§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Coleman.]
§ 1.11 a.m.
§ Miss Janet Fookes (Plymouth, Drake)I have sought the Adjournment debate tonight on the staffing level of the Royal Eye Infirmary at Plymouth because the position there is now desperate, and because all normal channels have been exhausted. The position can perhaps best be summed up in a letter that a patient at the Eye Infirmary wrote to me last weekend. She stated:
I have attended the Eye Infirmary this past six weeks, so I can speak from experience of how the consultants and nursing staff are working themselves into the ground trying to cope with the hundreds of people that need their help. I myself went to Mr. Ellis's clinic"—Mr. Ellis is one of the four consultants—and when he arrived to start work he had to push his way through the crowd of patients that were unable to find a seat. There were so many there that when I left two and a half hours later there was still the same number of people waiting for attention.In the final part of her letter she begs me to do all I can to help her and a number of other people who are very much affected by the situation.If one looks at the background one sees that it becomes worse. The Royal Eye Infirmary serves the population not simply of Plymouth but of the surrounding districts, about 412,000 people. In the summer months this number is swollen by the great influx of holidaymakers, so in summer we are thinking in terms of half a million people.
The waiting list is shocking. It is about 1,600 at present. Despite the fact that the amount of surgery has increased enormously, by 62 per cent since 1971, the waiting list remains the same. The waiting period for individual patients in a routine case—I put "routine" in inverted commas—can be two or three years. Imagine the misery, worry and anxiety that can afflict these individual patients as they wait to be seen. Eyesight is, after all, most precious, and should never be risked.
What is more disturbing is that there is evidence that some people have actually 465 gone blind while they were waiting. One case of which I know concerns a patient who had impaired vision. His doctor quite properly referred him to an ophthalmic optician who thought that there were early cataracts and referred the patient to the infirmary. He was put on the routine list—quite properly, as it seemed at the time. It was not until two years later that the patient was seen. He had cataracts, but he was also found to have glaucoma, and he went blind.
Even for one patient, that is intolerable. It is not something that I would care to endure, and I strongly suspect that the Minister would not care to endure it, either. I fail to see why my constituents or the people of Plymouth and the surrounding districts are asked to put up with something that I would not tolerate.
What is more, the position makes for great strain, not only physical but nervous, on the staff. How can they be expected to do a really good job in those circumstances? They do very fine work, but it must be a great anxiety to them to know that there are the present waiting lists. I know of a consultant who is away on sick leave, and it is a fair bet that his sickness is in part caused by the strain and pressure of the work that he has done.
There is no doubt that the key point is the shortage of staff. There are recommended minimum acceptable staffing levels laid down by the Faculty of Ophthalmologists of the Royal College of Surgeons. On those criteria, the staffing levels at the Royal Eye Infirmary in Plymouth are only 68 per cent of what the faculty regards as the minimum. I emphasise that that assumes that everybody is in post. In fact, through vacancies and sickness the present level is about 50 per cent. It is hardly surprising that the situation is becoming so difficult.
I have discussed with the consultants, and with one in particular who has acted as their spokesman, what they regard as the necessary additions to the staff. They are firmly of the opinion that what is required are two registrars, preferably one senior and one ordinary one, but certainly two. The registrars are in a sense the middle rank of staff. At present there is a complete lack of middle-rank staff at the Royal Eye Infirmary. There are 466 four consultants at the top and then junior staff underneath.
The difficulty is that if one consultant is away sick, on holiday or away for any other reason, there is no one who can take over his work. Registrars are sufficiently senior to be able to take operations on their own, provided the operations are not too difficult. They can take over the out-patient clinics and generally provide the specialised back-up for the consultants. They are consultants in training, and I should have thought that an area such as Plymouth, with its wide population base and the work that is already done at the Royal Eye Infirmary, would be an excellent training ground for them, apart from the value of the work they could give to the infirmary.
I have specifically asked whether the consultants would want another consultant to join them, and they have made it abundantly clear that a fifth consultant is not the option that they would wish. It is interesting to compare the position with that in Exeter, the nearest comparable centre, where there are two registrars and there are not the same difficulties. The appointment of two registrars is supported by not only the community health council and the district management team but the area health authority and, I understand, the regional health authority.
