§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Goodlad.]12.32 am
§ Dr. Brian Mawhinney (Peterborough)
This Adjournment debate had its origins last December. when our son David went into the Royal Free hospital to have his tonsils out. He was to be one of a surgical list of 14, and, to our surprise, he turned out to be the only one of those 14 patients who actually showed up. I asked the hospital whether it had any figures on non-attendance, and it told me that it did not. My hon. Friend the Minister will remember that I put down a parliamentary question on this, and he told me that the Government did not have any information on non-attendance. I then wrote to each of the 14 regional health authorities, asking them whether they could give me the numbers and percentages of non-attendance for out-patients and in-patients over the past five years. Some 12 of the 14 regions wrote back and told me that they did not have any figures, and nor did any of the districts.
Two regions did have some information, and it might be useful if I were to put the information that I have on the record. East Anglian, Trent, Northern region, Oxford, Wessex, North West Thames, South East Thames and South West Thames had no information whatsoever. The South Western region, Yorkshire and Mersey each had one hospital, or one short-term study that produced some figures. In the South Western region, the non-attendance of out-patients was 14.8 per cent., in Yorkshire, it was 23.2 per cent. and 1.9 per cent. for in-patients, and in Mersey it was 14 per cent. for in-patients. In North East Thames, there was one hospital that, in 1982, had an out-patient absentee rate of 11 per cent., with an in-patient rate for the Newham district in 1983 of about 18 per cent.
I was also given figures from one of the regional administrators which might pertain to London. He sent me details of abortive London ambulance trips. Almost 1,800 trips a week by the London ambulance service are non-viable. They go to collect a patient but return without him. As they go to bring patients to appointments at clinics or at in-patients, it is a measure of what happens in London.
Two regions had statistics. The north-west region had figures from about 20 districts, which showed an average out-patients absentee figure of 12.6 per cent. The in-patients figure for 1977 was 13.6 per cent. The west midlands gave me figures from nine districts, which showed an out-patients absentee figure of 11.2 per cent, and two figures for in-patients of 12.3 per cent. and of 3.1 per cent.
The figures vary widely according to the hospital and specialty. They range from about 2 per cent. to 30 per cent. The figures are, however, sketchy and few and far between. What we discovered was that no proper statistics were being kept. That reflects a huge waste of manpower and resources. In the case of our son, a full operating theatre team was in attendance for a day in a theatre in a London teaching hospital, which had been booked for the day. After the team of specialists operated on David in the morning, they had nothing to do for the rest of the day and the theatre was not used for any other purpose.
I wonder whether the figures make sense because the average national non-attendance for out-patients must be between 12 per cent. and 15 per cent., and for in-patients 889 between 10 per cent. and 12 per cent. The latest figures from the Minister and his Department showed that there were about 35.5 million out-patients appointments in 1982—the last year for which figures are available. That means the between 4.25 million and 5.33 million outpatients clinic appointments were not kept. On the figures, which the Minister gave during questions today when he said that a wasted out-patients appointment might be worth anything between £20 and £50, the waste to the National Health Service of out-patients appointments alone is between £85 million and £266 million a year. The Minister will be as disturbed by those figures as I am.
The in-patients estimate seems to be reasonable. In 1982 there were approximately 348,000 beds, of which approximately 278,000 were occupied—that is an 80 per cent. occupancy rate. I suggest that the non-attendance figures are about 10 per cent. It does not seem unreasonable that about half of the empty beds were due to non-attendance and half to keeping them free for emergencies.
No hon. Member has been more supportive of the Government's health policy than I have. The Government have initiated many reviews, all of which were designed to produce information, which would enable managers in the NHS to run the service more efficiently and cost effectively.
The Rayner scrutiny of non-ambulance transport showed that we had more vehicles than drivers and that the average district could save up to £70,000 per year. The Rayner scrutiny of recruitment advertising showed that the Health Service was spending £8 million per year advertising to its own staff. The study on central stores showed that 20 per cent. was being added to the cost of goods compared with best commercial practice of between 4 per cent. and 12 per cent. Presumably, at one time nobody knew those figures, but it was suspected that there was waste so a review was undertaken which identified the waste so that better value for money could be achieved and directed towards care of the patient.
That is the essence of my case to my hon. Friend the Minister today. He and his colleagues have an enviable record of commitment to cost effectiveness and value for money in the Health Service—for the sake of the patients, not for the sake of the Government's reputation—and I see this debate very much in that context. If thousands of beds are standing empty thousands of people on the waiting lists must be suffering because they cannot get into those beds which are being blocked by people who do not show up.
My hon. Friend the Minister, quite properly, is ahead of me on this. He and my right hon. and learned Friend the Minister for Health set up the Körner committee to examine statistics in the Health Service. We have both read its first three reports and my hon. Friend has already committed the Government not just to accepting but to implementing those recommendations, which include the subject of today's debate.
