Health (Wales) (Hansard, 17 January 1984)

§ Mr. Gareth Wardell (Gower)

I am pleased that I have been successful in the ballot so as to be able to draw attention to the very important problem of inequalities in health within Wales.

In Wales in 1981 453 infants under the age of one year died. The report of the committee on child health services stated: In contemporary terms, infant mortality is a holocaust equal to all the deaths of the succeeding twenty-four years of life". The infant mortality rate has long been regarded as a useful indicator of the state of health and health services in a country. If we compare the situation in Wales with that in France, Finland, Sweden and Japan for the years 1964 to 1980 on a two-year basis, the infant mortality rate is worse in Wales than in every one of those countries and for every year except for France in 1966 and 1968.

In 1980 the infant mortality rate in Sweden was 6.9, and in Wales it was 11. Considerable as the differences are between Wales and other countries in the infant mortality rate, the differences within Wales are very much greater. No doubt that is partly why doctors in west Glamorgan, for very good reason, have been conducting confidential inquiries into perinatal deaths since January 1981. It is the same fact that has prompted the setting up of the catalyst team and survey group that will prepare the Wales perinatal mortality survey. I welcome the aim of this initiative as a stimulation for improvement in maternity and neonatal care in the Principality. A clear need for such improvements is indicated by the large disparity in the infant mortality rate by socio-economic groups.

For example, in west Glamorgan—part of the county that I represent—the latest figures available show that the infant mortality rate is 7 per 1,000 live births for socio-economic group 1, while it stands at 19 per 1,000 for socio-economic group 5. If the perinatal rate is examined, the gap is far wider: 7 per 1,000 total births for socioeconomic group 1 and 27 per 1,000 for socio-economic group 5.

On 12 December 1983, the Minister gave me an assurance that the new system of capital expenditure allocation to health authorities in Wales would in no way delay the implementation of the planned new paediatric and obstetric unit at Singleton hospital, Swansea. That was a most welcome assurance.

But the fundamental need, clearly demonstrated in the DHSS working party report of 1980, is a comprehensive anti-poverty strategy, and, as the Black report stated, pride of place in that strategy must be a massive redistribution of income and wealth. I wish that the Government would pursue that goal and fully realise the grim reality portrayed by Dylan Thomas, one of the greatest Anglo-Welsh poets, in his little-known poem, A Refusal to mourn the death, by fire, of a child in London", in which he said: Deep with the first dead lies London's daughter,

Robed in the long friends,

The grains beyond age, the dark veins of her mother,

Secret by the unmourning water

Of the riding Thames.

After the first death, there is no other. 293 The disadvantages of birth and early life cast long shadows forward. It is at that time that Government can most usefully and productively contribute to a vast improvement in the health of the British people.

I come to the services provided within the NHS for the care of the mentally ill and mentally handicapped. While the Welsh Office initiative to promote, so far as possible, the rehabilitation of the mentally ill and mentally handicapped into the community is welcome, at least one major aspect of it is extremely worrying. That is the problem of those elderly mentally handicapped and disturbed mentally handicapped who are of necessity being maintained in hospitals and for whom there is no provision in the new initiative.

It would seem inappropriate, therefore, not to plan to improve our existing services to accommodate these people; but the same money cannot be spent in two areas, in health and social services. Within our existing hospital units—for example, Cefn Coed hospital, Swansea — which are overcrowded, old, and in need of refurbishing, the amount of money that we can expect to spend is limited. Yet the problem of accommodating the frail elderly mentally handicapped will be with us for some time.

The future pattern of psychiatric service development provides the main thrust between acute and psycho-geriatric services. There is a small, important and ever-present body of long-stay patients who may be left behind in the main thrust of initiative but whose presence in the community is a continuing problem. This problem was courageously and expertly examined by Marjorie Wallace in an article in The Sunday Times of 20 November 1983. The article examines the failure of community care to cope with the mentally sick. While the article focuses on Southampton, it also states: the scandal of the mentally sick is a national one. I found similar patterns in London, Oxford, Birmingham, Newcastle and Swansea. The community care policy throws the onus on to the local authorities, but they are not legally obliged to act. In the United Kingdom as a whole, only 1.1 per cent. of the total social services budgets is spent on community health for the mentally ill. One quarter of local councils provide no day care whatever for the mentally ill. One fifth offer no council residential accommodation.

John Wilder, director of the Psychiatric Rehabilitation Association, has said that People who need to be in hospital are walking the streets, often dangerous to themselves and others. They are the new vagrants".

I question the accuracy and validity of the method by which National Health Service funds are distributed among the regions. That is a crucial consideration in assessing the extent to which Wales receives its equitable share of available allocations. It is questionable whether the four present formulae used perform a useful function. If they do, I hope that the Minister will explain the rationale underlying their use and will also explain the Government's opposition towards a single national formula. If the Minister chooses not to do so, it would be helpful for the people of Wales to know at least whether a move towards the use of the resource allocation working party formula would increase Wales' allocation of National Health Service funds. Research published in The Lancet on 12 December 1980, referring to 1977–78, showed that if the RAWP formula was applied to the health care budget Wales would have benefited 294 substantially. If that is still the case, perhaps the Minister can tell us what steps he is taking to remedy the under-funding.

