§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Jim Marshall.]
§ 11.32 p.m.
§ Mr. Colin Shepherd (Hereford)
I am grateful to the Minister for the fact that he is here to answer the questions that I wish to raise on this subject, which is very important to my part of the world. I am even more delighted that he was here already. At least we did not have to drag him out of bed and we are not starting at a miserably late hour.
The Government's acceptance of an interpretation of the Professions Supplementary to Medicine Act 1960 and the National Health Service (Professions Supplementary to Medicine) Regulations 1974 will lead to a marked reduction in the service capable of being provided by 1268 cottage hospitals of communities in Herefordshire and Worcestershire from 1 April this year.
In the past, senior nursing staff in the cottage hospitals of Ross-on-Wye, Leominster, Ledbury and Kington in Herefordshire and Tenbury in Worcestershire have carried out minor X-rays of arms and legs under the supervision of a general practitioner. In Ross, the practice has been carried on for more than 50 years and it has enabled doctors to make swift and accurate diagnoses of minor accidents or injury on a seven days a week basis. That has facilitated treatment on the spot—and most effectively too.
Now that the Department has ruled (hat even these minor X-rays must be carried out only by fully qualified State registered radiographers, the resulting solution devised by the area health authority means that only once a day from Monday to Friday will the radiographer call at Ross and Leominster hospitals. Ledbury and Kington will be visited only on request on an ad hoc basis—that is, when there is an emergency.
§ Mr. Peter Temple-Morris (Leominster)
I am grateful to my hon. Friend for raising this important issue which is of great concern in Herefordshire, not only to his constituents, but to mine. He has been kind enough to mention Ledbury and Kington.
Does he agree that it is widely accepted locally that we shall have less of a service at an increased cost? One of the matters that concerns us most is the definition given by the Minister, who says that there are exceptions, but only in totally exceptional cases of emergency, when nurses can take X-rays. Is my hon. Friend also concerned about that? What does he have to say about that definition?
§ Mr. Shepherd
I am grateful to my hon. Friend for that intervention. I know how strongly he feels on this matter and how deeply affected his constituency is by the reduction of the service in Ledbury and Kington especially. I know, too, how deeply my hon. Friend the Member for Kidderminster (Mr. Bulmer) is affected, since he has great interest in Tenby hospital in Worcestershire. I will come to that point later.
1269 The additional cost of this arrangement for the Hereford health district alone will be not insubstantial. If we take the salary and employment costs of a radiographer as being about £5,000 per annum, and take into account that to service Ross and Leominster alone on a daily basis the minimum mileage will be some 145,000 miles at Civil Service rates, costing at least £2,100 per annum, we have direct on-costs of about £7,000 per annum.
Since very many of the occasions when X-rays are necessary are out of normal working hours, and doctors deprived of their aid to diagnosis will not care to risk a faulty one, many minor casualties which would have been treated at the cottage hospital will have to be transported into Hereford for the X-rays to be taken. On the face of it, this is a simple matter—it is only 16 miles. But apart from tying up an ambulance for at least an hour, with consequent stress upon ambulance resources in the event of a real emergency, the cost will be a minimum of £64 each time the ambulance is used, the running costs now being in excess of £2.50 per mile. If one-third of the 1,000-odd X-rays generally taken each year need to be done in Hereford, the extra cost will be about £20,000 in hidden ambulance charges.
The total extra cost of this departmental ruling will therefore be £27,000 at a conservative estimate. When this is seen against the announcement in the March edition of The Press, the Herefordshire health district house magazine, that due to Government policiesthe District Management Team already has to find more than £100,000 for the financial year starting on 1st April 1979 just to stand still ",and that is before it has to start funding the additional £27,000 to finance the lessening of X-ray facilities in our cottage hospitals, who can blame the public if they think completely unrepeatable thoughts about the apparent stupidity of the Government? It is the sort of situation which would delight the Red Queen in"Alice Through the Looking Glass"and at least be the main topic of conversation at the Mad Hatter's tea party.
This curious development has taken some time to develop. Up until 1977, the RHA, the AHA and the district had deemed that nurses who had voluntarily undergone X-ray training were not being 1270 employed in the capacity of radiographer, and therefore did not come within the scope of the 1974 regulations. The Society of Radiographers thought otherwise and complained to the Minister. This difference of opinion has still not been clarified in a legal sense, in spite of the departmental ruling. What steps is the Minister taking to clear up this matter by establishing case law?