The procrastination that has occurred is almost beyond belief. The consultants put forward their recommendations for registrars as long ago as 1971. In the meantime there have been one or two other more junior appointments, but not these two key appointments. The latest news is that the appointments have been refused.
One must see the matter against the background that at no time has any high-ranking official in the DHSS administration to my knowledge visited the Royal Eye Infirmary since 1970 to discuss the position with the consultants. What is more, the then Minister of Health was made aware of the situation in 1975. He was also the local Member of Parliament for one of the Plymouth seats. Nothing appeared to be done, so we now face an extremely difficult situation where every conceivable avenue has been explored 467 and still one comes up apparently against a brick wall of refusal.
I feel that I must tonight ask the Minister certain direct questions to which I should like direct answers. First, who precisely is responsible for the decision to refuse the appointment of the two registrars? It is certainly not the lower levels. Is it the Minister? Is it some high-ranking bureaucrat whom we cannot get at? Who is it?
Secondly, what are the reasons for the refusal? I cannot find any good reasons at all. One presumes that there must be reasons of a kind. It would be interesting and constructive to know what those reasons are.
Thirdly, I should like to know why it is that no high-ranking official has come to the Plymouth Eye Infirmary since 1970.
Fourthly, and most important, does the Minister—does his Department—accept the views of the Faculty of Ophthalmologists about staffing levels, and, if not, why not?
Fifthly, what is the point of permitting a brand new operating theatre to be built —it is hoped that it will be in operation within the next 12 months—or of having excellent modern equipment if there are inadequate numbers of staff to make full use of the operating theatre and of the very modern equipment that is there?
The Royal Eye Infirmary has a long and honourable history. It has everything there to make it a very fine centre, but it is being held back by the lack of these two registrars, and the patients and the potential patients are suffering as a result of it.
I find that there has been a pigheadedness over this refusal which is almost past belief. I also find almost incredible the extent of the procrastination, since this has dragged out over some seven years. I look to the Minister tonight to give direct answers to these questions, and I trust that he will be able to override this pigheadedness and end the procrastination which is causing such difficulties in the Royal Eye Infirmary.
I must say that I have rarely felt so angry as I have over this particular issue. If the Minister does not give me a satisfactory answer tonight, I warn him 468 that I shall go on and on until the situation is improved.
§ 1.23 a.m.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)I am very pleased that this issue has been raised, since this will give me a chance to correct some of the wilder assertions which have been made in the local Press. I think I shall be able to answer the five queries that the hon. Member for Plymouth, Drake (Miss Fookes) raised.
The ophthalmology service provided from the Royal Eye Infirmary, Plymouth, is a subject which has been shown to be of considerable concern to many people —the staff working in the hospital, those whose task it is to manage the service locally, and the Plymouth Community Health Council, representing the interests of local people who have been very active in pursuing this matter and in attempting to enlist the support of hon. Members whose constituents look to the Royal Eye Infirmary at Plymouth for an ophthalmology service.
If we may first mark out the areas of agreement between us, there is no doubt that the waiting times for treatment, especially for out-patient treatment, at the hospital are unacceptably long. I certainly share the concern which has been expressed in this matter by the hon. Lady. Indeed, I sympathise very much with the people who are having to wait for treatment. It is a very difficult and worring time for them. It is especially worrying to have to wait such a long time to see a consultant after the general practitioner or local optician has diagnosed that something is wrong.
It is interesting to note that the inpatient waiting list at the hospital has not altered dramatically over the past few years. In March 1972 there were 222 patients awaiting admission for inpatient treatment. At the end of September this year there were 261 people awaiting admission.
In this respect at least we are facing a new problem. The problem of waiting lists and waiting times for hospital treatment in general has been with us a long time, since the inception of the NHS. It is a problem that successive Governments have had to contend with. Even in 1951, when the population was much smaller 469 and younger than it is now, the number on the waiting list was 500,000. At 31st March this year it was 596,000, but this is about 11,500 fewer than three months previously.
The size of waiting lists is governed by a number of inter-acting factors. I can identify about nine separate factors including fluctuations in the level of illness, changing public expectations of our ability to treat it with new surgical techniques, changes in population, the referral practices of general practitioners, consultants' clinical decisions, seasonal influences, the availability of resources, and, of course, our ability to manage them efficiently.
