§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Jim Marshall.]
§ 1.5 a.m.
§ Mr. Tim Sainsbury (Hove)
I am glad to have the opportunity to initiate a brief debate this morning on the National Health Service resources available to the Brighton health district.
I should like to make two points clear initially. First, I am not attacking the National Health Service as such, and least of all the devoted work of the medical staff and the nurses, and the commendable efforts of most of the ancillary staff, to provide to all patients the best possible care. I would stress, indeed, that the Hove District Hospital is a model of what can be achieved by way of the best possible care in premises that are over 100 years old. Secondly, I am not calling for additional Government expenditure. I wish that it were available. Indeed, it is a depressing thought that capital spending on the NHS has declined so substantially over the last four years. If the economy had been rather better managed by the Minister's administration, perhaps we would have more money available for the many and evident needs of the NHS.
What I am asking for is a fairer allocation of the available resources for the 1535 Brighton health district, within which is my constituency of Hove. I should explain that I am not asking for this at the expense of the Eastbourne or Hastings health districts, which together with the Brighton health district make up the East Sussex Area Health Authority, because I know that both of those health districts have very similar problems and similar populations to those of the Brighton health district. What I am saying is that the East Sussex AHA as a whole is not getting a fair share of the resources available to the South-East Thames Regional Health Authority.
§ Mr. Sainsbury
As the Minister knows, the basic method of allocating resources is by means of a formula arrived at by the Resource Allocation Working Party. If for a moment we accept that that formula accurately reflects the need for resources, it is clear that the East Sussex AHA and the Brighton health district are seriously under-funded. The RAWP target allocation for East Sussex last year was £58.5 million, and yet the allocation this year is only £51.75 million—a very considerable shortfall of nearly 15 per cent.
To achieve the full RAWP target by 1986–87 would require an additional £12.5 million to be added to the existing allocation to East Sussex. That gives us an indication of the size of the problem. I do not see how the problem can be reconciled with the Secretary of State's statement in December 1976, when he said:I am determined that the resources of this national service should be more fairly shared. Redistribution must not only be between regions but within regions.The Minister quoted that on 3rd March this year, as reported in Hansard for that date, at column 939.
But I would further argue that the RAWP formula does not fairly reflect the needs of Brighton health district and East Sussex AHA. There are several reasons. First, I would cite population growth. Between censuses, area population statistics are always suspect, because they tend to underestimate migratory movements and are likely to understate the population of areas such as Brighton. The population in the area must be 1536 expected to continue to grow over the next decade, and this will continue to exacerbate the severe shortage of health care facilities.
It is calculated that if the RAWP formula remains unchanged and the population forecasts for the county prove fairly accurate East Sussex will require an additional £5.6 million by 1986–87 to provide services for the additional number and changed age structure of the population at that time.
The second reason why I believe that the formula does not accurately reflect the needs is that it takes no account of holiday visitors or student populations. Not only is the area attracting far more holidaymakers but the season is lengthening and students, including language students—a growing area—are present throughout the year.
The third reason is that National Health Service facilities in the area are old and expensive to run and maintain. The area's ability to meet the needs of the population is further aggravated by the age of the buildings, especially the geriatric accommodation. The current valuation of the capital stock is £68.9 million, compared with the RAWP target of £93 million.
But the fourth and by far the most important reason for doubting the RAWP formula being fair is the weighting given to the population make-up. Whilst the formula takes account, perhaps inadequately, of the over-65s, it does not take account of the proportion of over-75s. The Age Concern publication "Profiles of the Elderly" suggests that 35 per cent. of health and personal social service expenditure is devoted to those over 65, who are 17 per cent. of the national population, and no less than 20 per cent. to the over-75s, who are only 5 per cent. of the population. So they need four times the national average expenditure per head. The Brighton health district has 22.6 per cent. of its population over 65 and 9 per cent., which is nearly twice the national average, over 75.