Nothing in my remarks should be taken as being the least bit hostile to radiographers. Their full and valuable skills are far and away more extensive than are needed for a cottage hospital, where the only requirements are for extremity X-rays in relation to casualty work. It is rather because a radiographer's talents will not be fully exploited that I am concerned to find a way forward which will sustain the traditional level of service in cottage hospitals, which over these many years has been so successfully worked.
In much of the correspondence which has passed between the Minister and myself and my hon. Friends the Members for Leominster (Mr. Temple-Morris) and Kidderminster and my right hon. Friend the Member for Worcester (Mr. Walker), the Minister has repeatedly emphasised that all this isto ensure that the staff giving the service have the level of training necessary to meet with regard to radiation safety standards the wide range of demands on X-ray services which can arise within the NHS.I must emphasise two points. First, the X-rays about which I am speaking are often of very limited range, obviously, in the light of experience well suited to nurse training. It could be likened to a technician's work in comparison with that of a scientist.
The second point is that the X-ray needs of cottage hospitals in rural areas with scattered populations are very different from those of a hospital in a concentrated urban area where facilities are closely interrelated and distances are small. We must beware of the trap that we become too ultra-professional both in nursing and radiography. We must retain the ability to become Jacks-of-many-trades if the full value of a cottage hospital is to be realised and maintained in the community it serves.
In his letter to me dated 4 October 1978, the Minister of State recognised the need for the area health authority to ensure that the necessary X-ray services 1271 for these hospitals was provided, but allowed that intotally exceptional cases of emergency "—this was the point my hon. Friend raised—X-rays could be taken by others than State registered radiographers. If there are to be no other personnel trained in the operation and use of X-ray equipment, how are the cottage hospitals to cope with such an emergency, and what is the Minister's definition of such an emergency? One thing is certain, that if there is no one capable of even limited X-ray work there will be an inevitable and unacceptable delay.
I have said that we need to find a way forward. We need to find a way forward that will maintain the important level of service that is now in jeopardy, and one that we hope will improve the level of competence of the NHS personnel resource.
I want to put forward a proposal that I think could, given good will and a constructive approach by all parties involved, fulfil the needs of not only our cottage hospitals in Hereford and Worcester but those up and down the country which have already accepted this loss of level of service. I think that we can restore the level of service to that which everyone would like to see.
If we recognise the full range of skills attained by radiographers in all the complex aspects of X-rays and the special needs of cottage hospitals providing casualty service in rural areas, and if we recognise that, although there are differing opinions within the nursing profession, there are not an insubstantial number of nurses who would like to maintain or increase their expertise, we have the ingredients for a constructive solution.
The Secretary of State should set up a working party—after suitable discussion—consisting of representatives of his Department, the Society of Radiographers and the General Nursing Council, with the objective of developing a new concept of a limited qualification, able to be achieved by volunteer nurses, by training and examination under the auspices of the two bodies I have mentioned. That qualification would signify competence to undertake limited extremity X-rays, under the overall supervision and responsibility of the general practitioner.
1272 A nurse so qualified would be entitled to a small additional supplementary emolument designed both to recognise this skill and to acknowledge the status of the radiographic profession. There could also be qualification for a limited asso-ciateship of the Society of Radiographers, to which no doubt a small registration fee would be payable. In view of the numbers of X-rays involved, a supplementary emolument of, say, about £300 a year could recognise this qualification and ensure a proper supply of nurses trained for limited extremity X-ray.
The consultant radiologist would be relieved of the need to take the personal risk of certifying competence, which arose as a result of the Medical Defence Union's reluctance to underwrite his decisions in the light of the confusion over interpretation of the Acts that I have mentioned.
The nursing staff of our cottage hospitals recognise the desirability of being able to undertake limited X-rays. Let us make sure that they can do what they recognise is necessary, and do it in such a way as to enable qualified and expert radiographers to be fully and exactingly employed in our major hospitals, doing the difficult and the complex work. They should not be spending their valuable time tearing around the countryside, covering vast distances.
If the nursing qualification means a little more expenditure, it will be more than saved by lessening the calls upon the ambulance service. Above all, the level of service in our cottage hospitals will be maintained.
I advised the Minister of a number of the points I would raise. I look forward to hearing what he has to say.
§ 11.45 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)
I congratulate the hon. Member for Hereford (Mr. Shepherd) on securing this debate tonight and thereby giving us a chance to discuss X-ray services in cottage hospitals in general as well as those in Hereford and Worcester. I am grateful to him for having given me notice of the detailed points that he wished to raise.