It is crucial to remind the Minister of a statement in the Court report of 1976, which was recently reprinted: Despite recent efforts to bring about more equality, the variations in regional provision of service are still much the same as they were in 1948 when the National Health Service began.

§ The Under-Secretary of State for Wales (Mr. Wyn Roberts)

I am delighted to have an opportunity to discuss the subject of inequalities in health in Wales. I begin with the last point made by the hon. Member for Gower (Mr. Wardell). A great deal has been said about this subject in recent months by those who should know better. It is opportune that I should be able to make an unequivocal statement on the issues and the facts.

When the major reorganisation of the NHS took place in 1973, one of the first problems to which everyone concerned addressed his mind was the generally accepted fact that health resources were not distributed in a way which necessarily reflected health needs. The ideal way to tackle the problem was to measure health need, then to measure the amount of health care available and finally to bring the two into line.

The trouble was that neither health need nor care proved to be directly measurable. Eventually, it was concluded that need and supply could be measured indirectly. The major determinant of need was seen to be population and the principal determinant of supply was revenue funding. Inequalities could be identified by taking a particular area's share of the total population and comparing it with that area's share of the total revenue funding. But the population of a particular area need not necessarily be directly comparable, head for head, with that of another area. In particular, it was a well-established fact that the age and sex structure of a population significantly affects the likely need for health care. It also accepted that even when the age and sex structure of the population is taken into account, there can still be differences between otherwise similar populations in the amount of illness occurring. Although this latter point has occasionally caused some controversy because of the extreme difficulty of measurement in this field, a consensus has been reached that the best available way to measure this uneven incidence of sickness is to use the death rate for particular population groups — that is, standardised mortality ratios.

The conclusion reached, therefore, was that, to identify inequalities in the distribution of health resources, weighted populations would be calculated for health authorities and their weighted proportion of total population compared with their weighted proportion of health resources. That has been the basis on which in Wales, Scotland and England inequalities have been identified for the past eight years.

Two major areas of concern need to be dealt with. The first is a point that has been raised repeatedly lately, and to which the hon. Gentleman referred. It concerns claims that Wales is seriously underprovided relative to the other parts of the United Kingdom. Those making these claims have referred to work done by Professor Maynard of York university. He calculated the shares of population of the four constituent countries of the United Kingdom and compared them with actual revenue expenditure by health 295 authorities in those countries in 1977–1978. His figures appeared to show that Wales was at that time 7.5 per cent. underprovided.

I do not wish to weary the House with an explanation of the way in which public expenditure levels on particular programmes are set in Wales these days. Suffice it to say that for the past four years my right hon. Friend the Secretary of State for Wales, like his colleague in Scotland, has had discretion within a total block of expenditure to distribute the money between the individual programmes in the light of his assessment of Welsh needs. Programmes are not, therefore, directly linked with their English counterparts, but can be developed on lines dictated principally by the needs of Wales.

For that reason, therefore, we do not set the level of spending on health in Wales by some mechanistic link with what is being done in the NHS in England. We do the best we can in the overall public expenditure environment to make appropriate provision for the development of all services, including the NHS, in the Principality.

We do not, therefore, undertake the sort of exercise which Professor Maynard did to compare ourselves with the rest of the United Kingdom.

It is worth saying that if we were to take the proportions between the countries which Professor Maynard suggested as the right ones in 1977–78 and applied them to the provision for revenue expenditure by health authorities made in the Supply Estimates for the four countries in the current financial year, 1983–84, it should give us a broad indication as to whether things have changed. The result of doing so is to show that, on the basis described, Wales in 1983–84 was only 0.3 per cent.—that is one third of 1 per cent. — below the share which Professor Maynard's figure suggested was the right one compared with 7.5 per cent. in 1977–78. I would not for one moment claim that such a calculation — any more than the original one on which it is based—was totally reliable and accurate. In so far as it shows anything, it indicates that if there was a gap in 1977–78 the Government have virtually eliminated it.

When I tell the House that these figures do not take into account the fact that my right hon. Friend has already announced that growth in revenue spending by health authorities next year will be a further 2 per cent. over this year's levels, and that that is significantly greater than the level announced for England and Scotland, I think that it can be seen in terms of our share of United Kingdom funding that Wales under this Government has certainly not been disadvantaged.

The second area in which inequalities exist is that of the differences between health authorities in Wales. On that point I need detain the House no longer than to say that my right hon. Friend is committed to removing major inequalities within a three-year period, of which 1984–85 is the second year. Those problems exist and the Government have not only given a firm commitment to deal with them but have set themselves a very testing timetable within which to meet that commitment.

I understand fully the almost limitless extent of demand for health services. We are all aware that there remain bottlenecks in the provision of services and that each new expansion and development of health care appears as much to generate new demands as to satisfy old ones. The 296 Government's commitment to finding extra resources for the Health Service cannot be questioned in the light of our record, but for the foreseeable future we will always be faced with a total potential and actual demand that exceeds our ability to meet it. There is no point in being unrealistic about that — every Government, even a Labour Government, must recognise that fact of life.

