Addenbrooke's Hospital, Cambridge (Liver Transplants) (Hansard, 28 February 1985)

§ Sir Anthony Grant (Cambridgeshire, South-West)
I am grateful for the opportunity to raise this important issue in the House. My hon. Friend the Member for Cambridge (Mr. Rhodes James), in whose constituency Addenbrooke's hospital used to be, is equally concerned about the matter, and has taken an equally keen interest as I have myself. As I shall be critical of Government handling of Addenbrooke's hospital, let me say straight away that I greatly admire both the Minister for Health and the Parliamentary Under-Secretary who is to reply. In my view, they are among the most successful Ministers of this Administration.
I broadly support — and indeed enthusiastically support—the Government's policy towards the National Health Service. In particular, the policy of privatising the ancillary services and curbing excessive expenditure on drugs in order to release more funds for essential medical services meets with my complete approval. I am delighted that, since 1979, the Government have doubled the overall amount allocated to the NHS.
I am very proud that Addenbrooke's hospital is in my constituency. It is one of the best hospitals in the country and probably, indeed, in the world. Outstanding medical work is done there, especially in liver transplants, under Professor Calne. As the Minister has said publicly, liver transplantation is a life-saving procedure. Following the case of little Ben Hardwick, which was widely publicised on television, the public responded with their traditional great generosity by contributing £150,000 for a special unit for liver transplants at Addenbrooke's. Not unnaturally, however, the health authority's delight was tempered with anxiety because the actual cost exceeded that sum, and there would be continuing costs each year. But then a good fairy arrived in the shape of my right hon. and learned Friend the Minister for Health. On 30 April 1984 he told the health authority that he certainly did not envisage that the authority would be expected to divert money from its own patient care to what was a national service. He said: It is certainly not my intention that other services at Cambridge should suffer. On the strength of this, the authority went ahead and submitted its estimated cost of about £1.3 million to £1.4 million to a departmental expert committee. That committee, without any explanation, announced that it would provide the sum of £859,000. Although this was less than was asked for and needed, it was hailed with pleasure in my constituency by professionals, patients and public alike.
Then the bombshell landed because, of that sum, it transpired from the Minister's subsequent statement that no less than £567,000 of existing spending by the authority was to be deducted, leaving only £290,000 new money for a new and vital life-saving service. This, according to Professor Calne, the distinguished surgeon, is barely enough to carry out the 40 operations per annum, let alone the 50 envisaged. Therefore, 10 patients per annum will be at risk unless the local regional budget is raided.
560 The result of all this—it is a disease well known in Whitehall that I call accountant-itis—is that Cambridge will have to cut other services if it is to sustain the number of liver transplant operations envisaged. If liver sufferers are to be saved, services such as development of the intensive care unit, the work on bone marrow transplants and, indeed, other local medical services will be hit in order to pay for what is acknowledged by the Minister to be a supra-regional or national service. In this context, therefore, let me stress that less than 5 per cent. of liver transplant cases at Addenbrooke's hospital come from the local area; these cases come from the whole country and, indeed, some come from abroad.
All this—and I must say this in forceful terms—is in direct contrast with what the Minister for Health said in April 1984 on which the authority based its future plans. This accountant-itis has caused dismay in the area and deep anxiety for those unfortunates whose lives may depend upon this unique service. Frankly, this is not good enough.
The amount involved is small in the context of the National Health Service budget as a whole. I have worked out that it is .004 per cent. of the amount spent each year by the Government on the National Health Service. It is dwarfed by some of the appalling waste to which I could refer if I had the time. Nor, indeed, is it the sort of expenditure that will be repeated all over the country. These operations require a high degree of skill which can be exploited only at Addenbrooke's and King's. It would be tragic if, through bureaucratic obscurity and/or Treasury parsimony, this skill was lost, and lives were lost in the process.
I know that the Minister believes, as I do, in the importance of giving priority to patient care. There are few patients who are in need of such care as are the sufferers of liver disease, many of them little children like the famous Ben Hardwick. Therefore, I beg the Minister with all the force at my command to think again, and to give the life-saving service that is carried out at Addenbrooke's the resources that it needs.

