§ 4.30 p.m.
§ Mr. Paul Dean (Somerset, North)
I am very grateful for this opportunity to raise the very important subject of hospital building. Time is very short and I shall be very brief. I am particularly grateful to the Minister for coming here to answer the debate personally at this late hour before we break up. I am sure that he will agree with me that there can be no subject more appropriate before we break up for this great Christian family festival of Christmas than that of the sick and of not only those who will be separated from their families at this festival, but the many staff and voluntary workers who will be giving up their Christmas to try to bring joy to those not so fortunately placed.
The hospital building programme, published in 1962, was a bold attempt to set us on the road to a hospital system worthy of the nation. It has gone some way, but, we would all agree, not yet very far along that road. There are many uncertainties about its future. The original intention was a ten-year look ahead, reviewed every year. There were reviews for the first two years, but the third review has been postponed from last year to next year. We understand the Minister's difficulties, but I ask whether he can now tell the House when he expects the third review of the programme to be published.
There are a number of indications from statements by the right hon. Gentleman in recent months that the hospital building programme is running into some trouble, that the original promise has been somewhat tarnished by time and buffeted by events. The right hon. Gentleman will recollect answers which he gave to my right hon. Friend the Member for Bridlington (Mr. Wood) about the postponement of a number of major projects during the year. Those answers appeared to indicate a fairly substantial cut in the programme for this year. It appears that about £27 million worth of work has been postponed and only half that amount put in. Perhaps the right hon. Gentleman can expand a little on that.
Another issue I want to raise is that of the National Plan from which it 2204 appears that health and welfare in general are to have a smaller increase in resources over the plan period than any other of the social services. It also appears that the amount of money going into health and welfare in general will be rather less than the estimated increase in the gross national product. As I understand the figures, the figure for health and welfare is now about 4 per cent, of the gross national product and in 1970 it will be about 3.9 per cent. Perhaps the right hon. Gentleman can say whether that is correct. That and other factors which I do not now have time to mention suggest that there are doubts about the programme, and the sooner they can be cleared up, the better it will be for the hospital service and those who work in it.
I want briefly to refer to the long-term prospects. It is clear that we cannot build as fast as we should like, that we cannot meet all the requirements which we should like tip meet as speedily as we would wish. It appears that we shall not be able to meet them as fast as the Plan suggests.
This situation seems to pose two fundamental questions. The first is, "Are we using scarce resources to the best possible effect?" and the second is, "Are there ways in which we can draw in additional resources, over and above those provided by taxes and rates?" We have to consider whether we have our priorities right. I know that the hospital building programme tries to concentrate on putting money where it will do the most good, in operating theatres, X-ray departments, accident deparaments, maintaining priority for maternity and so on. I wonder if we have sufficiently pinpointed the priorities in view of the scarcity of resources. I wonder too, whether we have tended to be a little ambitious, and neglected relatively modest improvements to existing facilities.
We all know hospitals which, for a comparatively modest sum of money, could improve their working very substantially. The establishment of the hospital could be so much easier than it is. The out-patients' department, for example, is very often scattered over a number of different buildings. A first-class out-patients' department, with good diagnostic facilities, could very often save 2205 hospital beds. Are we tending to be a little too ambitious about entirely new projects and neglecting the urgent needs of the moment in the existing hospitals?
The second point I wish to make concerns value for money. Why is there such a big difference in the cost per bed in different schemes? It appears that the cost per bed varies from something like £7,000 to, in some cases, over £15,000. It is clear that the cost of the site and the facilities which are required, are bound to mean some variation in the cost of different hospitals, but these big disparities appear to call for some explanation. Have we yet reached the stage where we are getting maximum value for the money which is being spent?
Since the war building costs have risen something like fourfold, whereas the cost of hospital building has risen much more. Is it not the case that we think too much in terms of asking a hospital "What would you like?" rather than saying, "Here is the cloth, cut your coat according to it."? Is there too much control over independent individual plans and designs and not enough over overall costs? I feel that there is not enough emphasis on standard units and fittings. I appreciate that the right hon. Gentleman and his predecessors have done a great deal in this connection in the Building Notes which they have produced and circulated, but I think he will be the first to agree that there is still a great deal more to be done if we are to get the cost of building down.