It is because of that that equal realism is needed to ensure that we get the maximum possible amount of health care—direct care for patients—out of every penny that we spend on the Health Service. We can equalise the distribution of resources, but it is as important, if not more important, to ensure the proper management of those resources in the interests of patients. All the Government's policies for the NHS are designed to ensure that the most efficient practices are employed everywhere and that every action undertaken by every member of the staff of the NHS aims to secure the best possible treatment for the maximum number of patients within the resources available. When we speak of inequalities in resources, it is important to recognise that there are also inequalities in the use of those resources, and we should be equally concerned about eliminating those.

The financial expansion provided has been accompanied by a significant growth in manpower. Since 1979 there has been an increase of 13 per cent. in the number of nurses and midwives, 15 per cent. in the professional and technical staff providing scientific services for doctors and nurses, and a provisional increase of 16 per cent. in medical staff.

Most importantly—returning to my theme of getting value for money and the maximum possible services from the record resources made available—all that has led to more people being treated. In 1982, the latest year for which figures are available, the Health Service in Wales treated 5.9 per cent. more in-patients than in 1979, 12.3 per cent more day cases and 8.6 per cent. more out-patient attendances.

Central to the drive for increased efficiency and effectiveness are the annual reviews of district health authorities that the Government introduced last year. Under those we require authorities to secure annually minimum efficiency savings amounting to 0.5 per cent. of their recurring revenue budgets. Those must be genuine improvements in efficiency and not involve any reduction in the volume or quality of existing services. I am glad that the response of the authorities has been extremely encouraging, such that we are hopeful that improvements in efficiency will yield savings significantly greater than the minimum required. That will mean improvements in services over and above the further growth incomes we have made available for next year and over and above the redeployment of the 0.5 per cent. required.

That leads me to the second and equally important aim of the reviews under which we require authorities to redeploy the first 0.5 per cent. of their efficiency savings on continuing care services for mentally ill, mentally handicapped and the elderly, precisely those mentioned by the hon. Member. These are the services which by common consent need special attention if both the quantum and the balance of services is to be got right. The requirement will lead to about £2.75 million of additional investment in these services in 1984–85. Individual projects for this reinvestment include, I am glad to say, 297 west Glamorgan health authority's intention to finance part of the costs of its assuming responsibility for mental illness services for the Neath and Port Talbot areas.

This is just part — although a vital part — of our concerted effort to redress the historic inequality of provision for these groups, both relative to the acute sector and as between authorities. Unlike the previous Labour Government, we have displaced rhetoric with achievement. Under our all-Wales mental handicap strategy, for example, additional spending will build up over 10 years to £26 million. It will be a fourfold increase on present levels of financial provision.

Through our "Care in the Community" initiative we have removed obstacles to the development of more appropriate care for people outside NHS institutions and provided greater flexibility in the operation of jointly financed schemes. These received a record level of Welsh Office support this year, as did central funding for special NHS psychiatric developments.

Taken together, these initiatives represent an unprecedented response to the needs of mentally handicapped, mentally ill and the elderly. Of course, there are local difficulties—if there were not, we would not be giving priority to the expansion of community care and support—and any system must rely on the good sense of health and social services authorities working together to ensure that people get the care that they need. In general, they show this good sense.

In the sphere of regional health services we have vigorously sought out where inadequacies exist and we are bringing forward plans to meet problems before they become entrenched. Our announced plan for expanding renal dialysis may well put Wales at the head of the European nations league table by 1985, and the provision of beds for the burns and plastic surgery specialty is the highest rate of any region in the United Kingdom. Nor do we overlook new medical technologies. A decision on a regional bone marrow transplant service will be made very soon, and the genetics centre will be housed in its own purpose-designed building. And in heart surgery, where 298 we inherited a shortfall, the number of operations are planned to rise to 600 by the end of this year—nearly two and a half times as many as in 1979. Notwithstanding the Government's achievements for the NHS — the record funding and the growth in the numbers of men and women providing direct patient care—we recognise that there remain in Wales inequalities between areas and by comparison with England in the incidence of disease.

It is nothing new to be told that the toll of death in Wales from heart disease, especially among middle-aged men, has been a cause of real concern for many years. What is new is the determination to tackle the problem. As I have already said, in the short term the number of heart operations to be performed annually in Wales will be increased to the full limit of present facilities. Within the next few years, there will be major investment to double the size of those facilities.

The hon. Member for Gower drew attention to deaths among the newly born and among very young children. He had a right to do so because this is an important issue which, for the families involved, is a deep human tragedy.

Having acknowledged that, I suggest that the hon. Gentleman underestimates the real progress which has been achieved, especially in the past three or four years. For many years Wales has had a rate of perinatal mortality consistently above those for England and Scotland. However, this hides the fact that the numbers and rate of perinatal deaths have dropped by half over the past 10 years. Moreover, the fall has been most dramatic in the past few years. In 1980 and 1982 the rate for Wales was actually below that for both Scotland and England.

Historically, Wales has done relatively better in respect of infant mortality. In six of the past eight years, the Welsh rate has been below—