The validity of the standardised mortality ratio for older age groups is highly suspect. That also adversely affects the allocation of funds on the morbidity factor in the RAWP formula for those areas with an above-average elderly population, as in the Brighton health district.
1537 The age structure of the population of East Sussex is perhaps the most outstanding characteristic of the county. A quarter of the residents are over 65 and a tenth are over 75. Population projections by the county show that by 1986 the population will have increased by 32,000 or 5 per cent., but that the total of over-75s will have increased by 26 per cent. to over 84,000, reaching 12 per cent. of the population.
The elderly make heavy demands on nearly all parts of the NHS, and make especially heavy use of hospital beds. It is not always appreciated, however, that this use is of acute hospital beds as well as of geriatric accommodation. The elderly suffer a much higher proportion of acute illness, as well as chronic disease, than other age groups. For example, much of the work of the orthopaedic service is in treating fractures of the hip in old ladies.
The elderly also make heavy use of many high technology and expensive acute services. About one in three of admissions to a coronary care unit are patients aged over 65. The need for cardiac pacemakers also rises steeply with age, as do the need for joint replacements and the use of radiotherapy and chemotherapy for cancer. For example, a population with 24 per cent. aged over 65 would be expected to produce 47 per cent. more malignant disease than the same size of population with an age structure similar to that of England and Wales. That is the sort of position we have in East Sussex. Even such new developments in technology as the whole-body scanner are likely to be used to a considerable extent for elderly patients. Moreover, the social and other difficulties faced by many elderly people means that their length of stay in hospital, even for acute conditions, is longer than for the middle-aged.
All these factors underline the fact that a population with an age structure like that in East Sussex puts considerable pressure on the acute hospital services.
The implications of a population with that age structure for community services are just as great. The simple aim of maintaining reasonable mobility in the elderly requires considerable investment in chiropody services. Common to the proper functioning of hospital day care and community services is the need for an adequate 1538 transport facility. Public services are limited and, in any event, present real difficulties to the elderly, especially those with some disability. This throws a considerable burden on ambulance and hospital care services, which are at present unable to meet all the calls upon them.
Even on the basis of the RAWP formula, Brighton health district is seriously under-funded. These inadequacies in the formula make the shortage of resources that much worse.
Let me give a few brief examples of what this means on the ground. Although in the area there is a desperate shortage of psycho-geriatric beds, it has been possible to open only half of F-block at the Brighton General Hospital, which would provide just the beds needed, with 35 left unused. At this moment there are 35 chronic sick in need of hospital accommodation who cannot be accommodated, mainly because the district has a shortage of 257 beds, or 41 per cent. of its estimated needs. There are excessive waiting lists for non-acute treatment. In Portslade it has not been possible to start on the desperately needed health centre, with the inevitable result that doctors struggling to work under poor conditions are not able to give of their full potential.
I wish to conclude by putting some specific questions to the Minister which I hope he will be able to answer in his reply, or will let me have a reply shortly after this debate.
First, will he review the RAWP formula to ensure that it takes adequate account of the demands on the NHS by the elderly, especially of the over-75s? Secondly, will he undertake to ensure a faster reallocation of resources within the South-East Thames Regional Health Authority? Thirdly, will he as soon as possible come down to Brighton and Hove to examine our problems? I regret that the Minister of State has not yet been able to accept the invitation issued to him by my hon. Friend the Member for Brighton, Kemptown (Mr. Bowden) on the grounds that his diary is full until August. I regret even more that the Secretary of State for Social Services found time this week to visit China rather than East Sussex.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
My right hon. Friend was in 1539 East Sussex a few weeks ago, met the area health authority and discussed its problems at a meeting there.
§ Mr. Sainsbury
I am grateful to the Minister for that intervention. Unfortunately, the right hon. Gentleman did not come down as far as Brighton and Hove to talk to those on the ground, including Members of Parliament.
