeed impossible for the patients concerned to move to the hospital; but we have made it clear that it was our desire to establish any domiciliary service which might be needed through the hospital itself at the earliest possible moment.
It seems from experience of what is happening, not only in this centre but in others, that these contracts create what we regard as an unwarranted demand on 168 purely medical grounds. It seemed to us essential to insist upon a stricter control than was available initially. Therefore, we sent out this general circular to the regional hospital boards calling attention to this situation and asking the boards to bring the contracts they had entered into to an end at the earliest possible moment. We have, of course, entered into discussions with the regional hospital boards on the best way of carrying this out and ensuring that there should not be any loss of treatment for those who must have it in this way.
I am glad to say that discussions are being entered into with the Liverpool Regional Hospital Board on this matter, as they have been with the other boards, to work out the practical ways in which the problem can be overcome, either by the use of the existing hospital staff or, if necessary, by the appointment of part-time or of one full-time physiotherapist to the staff. If that should prove impossible we shall look into the matter again to make sure that there is no loss of the service to those who really need it.
But I want to impress on hon. Members that, as in other matters under the Health Service, this subject, which I might say is on the periphery of the Health Service, is one into which a good deal of abuse can creep, and we must be very careful. This is a service which is partly medical and which is very important on medical grounds. It also can give value and encouragement to many people on other than medical grounds. I think it will be realised that it is essential, at a time when we need to ensure economy in the Health Service, to provide proper and effective control. It is for that reason that we have put out this more recent circular to the regional boards, and why we are entering into discussions with them now.

§ Mr. Thompson
Before the hon. Gentleman sits down, will he give the assurance that if the discussions now proceeding between his officers and the boards mean that it may be necessary, in order to tide over the period for which no arrangements exist, any board will be free to make such necessary arrangements to cover the interim period?

§ Mr. Blenkinsop
We have extended the time once already to meet that sort difficulty, and I think I can tell the hon. Gentleman that we should be willing to do so again. We want to check up on the individual cases to see whether they do need domiciliary treatment or not, and 170 to discuss the best method of overcoming the problem.