The example of schools is relevant here. Great progress has been made in holding down the cost per school building, and this is one of the great credit stories of the last decade or so. Might it not he that there are lessons here for the hospital service? I should like to put in a special plea for the small hospital. I appreciate that the district general hospital has a considerable part to play in the future and that it requires expensive equipment. There are however many occasions where expensive equipment is not required, and where a hospital nearby is not only valuable to the patient but to relatives and also from a staffing point of view, because many of the nurses who work part time in hospitals would find it impossible to do 2206 that, were their nearest hospital some distance from them.
I turn briefly to my second main point, namely, how to get in additional resources. As long as the hospital building programme is largely dependent on an annual allocation of taxpayers' money, it is bound to be very largely at the mercy of the Treasury. Is there the possibility that some form of hospital building loan fund might be set up which would enable us to get away, to some extent, from the year-by-year allocation for what is, after all, a major programme looking far into the future? Secondly, can we tap to a greater extent the local funds on the basis of pride in the local hospital?
One of the encouraging things in the last few years has been the way in which leagues of hospital friends have sprung up. They are now attached to most hospitals. They are bringing in resources largely on the fringes—television sets and the rest—but increasingly they are embarking on fairly major schemes. I can think of a number of comparatively small hospitals in my constituency the friends of which have raised fairly substantial sums to provide day rooms in the hospitals. I wonder whether there is some way in which we can bring these extremely valuable organisations and this local effort, both financial and otherwise, into the main stream of our hospital building programme.
Private sources are making a very considerable contribution to the number of hospital beds available. The example about which I know most is the B.U.P.A. and its insurance scheme. In 1957 the Association set up the Nuffield Nursing Homes Trust. Since that time it has spent no less than £2¼ million on nursing homes. Nearly half of this money has been raised locally and the rest has come from B.U.P.A. resources. I hope that we shall see increasingly co-operation between both public and private sources to get the hospitals in a position which a country like ours deserves.
§ 4.43 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
I must apologise to the right hon. Member for Bridlington (Mr. Wood) and the hon. Member for Norfolk, South (Mr. J. E. B. Hill), who I know wanted to intervene in the debate, but 2207 the hon. Member for Somerset, North (Mr. Dean) has raised a number of important matters, and if I am to have the chance to answer even most of them, and in view of the fact that the debate is taking half the time which it was scheduled to take, I am forced to speak now.
I am glad to have this opportunity of discussing the Hospital Plan and to confirm that the Government accept the need for a large hospital building programme. This is precisely what we are now carrying out. I should like to associate myself with the hon. Member's opening thoughts for the sick in hospital at this time of Christmas.
Expenditure is increasing annually on the hospital building programme. In this current year we have £68 million, including a special allocation of £5 million, additional to what was planned by the previous Government. The hon. Member said that he thought that the hospital programme might be running into trouble. In a sense, it has run into trouble since the original Hospital Plan was published in 1962. I would only suggest that perhaps it is in slightly less trouble now than it has been in earlier years.
The hon. Member was under a misunderstanding in the conclusions which he drew from some replies which I gave to the right hon. Member for Bridlington a week or so ago. If I understood him aright, he said that he thought that what I said indicated that £27 million worth of work had been postponed and that a lesser sum had been brought into the programme in this current year. These figures bear no relationship whatever to expenditure in the current year because the value of the works which have not been able to be included in the current year were the total estimated cost of schemes most of which would have to be spread over two, three or even four years. I can assure the hon. Member that we are spending more on hospital building, and substantially more this year, than has ever been spent before. I wish that I could give more details about future plans, but, as the hon. Member knows, a fundamental review of the hospital building programme is now being undertaken.