The hon. Lady has concentrated on staffing resources, in particular medical staffing in the senior training grades. But this is a very complex issue and it does not follow automatically that, even if the medical staffing problem, is solved, three will be a significant reduction in waiting lists.
However, the responsibility for managing the service rests with health authorities and it is they, in consultation with the intested parties, who have to seek a solution to local problems. I think that the hon. Lady's view would be that the local health authorities have attempted to tackle the problem at the Royal Eye Infirmary by creating new registrar posts, but have been prevented from doing so by the Department. That is not an accurate representation of the situation. I ought to stress that my Department has never suggested that there is not a need for additional medical staff at the Plymouth Royal Eye Infirmary.
The only point of disagreement with the local health administration is about the grade that is required to remedy the situation. To understand why this latter point should be a matter of national rather than local decision it is necessary to look at the whole question of staff in NHS hospitals. Ever since the early days of the NHS there have been disagreements about the role of doctors in junior posts. The difficulty is to identify whether they should be regarded as training posts or primarily as service posts.
On the latter view—that is the service post—junior doctors are employed essentially as assistant consultants, and are 470 asked to carry out the more routine or simpler medical tasks, thus leaving consultants free to deal with the particularly difficult cases. Although there are arguments that can be put forward in favour of this view, the difficult question is what is to become of the junior doctors.
Medical students are chosen from the brightest section of the population and have a long training. Virtually no qualified doctor wants to spend his time doing the simpler medical tasks under supervision, and all those young men and women in the hospital training posts want the opportunity to practise the full range of skills and to accept full responsibility for the care of patients as consultants. If there are too many juniors in relation to the number of consultants, this will not be possible.
On average, a consultant is in post for 30 years and a registrar for two. During his professional career, therefore, the consultant could train 15 registrars. One of these could replace him when he retired, but what would become of the other 14? They would have spent a number of years acquiring highly specialised skills which they would then be unable to use.
Some might enter general practice, but it is surely preferable that our future family doctors should be trained as family doctors rather than as opthalmologists or surgeons. Some would remain in training posts long after they had completed training, becoming progressively more and more dissatisfied. Many would emigrate. In fact, it is generally agreed that it was the lack of career prospects for junior hospital doctors under the old system which led many of them to emigrate and resulted in the high level of emigration in the 1960s. We would not want to encourage that any more.
The hon. Lady argued that Plymouth was asking not for one registrar for each consultant but for one to be shared between two or even among four consultants. One can go through exactly the same argument again. If every consultant has a registrar, 95 per cent. of these registrars cannot then find suitable posts. If there is only one registrar for every four consultants, this figure drops to 75 per cent. of registrars. This is surely still unacceptable. It is only when one reaches one registrar for every 10 or more consultants that the figures come into balance.
471 It has been argued that these calculations take no account of doctors from overseas who come here for training and then return home, or of general practitioners who choose to gain extra experience in a hospital speciality, or even of doctors who leave medical practice because of marriage or who die. The answer is that in the speciality of ophthalmology there are presently more doctors being trained for consultant posts than can hope to find them. The result is that there are twice as many doctors looking for posts as posts available, so that applicants are spending far longer in the training grades than is necessary, and are not being appointed consultants the training grades than is necessary, This situation has arisen over a period of many years, and everyone must recognise that it is far from ideal. It would be foolish to make it worse.
This attitude has been criticised as putting more emphasis on offering a career to doctors than in providing a service for patients. I think we must recognise that it is impossible to provide any service to patients without doctors, and no employer can ignore the legitimate aspirations of his employees. The problems of medical staffing in hospitals have been discussed with the profession on a number of occasions, and a number of schemes have been tried without a great deal of success.
In the late 1960s, the Department of Health and Social Security agreed with the profession that the junior grades would be regarded as primarily training rather than service grades and that service needs would be met by the appointment of consultants. This agreement was debated extensively within the profession, and, unless it is re-negotiated, it is an agreement which we regard as binding on the Department. Therefore, this whole question of meeting service needs is a matter in which the profession takes at least half of the responsibility. I do not disagree with that view, because we have entered into an agreement with the profession on that basis.
