Orthopaedic Operations (Bournemouth) (Hansard, 3 December 1982)

§ Sir John Eden (Bournemouth, West)

People requiring urgent orthopaedic surgery have to wait too long for an operation. Over the years that I have made representations on behalf of my constituents, I am sorry to say that the waiting lists have grown longer. The statistics show what has happened.

Within the East Dorset health authority district, 1,417 people are on the orthopaedic waiting list, of whom 813 are classified as urgently in need of an operation. However, depending on the consultant chosen, the waiting time for urgent cases is from 12 to 24 months.

I cannot help but compare that situation with the DHSS target that no patient needing treatment urgently should wait for more than one month and no non-urgent case should wait for more than one year. In the health authority district serving the Bournemouth area cases have to wait from one to two and a half years. I stress that those are urgent cases, and urgency in that health area relates directly to the amount of pain suffered by the patient.

The recent Health Service strike led to 42 operations having to be rearranged. It is grotesque that anyone, least of all Health Service employees, should take action that can only aggravate a serious problem and add to individual suffering.

Before patients can even come on to the waiting list for an operation, most will have waited a long time for consultation. The waiting period for an initial out-patient consultation has increased year by year. In 1978, the shortest and longest waiting lists for consultations were nine weeks and 23 weeks, respectively. In 1980, they were 11 weeks and 31 weeks, and they are now 20 weeks and 45 weeks. The problem is getting worse, despite strenuous efforts by all concerned to overcome it.

Recently, I spoke to consultants, geriatricians, administrators and others in the Bournemouth hospital area. They are all deeply concerned about those figures and anxious to improve the situation. For years, they have been working on different schemes and trying out various methods to ease the pressure. By 1977, a £2 million interim development programme had been fully implemented. This led to cold orthopaedic surgery being concentrated at Christchurch hospital while accident and traumatic orthopaedic surgery was centred at Poole general hospital.

Between 1974 and 1981, there was a 100 per cent. increase in patient throughput, and the number of beds available increased from 130 to 167. Further plans have been prepared to transfer a number of general surgical beds to the geriatricians to provide for the continuing care of post-trauma patients. There has also been a reallocation of male and female orthopaedic beds to take account of the fact that more women than men require these operations.

This year, 45 residents of the East Dorset health authority district were sent to the Lord Mayor Treloar hospital for hip replacement operations. The total number of such operations carried out in 1981 was 261. Yet, in September this year, 356 people were awaiting hip 562 replacement operations. It is clear that the demand for these operations is growing faster than the resources are being made available to meet it. There seem to be three main reasons for that.

First, there have been significant changes and advances in orthopaedic practice in recent years. For example, the surgical treatment for arthritis is now total hip replacement. That is probably one of the most outstanding surgical advances in the past quarter of a century. It means that many people who might otherwise have had to continue to suffer from arthritis and other types of rheumatism have now been given the hope that, through surgery—particularly hip replacement surgery—they can be cured. As a result, many of those people are now prepared to come forward for hip replacements, knowing how widely successful the operations have been.

The second main cause, inescapably, is that people now live longer. There is a continuing increase in the number of elderly people and the percentage of the population that they represent. That puts extra pressure on the hospital services and on the demand for orthopaedic attention in particular. That is because old age naturally brings with it failure in the skeletal system which has been caused by degenerative diseases of the joints and fractures of the weakened long bones, such as the femur.

The third main underlying cause of the increased demand is the higher incidence of accident and trauma cases. There has been a big increase in trauma cases in the Bournemouth district. That means that accident and emergency cases take beds from elective surgery cases. We are finding that beds allocated to other specialties are having to be used for those trauma cases.

In 1979, a working party was set up, under the chairmanship of Professor Duthie, to inquire into the causes of long waiting time for orthopaedic services. The report makes it clear that the problem has been with us for many years, and I am sure that we are all grateful to the Government for having set up the Duthie inquiry. The report, published in 1981, is a most admirable survey, and I commend it to every hon. Member.

The report shows all too starkly that the problem is not confined to my constituency. All the English regional hospital authorities can number their orthopaedic waiting lists in thousands. The Duthie report puts it in these terms: The lengthening queues for the orthopaedic service suggest a growing imbalance between the demands made of the service and its capacity to meet them.

Behind the statistics and generalities are individual cases. I could give many examples to the House, but I have picked only two. I shall not identify them by name, because that would be unfair to the people concerned.

One case is that of an 80-year-old man who suffered from osteo-arthritis in both knees. His left leg was particularly bad. He could not walk without the aid of crutches. The operation had been planned, after a period of waiting, but, most unfortunately, there was a sudden death in his family and he had to stay at home in order to help cope with it. Six years after that he was still waiting for that urgent operation.