The original Hospital Plan of 1962, which was the first occasion for a compre- 2208 hensive statement of the capital requirements of the hospitals and the Health Service, was generally welcomed in all parts of the House. As I have had occasion to explain previously, however, it was presented as a list of schemes to be undertaken in a specified period. Unfortunately, such was the haste with which it was produced, coupled with a lack of experience of large-scale hospital building, which was understandable because so little had been done, the cost of many individual schemes has proved in the event to be far greater than was provided for in the original plan.
That was partly because the full implications of schemes were not always fully appreciated in the first instance and there was a marked tendency, once a scheme was accepted in the programme, for additional facilities continually to be requested, which was only natural when those immediately concerned were seeking to fulfil the requirements of their own particular service. This increase in scope, however, together with the inadequate costing, simply meant that individual schemes rose substantially in cost; and thus, despite the fact that increased sums of money were made available at the first and second review of the programme, this has meant that fewer schemes could be undertaken.
Consequential deferment, and sometimes abandonment of schemes, has caused disappointment and a good deal of frustration among both hospital authorities and the public at large. It was for that reason that when I became Minister of Health, I was determined that the next review should tackle this problem. Any proposed schemes must now be defined adequately and costed as well as possible. The programme will be presented in terms of money. In a sense, it always was a programme in terms of money, but the mode of presentation tended to obscure that fact.
In addition, hospital boards are taking the opportunity to look again at priorities and to strengthen their planning links with other Health Service authorities. At this stage, I cannot say more about the progress of the review except to confirm my intention to publish a report next year, I hope not later than June.
The hon. Member for Somerset, North talked about the third review. I assure him that it is really a far more radical 2209 and more far-reaching review than the first and second reviews of the Hospital Plan. He talked about small hospitals. I should like also to give him an assurance that it is not my intention to eliminate small hospitals. Many of them, perhaps most of them, will be needed for many years to come. I repeat, as I have said before at this Box, that no small hospital will be closed or its use basically changed without the case coming to me for personal decision.
The hospital building programme represents quite simply the proportion of the national capital resources which can be devoted to hospitals. We talk of these things for convenience in money terms, but they represent the employment of physical resources. The amount of these available to the Government for public services as a whole is limited and the Government have to decide their broad distribution regardless of the source of the money to pay for them. It does not matter whether this money is raised by taxation or by lottery; indeed, it is a general Government conclusion that, on balance, the arguments, both financial and moral, are against Government sponsoring lotteries. We accept that there is an immense need for hospital building. We have to provide for increasing population and for new advances in medicine as well as for replacing many hospitals which are obsolete or are now in the wrong places.
Although there is almost no limit to the immediate needs, we have to be realistic in meeting them. In the early years of a building programme the capacity of the service to plan new hospitals was a limiting factor, and it would be again if the programme were to expand too rapidly. Furthermore, the national purse is not bottomless and there are many other claims on our resources. The hon. Member raised the question of the National Plan. That set out how the Government aim not only to balance the economy but also how it tackles the problem of resources allocation. The figures for hospital building in the Plan show a substantial rate of growth and they could be increased if future circumstances permit. The hon. Member referred to the rate of growth for health and welfare services as a whole. I think he has done his arithmetic incorrectly. I can assure him that the rate of growth 2210 is the same as that planned for public expenditure as a whole—4¼ per cent.
Since in the immediate future we cannot carry out more than a part of the total programme it is important to make the best use of the resources available to us by concentrating on the most urgent needs and leaving for later those hospital buildings which can continue in operation, with only minor improvements, to provide a reasonable standard of service for some years. We certainly must ensure that we get the best value for money by good planning.
There are two ways in which I can contribute to efficient hospital planning. I can give guidance to boards on what sorts of accommodation and equipment are needed, how these can best be provided, and what they should cost; and I can ensure that the examination of schemes in the Ministry leads wherever possible to their improvement and is neither unnecessarily detailed nor unduly prolonged. We have made and are making considerable progress in that respect.
