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§ Mr. Toby Jessel (Twickenham)
I am grateful for the opportunity to raise this matter and I am grateful to my hon. and learned Friend the Minister for Health for attending the debate personally to reply to me on a matter of deep concern to an exceptionally large number of my constituents. In the space of four weeks 54,000 people signed petitions organised by two hospital leagues of friends to retain two local community hospitals—St. John's, Twickenham, and Teddington Memorial hospital. Those must be the two biggest petitions ever produced in Twickenham. They reflect how enormously the public value and cherish these two community hospitals. There is nothing in the world that I want to see more than that those two hospitals should stay open in their present form.
No formal proposals will yet have reached my hon. and learned Friend. Some people might say that I should defer raising this matter until later. But I am not prepared to do so. I want to get my oar in early. That is why I asked my hon. and learned Friend to see me, as he was kind enough to do, on 27 October, soon after rumours began to circulate. Following that, my hon. and learned Friend wrote to me on 17 November and said:I will look at any proposal entirely on its merits from the point of view of whether it provides the best service to patients in the area affected, regardless of administrative boundaries.The vice-chairman of the district health authority, Mr. Alan Sweetman, was quoted last week as saying thatTeddington Memorial hospital should be closed because it was providing a superior service and could clear waiting lists with greater speed than other hospitals".He said that it was unfair to provide a service that was whatthose who live in Hounslow and other areas would consider a luxury service".That attitude is terrible. Mr. Sweetman, a leading member of the district health authority concerned, wants to close Teddington Memorial hospital and, by analogy, also St. John's hospital, Twickenham, because they are good and not everyone can have the service that they provide. The service that they provide is not luxurious. I have been frequently to both hospitals. I was in Teddington Memorial hospital yesterday. It is not a luxury service, but it is a caring service and it is intimate compared to the service in some other hospitals. It is efficient in the medical care that it provides.
I would like to tell my hon. and learned Friend some more of what these hospitals do and quote from the excellent summaries given in the Richmond and Twickenham Times:Teddington Memorial Hospital has … 49 beds and one operating theatre where 654 operations were carried out last year, ranging from ear, nose and throat surgery, to hysterectomies.A wide range of out-patient clinics are held at the hospital, including orthopaedics, pathology, dermatology, general medicine, and eyes.The casualty department had 15,000 patients this year, up to the end of November,including follow-ups, and the equally busy physiotherapy unit treated 18,626 people last year.The X-ray department, with a patient load of 5,372 … has open access for the GP's, who can refer their patients direct. This is impossible at West Middlesex hospital, because of the pressure there, and they have indicated that they could not possibly absorb the Teddington Memorial work-load, should it close.Total running costs: £770,000.St. Johns hospital, Twickenham, has 1107outpatient facilities for general surgery, gynaecology, antenatal care, ear, nose and throat conditions, medical and psychiatric problems".The psychiatric clinic run by Dr. Low-Beer is particularly well known. There are about 4,500 attendances each year, of which about 400 involve operations.
The hospital's X-ray department, described as 'frantically busy', copes with 3,000 cases a year, including screening procedure. Pathological tests are carried out, physiotherapy treatment given"—involving about 1,000 cases a year—and minor casualties and minor operations dealt with by local GP's.The hospital has ten official geriatric beds as well as other beds for GP's own patients, including geriatric, terminal care cases and holiday care facilities for bed-ridden home cases.That is a very important service which enables elderly patients who cannot get full-time care to go into hospital for a short time to enable their families to take a holiday. It gives much needed relief to the families. The families then can look after the patients at other times of the year.
I should like to quote what Dr. Shearman, the president of the League of Friends of St. John's, said:Places like St. John's and Teddington help to reduce the stress factor of going into hospital. And they cater for the patient who doesn't necessarily need the sophisticated technology provided by larger hospitals. If these two hospitals close the problems facing West Middlesex will become even more serious.Although these two hospitals are not identical, I make no apology for bracketing them together, because to a large extent they both provide for the same kind of need in the separate districts of Twickenham and Teddington. I have had a very large number of letters both from organisations and individuals which I shall be sending to my hon. and learned Friend. I ask him to give me an assurance that he will scrutinise the contents very carefully. Most of the services that I have described are under threat. The district health authority has threatened to close all inpatient services at Teddington and to turn St. John's, Twickenham, basically into a geriatric hospital.