In answer to my representations, the district administrator, for whom I have the highest regard, said that the consultant could not give the patient greater priority over other equally distressing cases. The 563 administrator could not give me any firm indication as to when the patient would be able to have his operation. All he could do was to confirm that there was likely to be a considerable waiting period.

The second case concerns a 68-year-old woman. It was brought to my attention early in 1981. She was suffering acute pain and in need of urgent knee joint replacement. She was seen early in that year, when her condition clearly showed that an operation was necessary. By the end of the year no operation had taken place. The surgeon, apparently, can do only one such operation every three to four weeks. I have been told that if it proved necessary for beds to be closed during the Christmas holiday period, that would only extend the patient's waiting time.

I have no doubt that other hon. Members could produce similar examples. I know that my hon. Friends the Members for Poole (Mr. Ward), Christchurch and Lymington (Mr. Adley) and Bournemouth, East (Mr. Atkinson) have experience of similar cases in their constituencies, which are served by the same district health authority.

Professor Duthie summed up the position in the foreword to his report: This is not now just a logistic problem: it is one of human suffering, including loss of physical and social independence with degradation of the quality of life. I remind the House that the primary purpose of the NHS is the relief of human suffering.

The urgent need in Bournemouth is to take the pressure off the Poole general hospital and to reduce the blocking of beds, which is adding to delays. We are all glad that the authority is building a new hospital with an additional accident unit. It will undoubtedly help considerably, but in the meantime urgent action is necessary on a more comprehensive front.

I have a number of suggestions about the steps that ought to be taken. I know that some are already in the minds of those who are attempting to deal with the problems. The first need is to make general surgery beds available for post-operative care, thus easing the grave shortage of beds for geriatric patients.

Secondly, greater flexibility must be shown in the allocation of beds from other specialties where occupancy may be poor. I am calling for a shift in the balance of resources to take account of demand and the current waiting time. The NHS must be able to reflect the changing needs of the people who require its services.

Thirdly, account should be taken of the fact that there is a particularly high proportion of elderly people in Bournemouth. We have more than twice the national average of residents over the age of 75. I ask my hon. Friend the Under-Secretary of State for Health and Social Security to give that factor special recognition in the allocation of resources.

Fourthly, the ideal would be one more complete consultant team. It is desperately needed. Although I appreciate that it may be difficult to provide the necessary money, I urge my hon. Friend the Under-Secretary to make it possible for one more consultant team to serve the area as soon as possible.

Fifthly, I should like to see a special orthopaedic geriatric unit established for intensive rehabilitation. That has been done at Hastings, and no doubt my hon. 564 Friend the Under-Secretary has studied that experience. I am urging that a halfway house between hospital and home should be provided for those who do not need full hospital treatment, but still need care. It would be an important and imaginative step, because it would release at an early stage medical beds that are required for surgery cases.

Sixthly, I should like encouragement to be given to the closest possible co-operation between the hospitals, the social services department, the housing department and the voluntary agencies to ensure effective health help for elderly patients who are about to leave hospital. It should be realised that, as a result of having had an operation, quite a few elderly people cannot cope with their own home circumstances as they were able to do previously. This needs to be understood, even in the housing department. There should be regular visiting and help with the provision of meals, and here the voluntary services play a most important part. I know that it matters a lot that they should try to visit not only those who are asking for help, but those who have been discharged from hospital.

I hope that private medical treatment through insurance will get all the encouragement that we can give it. This may not make a major impact on the National Health Service, but operations carried out in private hospitals will ease the demand on the NHS.

I urge my hon. Friend not to put the file away after he has replied. I hope that, as a result of this debate, he will remind his Government colleagues of the findings of the Duthie report, translate that report into human terms so that there can be real understanding of what is happening in this sector of the Health Service, and vigorously campaign for a reallocation of resources to bring early and effective action to shorten waiting lists and to ease the suffering of so many of my constituents.

§ The Under-Secretary of State for Health and Social Security (Mr. Geoffrey Finsberg)

I am grateful to my right hon. Friend the Member for Bournemouth, West (Sir J. Eden) for raising the issue of orthopaedic operations in his constituency, which by local example highlights what has become an intractable and long-standing national problem which successive Administrations have sought but previously failed to resolve.

The local situation is, of course, best assessed and handled by the appropriate district health authority, since it, and only it, will have full knowledge of the local circumstances. I am sure that my right hon. Friend and other hon. Members accept that there is a limit to the extent to which it is sensible and proper for Ministers to become involved in the determination of local priorities and in local operational policies.

One of the objects of the recent reorganisation of the Health Service was to establish locally based health authorities which could be expected to be in tune with the needs of the communities they serve and thus be able to make sensible decisions about priorities. The Elephant and Castle cannot know best what is the right mix of services for a particular district. If we were to intervene, there 565 would be the obvious danger of distorting locally agreed priorities, to the detriment of one or other group of patients.