I am well aware from correspondence with the hon. Member and a number of 1273 his hon. Friends who are here tonight that there is considerable concern locally about the new arrangements which will be introduced shortly. I should like to describe the background to these new arrangements and also, perhaps more importantly, to give an assurance that when they are brought into effect they will be kept under review to ensure that adequate X-ray facilities continue to be available.
I shall start by referring to my Department's policy on the provision of X-ray services in hospitals generally and to the regulations which require that staff employed as radiographers in the NHS should be State-registered.
The provision of facilities for X-ray radiology in the National Health Service is the responsibility of regional and area health authorities. My Department has, however, given advice on a number of detailed matters relating to these facilities. In particular, we are able to advise on the number of radiodiagnostic rooms required for a given catchment population. This can be derived from the average number of examinations likely to arise from that population and the number which can be carried out efficiently and economically in an average radiodiagnostic room in a given period of time.
The most efficient use of trained and often scarce manpower resources, equipment and maintenance facilities can usually be obtained by concentrating radiodiagnostic services into larger radiology departments, such as those at district general hospitals. But health authorities have, of course, to balance the advantages of such an overall policy against the constraints of local geographical factors, such as population distribution and transport arrangements, so that patients are provided with the best possible service within the resources available. For these reasons, and despite a general policy of centralisation where-ever possible, many health authorities are known to have found it desirable to retain, and sometimes to establish, a number of X-ray units at smaller hospitals to undertake a limited range of the more straightforward and frequently required types of examinations. Understandably, considerable local resistance is often encountered when efforts are made to close such units.
§ Mr. Esmond Bulmer (Kidderminster)
The hon. Gentleman has touched on what, from the point of view of my constituents, is the nub of the problem. Of course they object if they are to be deprived of a service which has given them every satisfaction over many years. My hon. Friend the Member for Hereford (Mr. Shepherd) has made the points that need to be made. However, I should like to put on record that we are now being offered a less good service, that we are not at all happy and that it will cost more money.
§ Mr. Deakins
I shall come to the points made by the hon. Gentleman relating to his constituency. I well understand his view.
The most complete statement of general policy with respect to community hospitals was set out in a guidance memorandum entitled"Community Hospitals—Their role and development in the NHS"issued by the Department in August 1974. This memorandum pointed out that the concept of a"community hospital"differed in some respects from the traditional concept of a"cottage hospital"and suggested that health authorities would need to plan for the conversion of some local and cottage hospitals into community hospitals. The memorandum envisaged that limited radiological services requiring only simple equipment would be provided in some community hospitals and that complex investigations, including contrast media examinations, should be reserved for the district general hospital. Subsequent advice suggested that the detailed guidance set out in the memorandum should be interpreted flexibly to allow the continuation of radiological services at a community hospital on a scale beyond that originally recommended where, in the context of the provision in the district as a whole, such services would provide a useful and economic contribution.
I come now to one of the main points made by the hon. Member for Hereford. Under the Professions Supplementary to Medicine Regulations 1974 and the Professions Supplementary to Medicine Amendment Regulations 1978, it is illegal for a National Health Service employing authority to employ staff in the capacity of a radiographer unless they are State-registered radiographers—that is, those 1275 who have been trained in radiography work to the standards required for State registration under the Professions Supplementary to Medicine Act 1960. I understand—and the hon. Member for Hereford made much of this—that the West Midlands regional health authority has legal advice to the effect that the regulations do not preclude the regular taking of X-rays by nurses or other unregistered staff provided that the X-ray examinations are limited to the extremities of the body.
I find the advice given to the West Midlands health authority rather puzzling, but I would welcome the opportunity to consider it further with my own legal advisers. I can say, however, that the advice that I have been given in the past on such matters differs from that given to the regional health authority. A final interpretation of the regulations can authoritatively be given only in a court of law, but it is the underlying intention of the regulations to ensure high standards of safety in the quality of radiography carried out in NHS hospitals. I think there is no difference on that. I take the view therefore that, where there is need for a range of different kinds of X-ray examination to be undertaken on a regular basis, it must be done by a Stale registered radiographer or otherwise by staff recognised as qualified to do it, such as a radiologist. This is in the interests of the radiological safety of both staff and patients and in order to make the most effective use of X-ray equipment.