Therefore, I want to ask my hon. and learned Friend, next, if I set out in a letter to him in the near future the services that I have just described, will he, in turn, set out in a letter to me, against a list of each and all of these services, if they were cut, how and where they would be replaced and what the effect would be upon waiting lists for patients needing treatment, patients both from the Twickenham and Teddington areas and from other areas with whom the Twickenham and Teddington patients might find themselves in competition? The Hounslow and district health authority, when I went to see it to present a petition with 54,000 names, was quite unable to say how those services would be replaced.
The chairman, Mrs. Golding, admitted that it would mean a real and basic cut in patient services. I ask my hon. and learned Friend the Minister to assess this for himself. If he will reply to me in the way that I have suggested, his reply will be most carefully and critically scrutinised not only by me but by my constituents.
I also asked Mrs. Golding how much notice she and her health authority would take of the 54,000 signatures. I regret to say that I received no clear answer on that from Mrs. Golding or, indeed, from the North-West Thames district health authority. I therefore ask my hon. Friend the same question. Will he assure me that he will take notice of those signatures? After all, it is not a matter of 500 or even 5,000 but of 54,000, which is a colossal number of people.
1108 My hon. and learned Friend said in his letter of 17 November that he would call in the decision if there were objections from the community health council. That condition has been doubly met. Two community health councils—that covering Richmond, Twickenham and Roehampton, and that covering Hounslow and Spelthorne—have objected. Therefore, although complete closure is no longer proposed, but rather a drastic curtailment and a change in the basis of use, I take it that the decision will be called in.
The Hounslow and Spelthorne district health authority voted for the change by the very narrow majority of nine votes to seven. There is a constitutional argument for asking my hon. and learned Friend to reverse that decision. Both Teddington Memorial and St. John's hospitals are extra-territorial. They are outside the boundaries of that district health authority and, indeed, outside the North-West Thames regional health authority. In that sense, the Hounslow and Spelthorne district health authority is not fully representative. Of the four members who represent local authorities, none is from Twickenham, and most of the remaining 12 members are not from Twickenham either. One who is from Twickenham, Mr. Clive Thomson, who is on the general list, spoke up for Teddington Memorial and St. John's hospitals with great force, but was heavily outnumbered.
There is a strong feeling in my constituency that to ensure a properly democratic decision my hon. and learned Friend should decide the matter rather than allow the health authorities to do so, because the hospitals are extra-territorial and, with the best will in the world, that is bound to colour the attitudes of the health authorities towards them.
My hon. and learned Friend and the Secretary of State have repeatedly reminded us that the finances of the Health Service as a whole have not been cut. The total for 1978–79 was £7¾ billion and for 1982–83 it is £14½ billion, so the amount has increased faster than inflation and NHS expenditure in real terms is increasing.
Hounslow and Spelthorne district health authority, however, says that it is underfunded compared with other districts in the North-West Thames region. Can my hon. and learned Friend say whether that claim is justified? Will he also explain how annual funding is assigned by the region to the districts and how this works out in the case of Hounslow and Spelthorne, allowing for patients who cross boundaries from Twickenham to the West Middlesex hospital or to extra-territorial hospitals such as Teddington Memorial and St. John's?
The £1.3 million annual cost of running the two hospitals is only one-five-hundredth of the North-West Thames region's budget of £650 million. I cannot believe that with "efficiency savings" such as my hon. and learned Friend has advocated it is impossible to save one-five-hundredth of that budget in other ways, such as savings on heat, light and drugs. It also seems that the accumulated debts on West Middlesex hospital by past authorities such as the former Ealing, Hounslow and Hammersmith authority could have been paid off if the will had been there, and that that is a further reason why Teddington Memorial and St. John's are now at risk. Will my hon. Friend comment on that?
He said in his letter of 17 November that there might be a possible transfer of these two hospitals from Hounslow and Spelthorne to the Richmond, Twickenham and Roehampton district health authority. Can he throw 1109 any further light on that proposal? If Richmond, Twickenham and Roehampton were to take over those two hospitals, would the budget of north-west Thames, and, consequently, Hounslow and Spelthome be modified to allow for an increase in the budget of south-west Thames and, consequently, Richmond, Twickenham and Roehampton? The answer could affect a possible reconsideration by Hounslow and Spelthome.
Will my hon. and learned Friend take soundings from the authorities concerned to see whether, if the hospitals were taken over by Richmond, Twickenham and Roehampton, they would become geriatric units, or remain community hospitals as at present, which I should like to see, or become part of each, like St. Mary's hospital, Hampton?