I refer my hon. Friend the Minister to some words which he will recognise not just for their wisdom but for the tone in which they are given. In a written answer on 12 April my hon. Friend the Minister said to my hon. Friend the Member for Birmingham, Northfield (Mr. King): 890Health authority managers need information about the services for which they are responsible and about the resources of money and manpower which go into providing those services. It has long been recognised that the information currently available to NHS management is inadequate. It is too often incomplete, inaccurate and out of date. The result is that district and unit managers are not as well equipped as they should be to plan, budget and review their performance in the ways we are asking of them." —[Official Report, 12 April 1984; Vol. 58, c. 381–2.]My hon. Friend states better than I can exactly what I wish to put to him today. There is no point in a commitment to cost effectiveness if we do not give the new Griffiths managers the technology to enable them to do the job.
It has been agreed that the regions and districts should be computerised as quickly as possible. The regions which wrote to me made it clear that they could not begin to tackle the problems of non-attendance until they had information on computer which would allow them easily to resolve the problems uncovered. Those statistics are needed urgently. We shall not know why people do not show up for clinic and in-patient appointments until we are able to analyse the statistics.
I do not know why so mant people do not show up, but I think that my hon. Friend will accept that if it is because they do not need medical treatment we could knock 100,000 of the national waiting list today and bring the total down from about 720,000 to about 625,000. Some may not show up because they are already dead, some because they are already better, and some because the consultant put them on the waiting list in order to get them out of his clinic or surgery and had no real intention of ever giving them any treatment. That may sound harsh, but general practitioners use prescription forms in that way, day in and day out, throughout the NHS.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. John Patten)
There is sometimes a comparison with letters to Ministers.
§ Dr. Mawhinney
Just so. There is also a suspicion that many do not show up because the clinics are badly organised, and that consultants are not very keen to improve their techniques to make it possible for people to attend.
Some people may, of course, be really unable to attend at the given time and may have problems as a result.
There would be one other advantage, which I know that my hon. Friend will acknowledge, in having the statistics computerised. It would enable regions and districts to determine where the shortest waiting lists are within any region.
I pay tribute to my hon. Friend the Member for Mid-Staffordshire (Mr. Heddle). It is a delight to see him in his place at this late hour. My hon. Friend initiated an Adjournment debate on orthopaedic surgery waiting lists on 15 May 1981, and has been assiduous in following the matter up. He will be encouraged to know that some of us have been pressing our own regional health authorities on the matter for months and years. The answer has been that they can do nothing until they are computerised.
My time has run out. My message to my hon. Friend is simple. First, there is a huge gap in our knowledge of what is going on in the health service in terms of non-attendance by patients both at out-patient clinics and for in-patient appointments. It is very worrying to discover that 12 out of 14 regions had no information from their districts to channel through to my hon. Friend.
Secondly, we must give priority to computerising the districts and the regions, because we cannot tackle the 891 problems until that is done. Even if—dare I say this to my hon. Friend? —we have to spend a little more money in the short term, the long-term savings will make the short-term front-loading more than worthwhile.
I am sure that my hon. Friend will agree with me about those two points. The third point is the one that I hope he will respond to this evening. The point is that the need is urgent. It should not just be given priority by the regions. The Government should make it clear to the regions that the matter is given high and urgent priority by the Government. If my hon. Friend would throw his weight and that of his Department behind my request, computerisation would arrive much more quickly than might otherwise be the case. The consequences of that for the better management of the Health Service and the alleviation of suffering would be out of all proportion to the cost and effort of computerisation.
I am grateful to my hon. Friend for the courteous attention that he has paid to my comments.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. John Patten)
My hon. Friend the Member for Peterborough (Dr. Mawhinney) has addressed this problem with his characteristic fairness and clarity of reasoning. He has hit several nails on the head, and I must hit one or two as well. Each of us is as exasperated as the other that we do not have the information. It must be wrong, for example, that until two years ago we had no clear information about the number of people whom we employed at any one time in the National Health Service. We have a long way to go before information will be as refined as my hon. Friend, I, my right hon. Friend the Secretary of State and my right hon. and learned Friend the Minister for Health would like. There is no point in deceiving ourselves about that.
My hon. Friend drew our attention to just one area in which we suffer from a lack of information in the NHS—operation waiting times, outpatient waiting times and the failure of patients to turn up for appointments for a variety of reasons. We must set the problem against the background of the enormous size of the business that the NHS runs. Each year there are about 36 million outpatient attendances, more than 5 million regular day-patient attendances and nearly 6 million inpatient discharges. Problems occur. At present, information about the rate of non-attendance for inpatient and outpatient appointments is not collected rountinely throughout the country, although some health authorities collect some information.
Important work is done by the Steering Group on Health Services Information, which we know as the Körner committee. I pay warm tribute to Mrs. Körner for the four and a half years of sterling service that she has given to the NHS in an attempt to sort out this complex problem. I am glad to see my hon. Friend nodding assent to that tribute, which I also pay on behalf of my right hon. Friend the Secretary of State. The steering group made detailed recommendations in its first report, which are designed to rectify the problems to which my hon. Friend referred.
For outpatients, the report recommends that all districts collect information showing the number of patients with an appointment who did not attend. For inpatients who were to be admitted from waiting lists, the report recommends that all districts collect information showing the number of patients for whom arrangements to admit 892 were made, but who were not admitted, distinguishing those who were not admitted because they failed to attend. My hon. Friend and others could be excused for asking why that information has not been collected routinely since 1948.
