§ 4.30 p.m.
§ Mr. Michael Neubert (Romford)
Christmas is, by welcome tradition, a time of good cheer, family reunions and renewal of old friendships. But for some people this Christmas, like previous Christmases, will be an unhappy time—a time of anxiety and even a tragic occasion. Among those people will be patients in hospital and particularly patients in neurosurgical units such as the one at Old-church Hospital, Romford.
Among those already in the unit, and those who may be admitted as emergencies during the Christmas holiday, are casualties of horrifying accidents, on icy roads and victims, of all ages, of brain tumours which are indicated by memory failure or the loss of limbs. For these people and their families, Christmas is a miserable time, and the existence of the neurosurgical unit is their only hope for survival. Therefore, the concern expressed by the public at the possibility of the closure of the neurosurgical unit at Old-church Hospital can be easily understood.
The anxiety arises from the publication of draft proposals in the regional health plan, which is a strategic plan. Although, judging from the extracts that I have seen, that document in both original and revised form is not one of the utmost clarity, the threat to this unit is undoubted. The threat was confirmed by the regional medical officer in a letter he sent to me at the end of October.
1010 I appreciate the opportunity to raise this most important matter on behalf of my constituents and others. As coincidence would have it, it was my good fortune to be able to speak in an Adjournment debate on the eve of the Summer Recess. I spoke about the River Roding improvement scheme, which would prevent flooding—against which even last summer's record-breaking drought was no defence. There was a co-operative and vigorous response from the Ministry of Agriculture, Fisheries and Food. Approval was given to the appropriate grant, the contract has been let, and work has started. Therefore I look to the Minister this afternoon for an equally encouraging reply to my representations on this subject.
It seems strange to many people that there should be any question that such a fine neurosurgical unit as the one at Oldchurch Hospital should be closed now or at any time in the future. There has been a neurosurgical service at the hospital for about 30 years. For most of the time neurosurgical patients were distributed throughout the general wards, and that still happens in the case of children. Such an arrangement is not ideal for patients or for others in the wards, because the Presence of extremely ill patients is bad for morale.
The unit's service to the community can be measured in terms of 600 to 700 admissions annually. The need for the service is therefore established with absolute certainty. What appears to be behind the proposals for the possible closure of the unit is the financial limitation set upon the National Health Service, which is manifesting itself in this direction and in others.
There has been a review of all the neurological and neurosurgical services of the region and of the need for such services to be combined into a number of smaller units. This has been prompted by an agreed DHSS norm of 25 neurosurgical beds per million of the population. In the North-East Thames Region, within which my constituency falls and which extends from East Ham in London to the Essex coast—so that I am speaking not for my constituents alone, but for people in places as far apart as Chelmsford, Colchester and Southend—there are 41.9 beds per million of population, 1011 though that figure, given to me in a Written Answer, does not necessarily take account of the demand on the region's services by the North-West Thames Region.
We have here an established unit, and the proposal may be to retain units with at least 60 beds. The neurosurgical unit at Oldchurch would certainly qualify on that criterion because it has 50 beds with 10 supporting neurosurgical beds.
It is astonishing that there could be any question of such a unit being in danger of closure, but there are difficulties, to which I shall refer later, which may complicate the issue.
There is a proposal that the existing units at the London and St. Bartholomew's Hospitals in London should be expanded. The London has 50 beds, St. Bart's has 30 beds, and Oldchurch has 50 beds. If there is an established demand for beds it can be met, on present figures, only by a substantial expansion of facilities in London teaching hospitals.
But these hospitals are already in difficulties, as is known from reports in the Press and elsewhere. Not all wards are functioning, and there is a crisis in finance. It would seem the utmost folly to embark on such a reorganisation when the hospitals already face enormous difficulties.
Special factors affecting the neurosurgical unit at Oldchurch are not entirely those of finance; they also stem from a shortage of skilled staff, particularly neuroradiologists. This is a reflection of a general national problem, as I am advised that there are 70 vacancies for consultant radiologists in general and, as neuroradiologists have to spend a further year or two in training and receive no increased remuneration for undertaking this work, the problem with them is even more acute.
This has resulted in Oldchurch never having had a permanent neuroradiologist. It is hoped that if the future of the unit and the necessary finance can be assured, better facilities can be made available at the hospital, including the provision of an ENI scanner, the supply of which is committed to the financial year 1977–78. These better facilities would attract people of the necessary calibre.
1012 There is also a problem with neuropathologists, but I make no reference to that except to say that no appointments of consultant neuropathologists were made in England or Wales last year, though I do not know what that determines.