There is tremendous concern in my constituency about these two community hospitals. I hope that my hon. and learned Friend will attach the greatest weight to the petition that has been signed by 54,000 people who profoundly hope that it will be possible to keep both hospitals open broadly in their present form.
§ The Minister for Health (Mr. Kenneth Clarke)
I thank my hon. Friend the Member for Twickenham (Mr. Jessel) for raising this important subject. As he said when referring to the enormous petition that he received, these proposals have aroused considerable controversy, and he has approached me from the moment that the rumours first began. I am not at all surprised that he has felt it necessary to raise the matter on the Floor of the House at this comparatively early stage in the process of considering changes in the service.
As well as the problems of the hospitals, my hon. Friend also referred to the problems of the district health authority which feels that it has not been well treated in relation to funds. There is a contrast between the national position, where we are substantially increasing expenditure on the NHS, and the problems that are sometimes experienced in particular districts.
The problem is that in some districts in and around London there has historically been an overprovision of medical services and, consequently, an unfair distribution in national resources between London and the rest of the country. Successive Governments have tried to even out the expenditure between different regions and different districts within regions. The background to that, which I shall refer to later, is at the root of the problems facing the Hounslow district health authority.
As well as having a fair distribution of resources to ensure that citizens have fairly equal access to medical facilities, we must also insist on a system of cash limits so that overexpenditure does not take place in some districts at the expense of others.
The background to the immediate problem of this district health authority is that, earlier this year, it faced a large potential overspend beyond the cash limit allowed. At one point, it anticipated that it would be anything between £750,000 and £1 million overspent in 1983–84 unless it could identify specific areas of saving. The Government encouraged the district health authority, as they must, to find some method of meeting that overspend, otherwise £1 million would be abstracted from the budgets of other authorities.
1110 However, since the district looked at the potential problem earlier this year, it has become somewhat less serious because of the success of its own housekeeping and also because of the Government's success in reducing inflation. That has given the district an unexpected extra spending power and has eased its problems for the coming years.
At its meeting on 18 October, when it faced up to the full-scale problems, the district agreed to seek comments on 12 options, each involving substantial alterations to the services provided, including the closures of wards, the school of physiotherapy, theatres, and the closure of either St. John's hospital or Teddington Memorial hospital or both. At the same time, it took steps to reduce expenditure on non-patient services, administration, works and maintenance, and so on.
Because of the improved climate and because of the success in reducing unnecessary costs, the district now proposes to go to formal consultations on only three specific proposals: the closure of inpatient services at Teddington Memorial hospital—although the busy outpatient clinics and the radiology and physiotherapy departments there would continue; the closure of outpatient facilities at St. John's hospital, and the change of use of its acute beds to geriatric services; and the closure of a health clinic which currently provides only four sessions a week.
The district health authority has calculated that these measures would save rather more than £500,000. Although that might not be sufficient entirely to cover the projected deficit, it proposes to make representations to the region and to Ministers that part of the overspend should be met from outside its allocation. Obviously, I do not want to comment at the moment on any such application, although in considering any bids of that kind it is necessary for us to consider where else in the Health Service we might find the money to enable a district health authority to overspend. Meanwhile, the DHA is going to formal consultations on those three proposals only.
The proposals mean that neither of the two hospitals with which my hon. Friend is concerned would be completely closed, and an opportunity would remain for some reinstatement of services if the district's financial climate were to improve in the future. Meanwhile, I know that my hon. Friend and his constituents regard the quite drastic proposals put forward for the two hospitals as very serious. There is considerable opposition to them, and the consultation process will undoubtedly throw up a good deal of opposition.
§ Mr. Jessel
With regard to the consultation process, if the district health authority took so little notice of a petition containing 54,000 signatures, how can anyone expect it to take a blind bit of notice of the result of the consultation process?
§ Mr. Clarke
I do not know how much notice it took of the petition. I shall take serious notice of the petition and of all the other representations that my hon. Friend and his constituents put forward. I am sure that the district has had regard to them as well, but it now has to go through a formal consultation process, and it is obvious that it will have very strong representations put to it by the inhabitants of Twickenham.
If the community health councils are unable to agree to the main substance of the proposals, the health authority 1111 cannot implement them. Under the rules, the proposals would then have to be referred first to the regional health authority, which would consider whether the district health authority's case was sound. Then, if the community health councils still objected, Ministers would have to take the final decisions, so that the matter would, in effect, have to be called in. We would expect the community health council to submit constructive and detailed counterproposals, which Ministers could then judge against the proposals of the district health authority.