There is a joint committee of the profession and the Health Departments to look at questions of hospital staffing —the Central Manpower Committee—and it was on the advice of this committee that I turned down the application for a registrar post at Plymouth Royal Eye 472 Infirmary. I turned it down on the advice of the profession, amongst others.
Reference has been made to a report of the Faculty of Ophthalmology on staffing, but this reflects a school of thought which I mentioned earlier—that junior doctors are there primarily to act as assistants to consultants. Therefore, that is the reason why we do not accept the views of the Faculty of Ophthalmology in these matters.
If I may summarise what I have been saying, it is the advice of the Central Manpower Committee that the needs of Plymouth Royal Eye Infirmary could best be met by an additional career appointment—either by the appointment of a general practitioner working part time in hospital, or by the appointment of an additional consultant. The hon. Lady said that all avenues had been explored, but this is one avenue which does not seem to have been explored by the local people. If there is any pigheadedness—and I do not suggest there is—that is where it lies. We are saying that we can appoint a consultant to the infirmary. That is the way the profession wants us to work and it is the way we have agreed we shall work.
Central approval is needed to create a new consultant post, but I can assure the hon. Lady, that if a request for such a post were made by the South-Western Regional Health Authority, we would give it speedy and sympathetic consideration.
There is one more point here which is often overlooked, and which I should stress. No other country in the world relies on doctors in training to provide a major element in staffing the hospital service. It is surely more reasonable to provide a service with fully trained and skilled doctors, including GPs of the kind I have mentioned.
Having explained at some length why my Department is unable to agree to a particular course of action to increase an aspect of the medical staffing at the Eye Infirmary, I think it is worth noting the development that has taken place in the merical staffing there in recent years. In 1971 there were four consultants plus one medical assistant working at the hospital, and they had no junior staff in support. In 1977 there are four consultants, three senior house officers—a fourth 473 will take up appointment in January 1978 —two medical assistants, one full time, the other "maximum part time" spending six sessions a week on the school eye service, and two clinical assistants, one working two sessions a week, the other, a retired consultant, working a single session, whose duty it is to scrutinise the referrals from general practitioners for out-patient appointments so as to ensure, as far as is possible, that cases requiring urgent attention are not missed. Thus, one can see that, whatever else, we are not this evening talking about a victim of "the cuts". In any case, I believe the hon. Lady thought that the cuts had not been deep enough.
How, then, is it that if I can point to six years of development on the medical staffing front I cannot point to a corresponding development—and by that I mean a reduction—in the infirmary's waiting list? I have already dealt with this in my remarks on the overall problem of waiting lists. I must mention the interacting factors which go to make up the overall problem. I have mentioned that general practitioners' referral practices affected the position as did surgical developments and the public's expectations of our ability to cope with them. In short, the quality of the ophthalmology service provided from the Plymouth Royal Eye Infirmary is as good now as it ever was—and, in all probability, for the most part a good deal better. What has changed is our expectation of that service.
I do not, however, in any way wish to appear complacent, and I have acknowledged that waiting times for treatment at the infirmary are unacceptably long. I have indicated how my Department thinks, on the basis of advice from the Central Manpower Committee, that the 474 infirmary's staffing problems might be tackled in a certain way.
Before closing I should also mention other improvements which local management plans to make to the fabric of the infirmary—improvements which are factors bearing on the overall position. First, I would stress that a surgical service is dependent on its operating theatres and the infirmary is deficient in this respect. The theatre opens directly on to a main corridor and has a wooden floor which vibrates when the train passes. I have to travel on that train tomorrow, and I shall have an immediate reminder of tonight's debate. Work to provide a new theatre in an improved location will start in early 1978.
Secondly, I would point out that the specialty of ophthalmology is characterised by it proportionately high out-patient bias, and here again improvements to the infirmary's out-patient department will begin shortly. The cost of the new theatre and out-patient department improvements will be about £200,000.
That is the solution to the infirmary's problems. It is a solution that the profession wants and it is a solution that the profession has agreed with the Department and the Department with the profession, namely, that there should be fully trained doctors or a doctor appointed to the infirmary, and a consultant or general practitioner is the sort of skilled person who fulfils that category. If a request for a consultant for the hosptal is made to my Department, we shall regard it with a great deal of sympathy.
§ Question put and agreed to.
§ Adjourned accordingly at twenty minutes to Two o'clock.