We have asked health authorities to plan to implement the committee's first report throughout the country by April 1987. That might seem a long time away, but the implementation of this and the other Körner reports represent a substantial programme and we do not believe that it would be feasible to ask the service to proceed more quickly on this as against all other management tasks that we have set in the post-Griffiths era. It is open to individual districts and regions to progress at their own pace in the meantime. If I were appointed general manager to a district health authority under the post-Griffiths arrangements, I should want to make pretty rapid progress to demonstrate to my authority that money was being spent in a controlled way and not being wasted when it could have been spenton patient care.
By 1987 we expect at least one third of all districts to have a computerised patient administration system. Most will have the facility to monitor waiting lists and to provide consultants and family doctors with information about non-attenders. However, I think we must be careful not to pin our hopes too high and think that these systems can solve the real problem, because I do not think they can. Knowing what happened in the past is not of itself particularly helpful in overcoming the problem of filling gaps in theatre and clinical lists which appear without warning. There perhaps we need—and doubtless the Health Service will be directing its attention towards the need—attitude surveys which pick up exactly why people who have a good reason for not attending, such as further illness, bereavement, a recent move or whatever, do not show up and why they waste so much money which should be spent correctly on patient care.
Having a reserve list of patients on standby may sound attractive, but even if patients were willing to co-operate and come in at extremely short notice to fill in gaps, for example, in theatre time, it would be extremely difficult at such short notice to find patients sufficiently similar in nature that they could be slotted in without causing major disruption to theatre usage or clinic time. I am not saying that one should not move towards this system, but there are a lot of problems. One of the problems is cost.
My hon. Friend correctly raised the urgent need for computerisation in the National Health Service to provide us with better information for better planning or, to use his phraseology, more expenditure up front to produce longer-term benefits for patients. A computer-based system which can sort through those patients still on the waiting list and identify candidates on the basis of some predetermined classification is theoretically possible, but complex and certainly expensive. The systems available or under development at present will cost a district between £0.1 million and £0.5 million to install. That is an investment nationally of about £50 million or more and that money would have to come out of money already available to health authorities. No doubt all sorts of lessons can be learnt as local systems are developed. It is right that as more health authorities set up and use computerised systems, they also develop them to meet local situations. The needs of urban areas may be different from the needs of rural areas.
§ Dr. Mawhinney
My hon. Friend mentioned the cost to individual districts of putting in computers. Is he willing to consider the possibility that the main frame computer should be put in at regional level and that districts could then each have a terminal feeding in, which would probably be cheaper than each district putting in its own computer?
§ Mr. Patten
This is the sort of issue which has already been addressed by my Department's computer policy committee. It is probably clear that the sort of work carried out by Mrs. Körner's committee on information and the work of the computer policy committee on the purchase of main frame computers and associated software will have to come much closer together. They will be addressing themselves to the strategic points to which my hon. Friend has just referred. The sums to be spent are huge.
In the four minutes left to me I must turn to the other side of the coin from the development by the NHS, albeit belatedly, of a system which enables us to collect information, even though at considerable cost. The other side of the coin is the patient's individual responsibility to keep the appointment made for him as in any form of contract, both the Health Service and the patient have a responsibility. The patient's responsibility is, if possible, to keep the appointment made for him, or at the very least, to let the hospital know in good time if he cannot or no longer wishes to attend.
This afternoon during Question Time I said that patients had a moral responsibility, if they could not use hospital time or clinic time, to let the hospital or clinic know. I hope that, thanks to the publicity which will doubtless flow from this issue being raised on the Adjournment by my hon. Friend, more and more people will be given cause for thought if they are tempted to misuse the National Health Service. The NHS is based on the informal contract 894 between what we promise to supply and what people want. However sophisticated a system is developed to ensure efficient call-up of in and outpatients, the Health Service must know that the majority of those called will attend. To achieve that we need the co-operation of the public.
Interest has been shown in the idea of a bed bank for inpatients using a computer system to make information about the length of waiting lists in hospitals readily available to GPs. That is a sophisticated method of bringing information technology to the aid of an approach which the Department has advocated since the mid-1970s. It will not reduce waiting lists overall, but it might be a useful method by which the more extreme differences between hospitals and districts can be ironed out. That is why the Department and the West Midlands health authority have been discussing a pilot project. I welcome the great interest in the topic by my hon. Friend the Member for Mid-Staffordshire (Mr. Heddle).
§ Mr. John Heddle (Mid-Staffordshire)
I think that we have three minutes to spare. I thank my hon. Friend the Member for Peterborough (Dr. Mawhinney) for his courteous remarks and my hon. Friend the Minister for his welcome announcement. May we debate the findings of the pilot scheme in due course?
§ Mr. Patten
We shall have to wait to see, when the pilot scheme is set up, how long it takes and what it produces. With his characteristic interest in such matters, I know that my hon. Friend will press us further. I thank him and my hon. Friend the Member for Peterborough for raising this important issue.
§ The Question having been proposed after Ten o'clock and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at one minute past One o'clock.