We have emphasised to health authority chairmen the importance of their forging strong links with hon. Members so that matters concerning local issues or individual constituents can be taken up directly with those on the spot. In this way it should be possible for hon. Members to obtain speedier responses to their inquiries, though of course my ministerial colleagues and I will always be ready to look at questions of wider importance such as the one that my right hon. Friend has raised, or at matters on which it has not been possible to obtain satisfaction through local channels. I know that my right hon. Friend is in close touch with his district health authority, which is what I would have expected from such a distinguished parliamentarian.

My right hon. Friend has graphically illustrated the real problems that are being experienced in his constituency and which can, I am sad to say, be replicated in many other areas. The East Dorset health authority has been trying hard to find ways of reversing the upward trend in the figures to which my right hon. Friend referred. The current concentration on elective orthopaedic surgery at Christchurch hospital and accident and traumatic orthopaedic at Poole general hospital was, as he said, part of an interim development programme costing £2 million, which was designed to alleviate as much as possible the orthopaedic problem until the long-term plans, which I shall describe, come to fruition. The health authority is still considering other ways in which it can make improvements in the short term from within its available resources.

As my right hon. Friend said, the health authority is looking at an alternative use for 57 beds at Christchurch hospital. It hopes that some of those beds, which are used at present for general surgery, urology and gynaecology, can be moved to the Royal Victoria hospital, thus releasing them for orthaepidic use.

The availability of additional beds is, of course, a prerequisite for increasing operating output, and here there is scope, in terms of operating theatre time, for additional theatre sessions to be established. The health authority is also carefully and continuously reviewing its working practices to see what further improvements can be made in this respect, and is looking constantly for any other ways of increasing its present capacity to cope with the high level of demands upon its orthopaedic services.

My right hon. Friend will know that, in the long term, the health authority hopes to commence the construction of a new two-phase 660-bed district general hospital for Bournemouth over the next decade. This large development is planned eventually to provide, either on site or by the change of use of released beds elsewhere, an increase in beds within the district for acute, geriatric and psychogeriatric patients. The health authority is reviewing the range and mix of facilities which this scheme will provide, to achieve the most effective improvements to health care, including orthopaedics, in the district.

I shall not quote the figures spoken about by my right hon. Friend because, alas, they speak for themselves. However, I shall add a word about the Duthie report and what has flowed from it. As my right hon. Friend said, Duthie reported in 1981, and one of the interesting 566 features of the report was that it revealed that there was no common reason why waiting times were long, other than the expansion of the ways of treating orthopaedic disabilities and the increasing numbers of the elderly in the population as a whole who could most benefit from this.

Duthie's report concluded firmly that some reduction in waiting times could be achieved, even within the resources allocated to the specialty at present. The working party suggested that an increase in resources should be considered only if an assessment showed that additions to the waiting list and the existing backlog could not be met within the resources already allocated to the unit.

The follow-up has resulted in the British Orthopaedic Association preparing and distributing a pilot self-assessment questionnaire designed to help its members in reviewing the performance of their own units. I understand that in the light of this pilot study, a further questionnaire is being prepared for more widespread distribution by the association. We welcome this initiative.

Apart from the average length of waiting lists, it also has to be recognised that there are considerable differences in the time that people have to wait for operations, including orthopaedic operations, and that these times depend on where they live. It is for that reason that, in response to an initiative by my hon. Friend the Member for Lichfield and Tamworth (Mr. Heddle), we are examining with the West Midlands regional health authority the possibility of a better distribution of information to general practitioners about waiting lists for a sample of clinical specialties. While this would not of itself reduce the average waiting time, it might allow general practitioners to refer patients in a way that reduced the extremely long waiting lists that occur in some places.

A pilot study would provide valuable information about the attitudes of patients, consultants and general practitioners to the idea of referral as an in-patient to a hospital some considerable distance from the patient's home and the effect on long waiting lists of such referrals.

I accept that there may be human problems in such arrangements, with people wanting to visit their relative in hospital 100, 150 or 200 miles away. That would have to be set against the benefit of a much speedier chance of his having the operation. All this has to be looked at and will be one of the features which, if the West Midlands regional health authority is able to mount its pilot study, will help us to determine whether those results from the pilot study can be used on a national basis to reduce the inequality of access to treatment in some places.

My right hon. Friend will appreciate that there is little more that I can say to him in detail, but I hope that he will feel that the Government are desperately aware of the hardship caused by the enormous time that people in his constituency have to wait not only for operations but for consultations.

I am certain that my right hon. Friend will have told the chairman of the district health authority of his points of action, but I shall ensure that they are examined by my officials and that a copy of Hansard is sent to the chairman so that, if there is anything fresh that he can add on the local points, he will do so. I assure my right hon. Friend 567 that this is one of the subjects which, unlike a few, alas, will not be permitted to gather dust on the shelves of Alexander Fleming house.