§ Mr. Shepherd
I wonder whether the Minister has any figures of the number of radiological accidents that have occurred in cottage hospitals as a result of non-radiographers using X-ray equipment.
§ Mr. Deakins
The quick answer to that is that I do not have any such figures. I shall certainly check. I am not sure that central records are kept of this sort of matter. It might be that we could find out only by writing to the health authorities concerned. But I do not rest the case on the fact that accidents have occurred before we had State registration as a means of ensuring the safety of patients and staff. Obviously, those who were performing X-rays before that took sensible precautions.
This brings me to the point that the hon. Member for Hereford made about 1276 specialisation. There is no doubt that in the last decade or more there has been a tendency in the National Health Service towards increasing specialisation. What we have tried to do with nurses—even chiropodists—is to relieve these highly trained professional people of some of the more humdrum tasks they have performed in the past so that they can spend nearly all their time making use of their expensively acquired skills for the benefit of the people in the NHS.
Whether that would lead us to the conclusion that there are certain radiology tasks which can be undertaken by non-State registered people, I would very much doubt. What I have been thinking about is that the very large number of nurses in the NHS—we are all entirely dependent upon them—would be relieved of a large number of clerical duties which can be done by people who do not need a nursing qualification. We have been trying to do the same with doctors.
Returning to the issue of safety, it is my right hon. Friend's duty—any Minister in his position would have to take this very seriously indeed—to ensure that, where there are regulations, they are properly applied so that the aims I have mentioned can be achieved.
§ Mr. Temple-Morris
The Minister mentioned regulations and the fact that they should be properly applied. He knows that the regulations emanate from 1974 and the Government have been in office for five years since then. What many in my area wonder is"Why now?"There is an ugly rumour circulating that the Society of Radiographers may have communicated with the Minister or his right hon. Friend and that that has something to do with it. We wonder why it has to be now in, perhaps, the declining moments of this Government.
§ Mr. Deakins
I do not think that there is any secret about this—far from it. We are not aware in Whitehall or in DHSS of everything that occurs in every one of the 2,300 or so hospitals in the NHS. When a professional body draws our attention to an instance of regulations not being applied in the way that that body thinks they should be applied, obviously we have to take some action.
The hon. Member has put forward proposals which would involve a reassessment of the professional rules of nurses 1277 and radiographers in relation to the radiology services. I would have thought that over most of the country the respective roles of these two groups were well understood, and that the occasional problems that arise are of only a marginal or localised kind. If however, the General Nursing Council, the College of Radiographers or the Royal College of Radiologists wishes to draw my attention to wider problems of demarcation that are arising, I shall be more than happy to look at them.
I should like now to turn to the detailed position in Hereford and Worcester. Hereford and Worcester have a number of cottage hospitals, but I understand that it is at only four cottage hospitals, all in the Hereford health district, where radiography work is being undertaken by unregistered personnel without direct qualified supervision. The cottage hospitals involved are those at Ross, Ledbury, Kington and Leominster. The situation was first brought to my Department's notice in May 1977 when the Society of Radiographers drew attention to the fact that radiography was being undertaken by unregistered personnel in these cottage hospitals, and at one or two other places in England, contrary to the regulations I have mentioned. My Department took the matter up with the health authorities concerned, including the Hereford and Worcester area health authority. The authority confirmed that the arrangements were as advised by the society but had taken the view that it was not contravening the regulations as the staff carrying out the X-ray examinations were not employed as radiographers, but as nurses. There is scope for misunderstanding there. Our view, however, as I have already said, is that the test is not what designation is used for the staff concerned but whether in practice they are employed on the work of a radiographer. Otherwise, the underlying purpose of the regulations is being defeated.
In the light of the Department's advice on the matter, the area health authority is now tackling the problem in a way which meets the various needs of patients and staff at all these hospitals. Following the Department's approach, the Hereford and Worcester area health authority in August 1977 adopted a new policy on X-ray services. This policy had a number 1278 of important features, but its central theme was that the use of staff not qualified as radiographers on radiographic procedures should be phased out as soon as circumstances permitted, provided that this did not result in an unacceptable reduction of the availability of facilities to the local community.
As a means of achieving this aim, the authority decided to pursue the possibility of arranging for a radiographer or radiographers from general hospitals to attend the cottage hospitals concerned once or twice a week. As an alternative the recruitment of a radiographer locally on a part-time basis would be considered. In the interim, a number of requirements were applied to non-radiographic staff undertaking radiographic procedures.