There is also a problem with junior staff which relates, in part, to their preference to stay with their teaching hospitals. If it is not unique, it is certainly unusual for a neurosurgical unit to be provided outside a university centre. Apart from two examples in Germany, in Europe it is apparently unknown. It is therefore something of a pacemaker project that there should be a neurosurgical service at Oldchurch at all, only half an hour's drive from the London hospitals.
There is the important question of nursing support for the service. Although Bart's has a one to one ratio in its nursing staff in this service, at Oldchurch the ratio of nurses to patients is one to 1.9, which is only half as good. This relates to historical funding of the nursing establishment for the service, and it should be remedied. In this service there is a high dependency by patients on their nurses. Some patients need as many as three nurses, because they are on the very edge of life and death, and every palpitation is a small achievement.
All these problems will be aggravated in the immediate future by the EEC directive which allows skilled staff in the medical service to go abroad much more easily. This is particularly pressing in neuroradiology because only a minimum amount of a foreign language is required for such people. They are not in daily conversation with patients on anything other than rudimentary matters, and they are very much attracted by the higher salaries and better conditions of work.
In my considered view it would be a calamity for this unit to close. The debate on the closure will take place in the next six months. The regional hospital authority has decided that the decision must be reached by the end of June next year, and I am determined that this should be a matter for full public debate and not something that is decided in the rarified atmosphere of medical politics or the back rooms of hospital administration. The public is very concerned about this matter.
1013 If the closure were to proceed there would be four elements in that calamity. First, the closure would be a waste of public money. The unit is in purpose-built premises which were re-established in 1973 at a cost of £181,000. It is probably double that value now. There would be a great loss of public assets if the purpose of the unit were changed. At present, each bed has an oxygen suction pipe leading to it, designed for the purposes of the unit. If that purpose is changed, the result must involve a loss of taxpayers' money.
Secondly, there is the consideration of the current policy of dispersal of resources. If resources were concentrated in central London it would run counter to the proposals of the Resource Allocation Working Party Report. In the North-East Thames Region, the main distribution of resources is from the centre of London out to Essex, and Romford, which is about mid-way between the two, would benefit to the tune of £2 million on the present proposals. This would go a long way towards meeting the shortcomings of the neurological service.
Thirdly, the closure of the unit could be very inconvenient for some patients and their families. Romford is very easy to approach both by road and rail. There would be perhaps a very small number of cases—I do not want to exaggerate this—which could be adversely affected by the extra time taken to bring them into London for neurological treatment. Some injuries are so critical that every minute counts. The number of deaths that might be caused by the extra time might not be more than one a year, but I would think that that factor alone would lie on most people's consciences.
Fourthly, the closure would mean the break-up of a skilled team, consisting of the consultant neurosurgeon, Mr. Fair-bairn, and other skilled staff. I am indebted to Mrs. Temple, who is head of the area social services team in my constituency, who pointed out the relevant points from Gaius Petronius, who was adviser to Nero in AD68. He said:We trained hard, but it seemed that every time we were beginning to form into teams we would be reorganised. We tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.1014 That is most appropriate to devolution, local government reorganisation and the reorganisation of local health services.
I therefore make a plea to the Minister to use his influence with the authorities responsible for these decisions in order to ensure that they think most carefully. They then may well decide to leave well alone—indeed, to give renewed support to this unit so that it may continue to give to the community the vital service it has provided in the last 30 years.
§ 4.45 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)
I should like to thank the hon. Member for Romford (Mr. Neubert) for raising this topic and for the way in which he has done so, ending with that delightful quotation which will serve many other purposes in debates. The debate is of great importance to his constituents and to other people in the region, including some of my constituents who are within the same regional area. The debate gives me a chance to say something also about our efforts to bring a coherent pattern to the Health Service.
Following the reorganisation of 1974, a reorganisation devised by the previous Administration, one positive benefit is being developed. That is the emergence of a co-ordinated planning system. This was introduced in April this year and is intended to encourage the maximum devolution of responsibility for deciding the future patterns of service to those who provide the services, within guidelines set down by my Department. Its aim is to ensue the most effective use of resources locally for the benefit of those who use the service. The system operates at both strategic and operational levels.
The first set of strategic plans identifying general priorities for the development of services in the medium and longer term—that is, 10 to 15 years—will be submitted to my Department by each region in January 1977. These will reflect and coment on the Department's view of priorities as set out in the consultative document "Priorities for Health and Personal Social Services in England". Strategic plans will be fully revised every four years, but at first more frequent revision will be needed until the planning system has become fully effective, and in any event they will 1015 be reviewed annually to consider whether particular aspects may need to be modified in the light of the shorter-term operational plans, new policy developments and changed resource assumptions.