My final question to the Minister is to ask whether he will undertake that any additional resources that become available are allocated primarily to make up the shortfall in funding in areas such as the Brighton health district.
§ 1.17 a.m.
§ Mr. Deputy Speaker (Sir Myer Galpern)
Has the hon. Member for Lewes (Mr. Rathbone) obtained the agreement of the hon. Member for Hove (Mr. Sainsbury) to take part in the debate?
§ Mr. Rathbone
My hon. Friend has allowed me to associate myself with him in the debate.
Half of the Lewes constituency falls within the Brighton health district. The points made by my hon. Friend apply equally to my constituency as to the rest of the Brighton health district. I wish to congratulate my hon. Friend on instigating the debate and to associate myself on behalf of all my constituents with all he said.
§ 1.18 a.m.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
We have had a brief debate on the resources allocated to East Sussex for National Health Service purposes. I am grateful to the hon. Member for Hove (Mr. Sainsbury) for not asking for increased public expenditure. It is a temptation to which Opposition Members sometimes succumb to ask for public expenditure in particular cases while being opposed to it in general. I am glad that in this instance he avoided that pitfall.
My right hon. Friend the Secretary of State for Social Services has spoken a number of times about the Government's commitment to a fairer distribution of financial resources to the NHS in relation to health care needs, not only among the 14 regions of the country, but within the regions as well, because 1540 some of the biggest inequalities are between rich and poor areas in the same region. My right hon. Friend and I are equally determined not to destroy the quality of excellence in the NHS—for example, in teaching, which is absolutely vital for the future of the National Health Service in the opportunities to discover new techniques.
We do not want to put existing basic services at risk. Therefore, the task facing the Health Service under the RAWP is to strike a proper balance. The resources of the NHS are at any one time finite and we have to ensure that no community is deprived. At the same time, we want to ensure that significant imbalances in some regions are straightened out because the South-East Thames Region is a striking example of imbalances within a region.
The problem, with such a wide range of health services available, has always been how to devise a practical means of securing the necessary allocation of provision. From the beginning of the Health Service until fairly recently, successive Governments relied on historical factors, but the experience of relying on such factors was that the resources of the NHS went to the parts of the service where the activity was already greatest and served to increase the disparities between one part of the country and another. That is why we set up the Resource Allocation Working Party, to produce a new approach to the reallocation of resources in the service.
The working party interpreted the objective of its terms of reference as being to stress that there should eventually be equal access to health care for people equally at risk. Para 1.5 of its report said:Resources allocation is concerned with the distribution of financial resources which are used for the provision of real resources. In this sense it is concerned with the means rather than the end. We have not regarded our remit as being concerned with how the resources are deployed. This must be a matter for the administering authorities and is essentially part of their policy-making planning and decision-making functions in response to central guidelines on national policies and priorities. Resource allocation will clearly have an important influence on the discharge of those functions and be the most critical guideline within which they have to be discharged".The object of the working party was to set up target allocations, and such 1541 targets were used by the Department and the health authorities for improving and refining. Therefore, on a whole range of questions which the hon. Member put to me, the answer is that work on developing the formula is continuing all the time with a view to refining it and making it more efficient.
§ Mr. Sainsbury
I stressed the evidence of the over-75s who put a particularly heavy burden on the facilities of the NHS, and that does not appear to be adequately reflected in the formula as it exists. Can the hon. Gentleman assure the House that this point will be very carefully looked at in the light of the evidence now to hand?
§ Mr. Moyle
I cannot say that it will be looked at in the light of the evidence now to hand, but all these points for the refinement and improvement of the formula will be considered. We are conscious of some of the drawbacks to it, and they are the subject of further research with a view to making it a more sensitive reallocation.
The formula is aimed at producing target allocations, but once we have them there is not a mathematical approach towards achieving them. The targets cannot be mechanistically applied. The element of judgment has to be exercised all the time in deciding what is feasible and what has merit in switching resources towards the various target allocations of regions and areas.