I give guidance to boards by means of Building Notes, of which 28 have now been published, and also through the related series of Equipment Notes, Design Notes and Technical Memoranda. The aims of these Notes are, first, to show what we believe to be an acceptable standard of provision for the treatment and care of patients; secondly, to show how that standard can be satisfactorily achieved, and thirdly, to set a limit to the cost. We have told the boards that they may adopt the recommendations on the first two to the extent that they think fit, and that a cost allowance is a maximum and not a minimum. I do not want them to provide more expensive accommodation than they think they need merely in order to conform with some recommendation. On the contrary, I hope that they will continually seek more economical means of providing and operating hospitals while upholding proper standards of treatment, care, safety and maintenance. The more they can do this the further the money will go.
The cost allowances apply throughout England and Wales, and are for hospital departments, but a large part of the cost of any hospital building scheme is made up of what are called "on costs", which 2211 may be defined as the costs of putting the departments on the site. As the hon. Member indicated, these vary very much from one scheme to another, and largely account for the considerable differences in costs in building schemes of roughly the same size and scope. For example, it costs a good deal more to build a tall building on a restricted site than a low building on an open site. These differences in "on costs" will always exist but we are studying ways of reducing them and we are apt to be critical of schemes where they seem to be high. These differences, in their turn, are reflected in different costs per bed. But cost per bed is a very crude measure of hospital building costs and often, I think, highly misleading. For example, if a scheme consists of a ward block and nothing else, the cost per bed will probably seem to be very low. If, on the other hand, it consists of what are called supporting services, the cost per bed, if indeed there are any beds, may seem extremely high. Yet the second scheme may well fall more comfortably within the departmental cost allowance and have proportionately lower "on costs" than the first.
Already, a great deal has been achieved and more is being done. From the inception of the National Health Service to March of this year, work to the value of £310 million has been carried out, providing, among other things, 46,000 beds, 446 operating theatres and 337 X-ray departments—some additional and some in replacement. During the past three years, no fewer than 175 major schemes were completed, 68 substantially new hospitals and 193 other large schemes were started and no less than £147 million-worth of work is in hand at the moment. This represents nearly half of all that has been spent in capital costs on the Health Service since its inception.
It is sometimes said that only a few completely new hospitals have been built. This is a misunderstanding of the situation. It is comparatively rare for a new hospital to be constructed on a virgin site. The more usual project is the systematic reconstruction of an existing hospital which has to continue to function in the meantime. Moreover, the 2212 existing hospitals very often have one or more buildings which are perfectly sound and up to date. For this reason, it is usual to phase development and many schemes, though not new hospitals in the literal sense, are virtually reconstructions of existing hospitals. Since July, 1948, 13 hospitals have been newly built or virtually reconstructed, 67 partly reconstructed and 36 such schemes—that is, new hospitals and major reconstructions—are currently in progress. The success of the programme should be judged not only by the number of brand new complete hospitals but also by the improvement and modernisation of existing buildings.
The hon. Member mentioned, among other things, the Leagues of Hospital Friends. In passing, I should like to pay my tribute to the Leagues for the excellent work which they are doing. They are continuing to proliferate, I am happy to say, and they contribute greatly to the amenities for patients in our hospitals.
To sum up, it is not in dispute that a large hospital building programme—as large as possible within our resources—is desirable. Such is the importance which the Government attach to hospital building that hospitals were exempted from the general deferment of public building brought about by the economic situation last July. It is my hope and my firm expectation that the programme will continue to increase.
Mr. J. E. B. Hill (Norfolk, South)
Before the right hon. Gentleman sits down, will he bear in mind in his review the vital necessity of matching the hospital building allocation to the movement inwards of population to areas with a low standard of facilities at the moment—such as East Anglia—as, otherwise, the provision of hospital services will not be kept in step with the certain growth of new towns and other Government-sponsored schemes?
§ Mr. Robinson
I have assured the hon. Member before and I repeat it now that population growth is a factor which is being taken into account in the current review of the hospital building programme, which will lead to the fixing of allocations for the different regions.