Shorter-term operational plans, containing the specific proposals for each of three years ahead, are prepared at health district level. The area health authorities will incorporate the district plans in their operational plan. Regions will submit annual planning reports to the Department on expected progress towards achievement of agreed strategies and will take account of these operational plans.
What we are seeing now is the emergence of these first strategic plans. There should be consultation on both strategic and operational plans with a wide range of interests, and when the system is operating fully there should generally have been ample opportunity for consideration of developing ideas by all those with an interest before they become firm proposals for the first year of the operational plan.
The North-East Thames Region has issued its first draft strategic plan for consultation to advisory committees. Following the meeting of the authority on Monday 20th December, the plan, with some slight alterations, will be issued more widely for consultation. I shall be returning to the content of that plan later in my speech.
The 1972 White Paper on NHS reorganisation in England recognised the need to establish special co-ordination machinery for London. The London Co-ordinating Committee was established early in 1975 and consists of officers who represent the various health, academic and local authorities in London. Its terms of reference areTo co-ordinate the provision of health services in Greater London with reference to the matching of medical education and service needs and securing a rational distribution of specialised health services".At a subsequent meeting of the committee in June 1975, it was agreed that a working group should be set up to consider the scope for rationalisation of services for cardiological and neurological medicine and surgery in London. The working group was chaired by an officer 1016 of my Department and its membership comprised representatives of the Department, the four Thames regional health authorities, the National Heart and Chest Hospital and the National Hospital for Nervous Diseases. The representative from the North-East Thames Regional Health Authority was also a consultant neurologist at the London Hospital.
The final report of the working group was approved by the London Coordinating Committee on 25th May 1976 and on 5th August 1976 it was issued to the four Thames regional health authorities, which were asked to take account of the recommendations in the report when framing their operational and strategic plans for the services in question.
Before telling the House something of the report of that working group set up by the London Co-ordinating Committee and the recommendations it made in respect of nerology and neurosurgery, I should explain a little about these specialities.
Neurology and neurosurgery facilities are mutually dependent upon each other. The neurologist, having made a diagnosis, often needs the assistance of the special surgical skills of the neurosurgeon. Many patients who undergo neurosurgery will have been investigated by a neurologist and many more will return to a neurologist's care when surgery has been completed. Both neurologist and neurosurgeon require the help of others—for example, in radiology and pathology—who have specialised in the diseases of the brain and spinal cord.
A very wide range of highly specialised skills must therefore be brought together, and these skilled people should be supported by a wide range of expensive and rapidly developing diagnostic tools like the EMI scanner. Such diagnostic tools are expensive; the EMI scanner alone will cost at least £200,000. For the foreseeable future, it would be quite impossible to provide these facilities in each district or even each area. Patients' needs are best served by being transported to hospitals where skilled personnel and advanced technology can be concentrated.
The Royal College of Physicians has recommended that neurology and neurosurgery should be provided in unified departments. The minimum population served by such a unit should be between 1017 1 million and 1.5 million wtih a maximum of 2.3 million. The North-East Thames Region has a population of about 3.7 million. At least 30 neurology beds per million population are required, and neurosurgical beds are also required to be provided on the scale of 30 per million population. A minimum of 60 neurology/ neurosurgery beds in a unit is necessary for efficient working and justifies supporting services—for example, neuroradiology and neuropathology.
The working group recommended, as a basis for further planning, that three centres should serve the North-East Thames Region, plus centres at the National Hospital for Nervous Diseases and the Hospital for Sick Children. The working group also expected that districts will require the support of consultative advice in neurology, but with any further neurological beds that regions consider it necessary to identify provided on a sub-regional, not a district, basis, backed by neurosurgery and neurology, established together in a small number of regional centres.
In particular, with reference to North-East Thames the report said:The south-east sector of the North-East Thames region is served by three units—St. Bartholomew's London and Oldchurch. The RHA should examine the possibility of concentrating major neurosurgery on two centres. It is understood that Oldchurch is difficult to staff and therefore, despite the fact that this would repereseent a less than ideal geographical solution, it may be that St. Bartholomew's and the London should be the centres.In the north-west sector of the North-East Thames region services are based on the Whittington and University College Hospitals, which also serve the North-West Thames region. The possibility of providing services at one centre should be examined.It is this report which has aroused so much feeling in the hon. Member's constituency. I must emphasise again that this is a recommendation made by a group of experts and it is within the Department's guidelines.
Let us examine the recommendations again. The report simply says that the regional health authority should examine the possibility of concentrating major nuerosurgery on two centres in one sector and one centre at the other; it does not specify the centres. It does, however, point out that if Oldchurch is difficult to staff, it may be better, despite the geographical 1018 difficulties for patients in Essex, for all the neurosurgical centres to be sited in London. However, the hon. Member has pointed out that there are other factors which can be taken into account.