Much depends on the financial resources available and the practicalities of adjusting patient services, and resources allocation has to be linked all the time with NHS planning. We have told the local health authorities that they have to take account of local circumstances and not seek to apply a predetermined rate of change to the process of allocation.
This is what we call the pace of change. It must depend on the ability of above-target areas to rationalise services without disruption to the existing pattern of provision or to teaching or other specialist needs. Nevertheless, my right hon. Friend has told regions that he expects a significant redistribution of revenue to be achieved this year and next year, and if that does not happen the authorities will have to make clear to him just why it is not practical in particular circumstances.
1542 The task facing the South-East Regional Health Authority against the background of this policy is not easy, particularly as the continuing population movement that the hon. Gentleman has drawn attention to is likely to make disparity between the various areas in the region greater rather than less as time goes by.
The regional authority has committed itself to a more equal distribution of resources between the five health areas, and this means switching resources, broadly speaking, from London to East Sussex and Kent. A modest step was taken in this direction in 1976–77, but in 1977–78 it was felt that a temporary halt should be called to it, because a breathing space was needed to deal with various existing commitments, including the necessity of running new facilities and to adjust some overspending in some of the areas.
This year the regional health authority has reduced the revenue allocation to the teaching area by about £1.8 million and has obtained agreement from the Secretary of State to closures and changes of use in the Greenwich and Bexley area which will also make some significant savings available for redistribution to Kent and East Sussex. As a result, East Sussex is getting £600,000 extra from the redistribution exercise and a further £180,000 as a result of the extra money from the National Health Service budget.
There have been one or two alarms and excursions in the local Press about the attitude of Lambeth, Southwark and Lewisham Area Health Authority to the regional health authority's decision to reduce its revenue, but I think that these articles were probably based on a Press misunderstanding of decisions taken by the area and were probably wildly alarmist. Nevertheless, I am quite prepared to concede that there are difficult problems in the area, and my right hon. Friend has invited the chairman of the region and the chairman of the area to meet him to discuss the situation at an early date.
With regard to the regional health authority's longer term strategy, at the last meeting it agreed to pose regional strategic guidelines to its areas which provided for redistribution options, both of them to take effect by 1987–88. The 1543 first was based on a 25 per cent. movement towards target allocations, and the second on a 40 per cent. movement towards target allocations. The area health authorities have been asked to prepare their strategic plans showing what the effect of these options would be on their delivery of services. There will have to be a review of those options by the region when the area health authorities' plans are received.
§ Mr. Sainsbury
I appreciate that this movement is at least a movement in the right direction, but does the Minister regard it as satisfactory that over such a long period it is only a modest percentage movement towards achieving the target, which I have suggested is in any event probably inadequately reflecting the real needs because of the population make-up, and is in another sense a moving target because the population continues to shift from the over-provided areas to the underprovided areas?
§ Mr. Moyle
That is really an elaboration of the question the hon. Gentleman put to me about whether I would foresee the RAWP target allocation achievement being speeded up. One cannot be dogmatic, but I should have thought that the 40 per cent. target was the most extreme likely possibility that could be achieved.
The hon. Gentleman must remember that many of the resources of the teaching area, for example, are tied up in the three large teaching hospitals of Guy's, St. Thomas's and King's, and they will to a large extent produce the doctors which places such as East Sussex will need for the future. The hon. Gentleman must bear in mind that in his anxiety to relieve the shortage of health resources in Sussex now he should not mortgage the ability of the NHS to produce the doctors required in East Sussex for the future.
As I said earlier in an intervention in the hon. Gentleman's speech, my right hon. Friend visited East Sussex on 28th April and attended a meeting of the area health authority there. At that meeting, the area health authority discussed the question of resource allocation.