First, the staff had to be given suitable training in the X-ray department of the appropriate general hospital and should be familiar with and understand the local rules and the code of practice. Second, there would be medical examination prior to delegated authority being given, with a further annual check. In addition, the staff involved would attend the X-ray department in the appropriate general hospital for refresher sessions at not less than yearly intervals unless it was thought necessary to attend more frequently.
In recognition of the fact that more complex procedures can be carried out only by a qualified radiographer, the staff should be permitted to X-ray extremities only and, to that end, a certificate of competence would be issued by a consultant radiologist to the staff concerned indicating the radiography procedures which may be undertaken by such staff.
1 think it is quite clear that the authority, faced with a difficult and immediate situation, made every effort to protect the interests of staff and patients. But it was still, in our view, not acting wholly within the regulations. In the autumn of 1978 the following alternative arrangements for the four hospitals were approved by the Hereford district management team. X-rays in the four cottage hospitals would be taken only by qualified State registered radiographers. A full-time radiographer would be appointed to visit Leominster and Ross cottage hospitals daily on Monday to Fridays. Ross would be visited at 11 a.m. and Leominster at 3.30 p.m. Although this would not enable 1279 the same amount of open access X-ray work to be carried out, it would allow for cases to be held back for these clinics.
I understand that in Ledbury and Kington the small number of X-rays taken makes it uneconomic to have a radiographer based at either of these market towns for set clinics. The radiographer's time would be better used fulfilling the on-call requests from all four market towns. In addition, there would be an on-call facility during the opening hours of the radiography departments in Hereford general hospital. Cases not catered for in this way would have to be transported to Hereford general hospital. One further possibility, if there were trained radiography staff willing to take an appointment and living in the market town areas, is that additional part-time staff could be employed on top of this service, possibly with an on-call facility. It is not feasible to have this service, possibly with an on-call facility. It is not feasible to have an on-call facility from Hereford out of radiography department hours, but this might be an arrangement that could be made with any local part-time radiographers. I understand that it is hoped that these new arrangements will commence on 1 April this year.
What I have said so far does not necessarily preclude the possibility that a serious emergency might arise where an X-ray was required without delay but no radiographer or radiologist could be obtained in the time available. This was a matter which concerned the hon. Gentleman. As I understand the position, however, it is very unlikely that serious emergencies would, in practice, be admitted to one of these cottage hospitals, but, rather, they would be admitted and treated in Hereford general hospital, which is properly equipped to handle such cases. I can see that there might be circumstances where a decision might be taken to admit a lesser emergency case to one of these hospitals to avoid delay in treatment, and, clearly, such a decision can be taken only by the doctor dealing with the case. Where this is the case and an immediate X-ray is considered absolutely essential, in the absence of an available radiographer a doctor could take the X-ray or delegate, say, a nurse to take it under his general directions; 1280 the doctor would accept responsibility for the matter. In these circumstances, I would consider it appropriate for the doctor to seek any necessary advice on the safe taking of the X-ray by telephone from a more qualified person, such as a radiologist or radiographer.
I would not wish to define a serious emergency or a lesser emergency for these purposes, as these are matters for the discretion of medical staff, guided as may be by their senior medical colleagues. But, again, I do not see that any conceivable definition could be used to frustrate the intention of the regulations to which I have referred.
I must stress that it is a matter for the health authority as to the best means to rearrange X-ray services in a way which reflects its obligation under the regulations. I understand that the way it has chosen will cost around £5,000 a year—the hon. Gentleman thought that it might be £7,000—and it is, of course, for the authority to decide how to meet the expenditure and whether comparable savings can be made elsewhere.
I realise that local opinion is divided as to the effect that the new arrangements will have on the quality of the service. Some are of the view that the fact that X-rays will in future be taken by State registered radiographers represents an improvement in the quality and reliability of the service. Others hold the view that the fact that radiography will be available in cottage hospitals only at set times as opposed to the present walk-in service represents a deterioration in the service available to the rural parts of the Hereford health district.
I assure the hon. Member for Hereford that my Department's aim is not to deprive local general practitioners of access to the local X-ray facilities but, rather, to ensure, in the context of safety of both patients and staff, the most effective use of X-ray service. The Hereford health district management team will be keeping an eye on how the new arrangements work out in practice and will, no doubt, make adjustments should the need arise.
§ Question put and agreed to.
§ Adjourned accordingly at one minute past Twelve o'clock.