Now let me return to the North-East Thames Regional Health Authority's strategic plan. This plan has not yet been submitted to my Department. However, copies of the first draft strategic plan were issued for consultation to various advisory committess within the region. No doubt the hon. Member is aware of the content of that plan. The plan contained an edited report of the North-East Thames Region's own strategic planning group on the definition and future consideration of regional specialties.
That strategic planning group also made recommendations. If I may, I will quote them:The evidence suggests that there are too many, widely scattered, often under-used and small units of neurology and neurosurgery beds providing too many in-patient beds, even taking into account the commitment to North-West Thames patients. We recommend the centralisation of these services into no more than three Regional Units, one in each teaching area and one at Oldchurch Hospital. The representative from City and East London wishes to be dissociated from this recommendation. In the opinion of the remainder of the group, the service to patients will most conveniently be provided in this way and the location of the units in the teaching areas will depend on the economies of the provision which is needed, taken in conjunction with advisory committee recommendations.Those recommendations were made to the regional health authority, but they are not firm proposals.
On Monday 20th December the North-East Thames Regional Health Authority had a meeting to consider its draft regional strategic plan. At that meeting I am told it was agreed that the draft regional strategic plan, with preliminary amendments, should be issued widely for consultation within areas within the region. Consultations, I am told, are to continue until March next year on any aspects of the plan, while a considerable number of specific points will be open to consultation until June 1977. The location of the neurology and neurosurgical units is included in those points. In other words, the regional health authority does not expect to be in a position to make a firm proposal about neurology and neurosurgery before June 1977.
1019 The draft regional strategic plan with preliminary amendments contained the following statement of regional policy:Neurology and neurosurgery. The regional policy is that these specialities should be considered and planned together. Planning considerations suggest a need in neurosurgery for some 180 beds: clinical considerations suggest that units of some 60 beds are the most practical. In those circumstances, one of those units should be in the western sector of the region, the other two in the eastern.In the western sector, two sites are possible for the one unit proposed: the Whittington Hospital and the Royal Free Hospital.In the eastern sector, three sites are possible for the two units proposed: St. Bartholomew's Hospital, Oldchurch Hospital and the London Hospital.The regional health authority is aware of the difficulty of the decisions involved in this matter. It considers therefore that discussions should take place with all those concerned, and in the light of those discussions will make the necessary decisions by June 1977.The regional authorities are right to consider the best and most economical use of their precious resources. But I must repeat that no firm proposal has yet been made while discussions are still to be completed. Further, no firm proposal will be implemented without full discussions with local interests, including advisory committees and community health councils, as laid down by my Department. There will no doubt be a full public debate.
The major contribution made by Oldchurch is widely recognised, but I am told that an additional problem there derives from an acute national shortage of the specialised skills required, particularly in neuroradiology. The concern of everyone is to make the best possible use of the extremely scarce and highly skilled clinical resources available and provide a high quality service.
Should, finally, a proposal be made to close the Oldchurch unit and that proposal be opposed by the local community health council, then, and only then, will my Department be involved, when the Secretary of State will be required to make a decision.
In general, responsibility for determining the closure or change of use of health buildings rests with the appropriate area health authority, provided that the local community health council 1020 is in agreement. Where there is general local agreement, it should be possible to effect a closure or change of use within a period of six months.
If, having discussed informally a particular closure or change of use with the interested organisations, an area health authority considered such a measure would be beneficial, it would have to institute formal consultations. In this event the procedures require the authority to prepare a consultative document covering a variety of matters, to put that document to the public and to invite comments. Hon. Members whose constituents were affected would also be informed of the proposals.
The area health authority would then seek the community health council's views on the comments it received and on its own observations on those comments. The authority would then review its original proposals in the light of the comments received and, unless there were strong local opposition, it could then implement its original proposals provided that the community health council agreed. The regional health authority and my department would be informed of the decision.
However, if the community health council objects to the authority's proposals, it is required to submit to the authority a constructive and detailed counter-proposal. The matter must then be referred to the regional health authority and, if the regional health authority is unable to accept the views of the council and wishes to proceed with the closure or change of use, it falls to my right hon. Friend the Secretary of State to act as arbiter. Nothing I say today should therefore be construed as prejudging the issue.
§ Mr. Deputy Speaker (Mr. Bryant Godman Irvine)
I should like to take this opportunity of expressing to this rather select Sitting my good wishes to the whole House for Christmas and the New Year.
§ Question put and agreed to.
§ Adjourned accordingly at one minute to Five o'clock till Monday 10th January, pursuant to the Resolution of the House yesterday.