There is, I know, a particular need to provide services for the large elderly population. I think that about a quarter of the population is over 65, and that about one-tenth is over 75. There is also a need for services for the mentally 1544 handicapped, the young chronic sick and the mentally ill. These are all areas to which we have urged health authorities to give priority during the course of their planning.
With regard to the services for the elderly, there is a shortfall of hospital beds in the health district represented by the hon. Gentleman, and there is emphasis on the continuing improvement, therefore, of community health care. Extra health visitors have been appointed specifically to visit elderly people in their homes, and the health district has a very good night nursing service. There are also sufficient beds for the mentally handicapped in the area served by the East Sussex Area Health Authority, but they are poorly distributed. This is something which the health authority has to sort out. Recently, staffing levels have been increased at the Pouchlands Hospital and a children's unit of 18 beds has opened at Foredown. This unit has good community links.
The hon. Gentleman will appreciate that there is a desire with regard to the mentally ill, mentally handicapped and the elderly that as much as possible of the care for these groups will be done by community services rather than by hospital services. Consideration is being given—
§ Mr. Sainsbury
Does the Minister accept that it is highly desirable that mentally handicapped adults who do not need hospital treatment but who need in-care treatment should have a provision available which is not as elaborate or expensive as full hospital treatment? That is another shortfall which needs to be met.
§ Mr. Moyle
That, of course, falls primarily within the sphere of social service departments of local authorities. A wide range of care is needed for the elderly, the mentally ill and mentally handicapped in their homes with perhaps meals-on-wheels support at one end and full hospital treatment at the other, ranging from Part III accommodation, day centres, hostel accommodation and facilities of that sort.
Hospital provision for the mentally ill in Brighton does exist, but many of Brighton's patients are in St. Francis's Hospital, Haywards Heath, which is unduly far away from the ideal point 1545 of view. The health district is attaching priority to the provision of facilities for patients within the Brighton district. A start will be made on 1st June when it is planned to bring into use 35 psycho-geriatric beds in a new purpose-built unit at Brighton General Hospital. Eventually the unit will take 70 beds. A new psycho-geriatric day hospital is currently being planned for Hove, and capital provision for that has already been earmarked.
On 1st January 1979 the third phase of development at the Royal Sussex County Hospital will be brought into use. This will include three operating theatres, 40 acute beds and new kitchens. There will also be a whole-body "Cat Scanner" which will offer the local medical staff the very latest in modern X-ray techniques.
Nevertheless, having said all that, we accept that the district and the area remain under-funded. If we are to ensure that the standards of patient care in the health service continue to rise—an aim to which all Ministers at the Department are committed—and if we are to take a more objective view of priorities, the distribution of scarce resources requires us to ensure that there is a much fairer distribution within the South-East Thames region in favour of Kent and East Sussex.
Unless this major redistribution takes place, the demographic change, the increasing number of elderly and the movement of the population from London and its suburbs towards the coast will make the position even worse.
I hope that what I have said will be enough to reassure hon. Members that 1546 the regional health authority and my Department are determined to secure the necessary redistribution of resources. I hope that it also indicates some of the real difficulties, particularly with regard to the production of the appropriate medical manpower, which make it essential that we ensure that change is prosecuted at a realistic pace and that we do not destroy the seed-corn of the National Health Service in trying to achieve justice.
The hon. Gentleman asked whether I would visit Brighton and Hove. I shall look into that. It will probably not be before the autumn, and I shall try to do so then. He asked whether any additional resources would be directed towards areas such as Kent and East Sussex. That depends to some extent upon the current situation and what new projects are being brought on stream at any particular time. Obviously, it is much easier to achieve redistribution by directing new money and extra resources to the less well-funded areas than it is to close down existing services in the well-funded areas and try to direct that money towards the less well-funded ones. Obviously, there is a general tendency to direct additional resources to areas such as Sussex and Kent—
§ The Question having been proposed after Ten o'clock and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at twenty-six minutes to Two o'clock.