My hon. Friend said that the community health councils had already objected to the proposals. As I understand the position, the CHCs have objected to the previous package of proposals—that is part of the 12 options being considered by the district—and the process now requires that they must be given the opportunity to consider their reaction to the present proposals which have been put to them, and to consider what detailed counter-proposals they might wish to make.
I can confirm that there are two CHCs involved in the proposals—Hounslow and Spelthorne CHC and Richmond, Twickenham and Roehampton CHC—and I confirm to my hon. Friend, as I did when I met him earlier this year, that if either of those CHCs objects and the regional health authority, in the face of the objection, still endorses the DHA's proposals, the Ministers will call in the decision and take it themselves, having considered all the views and comments put forward by the interested parties.
Matters are at present at a fairly early stage, because the consultation process is going ahead, and the full weight of public opinion is being sounded out by the district health authority. The time has not therefore yet arisen for Ministers to call in the proposals and come to their own conclusions. My hon. Friend has warned me of what to expect if the proposals go ahead and he asked me a number of questions about the system of resource allocation that makes it necessary for the district to find a method of elminating its potential overspending.
We have both commented on the fact that money for the NHS has increased quickly since the Government came to power. In the past three years it has increased by 20 per cent. more than the rate of inflation as measured by the retail price index. The NHS has never had more money, doctors or nurses or such modern equipment and such up-to-date facilities.
Resources for London have traditionally been greater than those for the rest of the country. For some years, under formulae used by the resource allocation working party, there has been a reallocation of resources and a fairer distribution, based on the needs of populations in different parts of the country.
All the evidence confirms that spending on the NHS in London and the South-East compares favourably with that in other parts of the country, particularly Yorkshire and the North Midlands, where the health services are relatively worse off.
Our system allocates resources according to assessments of the size and needs of the population in each locality. There is an adjustment and weighting to take account of such important factors as the relative number of elderly and very young people, because they tend to make greater than average demands on the NHS. We also take account of variations in the mortality rates in different parts of the country.
1112 That process provides targets which we use in allocating resources to the regions. Within regions, including some of the better off, such as the North-West Thames region, there are considerable discrepancies in allocations to districts. My hon. Friend made the valid point that Hounslow and Spelthorne is relatively deprived compared with other districts in the region. He was correct to say that only four of the 15 districts in the region are worse off than Hounslow and Spelthorne.
However, the problem remains that the region is so far above its target that only two of those four districts are below the RAWP targets which are calculated on a national basis. If we disregarded the regional boundaries and if all district authorities received resources on the basis of their needs, nearly all the districts in my hon. Friend's region would lose money, and Hounslow and Spelthorne would at best receive only a few thousand pounds more each year.
With the Government's support and approval, the North-West Thames region is following a policy of allocating resources fairly between its districts, so that the position of Hounslow and Spelthorne is protected. However, because of the relative position of the region we cannot allow overspending and we must ask for solutions to be found.
There is also the difficulty, of which my hon. Friend reminded me, that the two hospitals about which he is so worried are outside Hounslow and Spelthorne's territory and there are, therefore, doubts about whether the interests of Twickenham are adequately represented on the health authority.
It is a basic principle of health authority membership that members do not represent particular interest groups. They should serve as individuals who represent professional, lay or local government interests. They should reach conclusions as individuals, in the best interests of the authority and the population that it serves.
Because of the difficulties that arose with the two hospitals when reorganisation took place, the Government asked the region to reserve one general place on the health authority for a nominee who would take a particular interest in the service provided by the district to Twickenham. I have met Mr. Clive Thomson, the member appointed for that purpose, and he has forcefully argued the case to his colleagues on the authority and to me when he and my hon. Friend visited me in October.
§ Mr. Clarke
I appreciate that. In trying to assess the public interest of the area and how best Ministers should evaluate any proposals that come forward from the authority, I will have regard to the fact that there is this curious geographical imbalance in the membership of the authority and try to make sure that the interests of Twickenham are not overlooked in relation to the rest of the district because of the extra-territorial position of these two hospitals.
I have not time to develop my remarks further. My hon. Friend has raised this issue at an early stage in the decision process. We do not yet know what will be the reaction of the district health authority to the comments that it receives on consultation. We do not know what will be the final decision of the community health council. We do not know if either will oppose the proposals. If there is opposition, we do not know what the regional health 1113 authority will say. It is only following the consultation process that must take place before the issue can come to Ministers. When that happens, I know that my hon. Friend will continue to press his case. I assure him that I will give it serious consideration and that I will not neglect any of the valuable points that he has made.