§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. John Patten)
I am grateful to my hon. Friend the Member for Cambridgeshire, South West, (Sir A. Grant) for raising this subject on the Adjournment, as it gives me the opportunity to clear up some misunderstandings that seem to have arisen. My hon. Friend has been pursuing this issue vigorously with both myself and my right hon. and learned Friend the Minister for Health. Indeed, he has already addressed us both on the issue personally, has written to us and has been successful now in raising the subject on the Adjournment of the House. He has pursued the whole issue with his customary vigour in the interests of his constituents, and I know that his concern is shared by my hon. Friend the Member for Cambridge (Mr. Rhodes James), in whose constituency Addenbrooke's hospital used to lie.
I think that there have been some misunderstandings, and I welcome this opportunity to try to set the record straight. But to do so I shall have to go into some detail about the mechanisms of funding what are now known as supra regional specialties. So I hope that my hon. Friend and the House will bear with me for a moment. However, let me first make clear at the outset that the Government 561 support the development of liver transplantation as a lifesaving procedure. We value the work of the talented and skilled transplant surgeons who undertake such work, supported as they are by devoted nursing staff and ancillary workers. Among those distinguished people, we value the work done by Professor Calne and by all those who work in his unit.
We have just announced that liver transplantation is to be designated as a supra regional service with effect from 1 April 1985, and it may be helpful if I begin by outlining the general arrangements for the designation and funding of supra regional services before moving on to the specific point about the funding of the Addenbrooke's unit that my hon. Friend has raised so forcefully and eloquently. We need to set the case, the problem and the misunderstandings that surround the Addenbrooke's issue within the overall context of how we fund such services nationally. It is impossible to understand one without the other.
Early in 1983 my Department agreed with regional health authorities and with the Joint Consultants Committee, which represents hospital consultants, on the introduction of new arrangements for the funding of a small number of highly specialised and very advanced health services which, in order to be economically viable and/or clinically effective, need to be provided for a population that is significantly larger than that of any one single health region. These are services that are provided by very few regional health authorities to meet a substantial part of a national caseload. It would clearly be unreasonable to expect any one region at present to provide funds out of its own resources for these very advanced forms of medical treatment. However, typically in the National Health Service, that is how things begin — with a few centres of excellence. Thus these techniques will undoubtedly be disseminated from centres of excellence such as Addenbrooke's to other hospitals until we no longer need to designate services as supra regional services, because they can be taken up within the generality of the NHS. That has been the story of many medical advances, particularly since the second world war. Under these arrangements, a supra regional services advisory group has been established with certain terms of reference. It is important to put them on the record. They are: To advise the Secretary of State, through the Chairmen of Regional Health Authorities, on the identification of services to be funded supra regionally, on the centres where these services should be provided, and on the appropriate level of provision. The advisory group is chaired by an experienced regional chairman, Mr. Tony Driver of South-West Thames, and we are grateful to him and to the group's membership. The group is made up of representatives of health authorities and of the medical profession. Thus it is very much a case of the Health Service itself making decisions about how these funds should be allocated and to whom they should be allocated, on the grounds not just of economy or of economic viability but of the clinical service and the excellence of the units themselves.
Each autumn the advisory group finalises its recommendations on funding for the next year. These are then put to a meeting of regional chairmen — the 14 regional chairmen who serve the Health Service so well, like Sir Arthur South, the chairman of the East Anglian regional health authority — so that they have an 562 opportunity to comment. The recommendations are then forwarded to the Secretary of State, who announces his decisions just before Christmas or, as was the case this year, just after Christmas.
Four services were designated as supra regional at the outset—spinal services, services for children who suffer end stage renal failure, services for the management of chorion carcinoma, and the national poisons information service. Since then the four services have had added to them neonatal and infant cardiac surgery — which are right at the boundaries of surgery — and now liver transplantation. I should make it clear that these arrangements do not apply to services that are still at the research or development stage. They apply only—quite properly to our mind — to services that are clinically established and which are already being provided and funded by one or other of a small number of regions to meet what, it appears, will be established clinical needs.
This means—these are important matters in trying to fill in the background to the Addenbrooke issue — that when a service is designated as supra regional for the first time, the regions concerned will already be spending part of their allocations on its provision. It would not be reasonable for this existing expenditure to be disregarded when the regional allocations are made. This money is "protected". In other words, it is reserved specifically for the unit providing the service.
This "protected" sum is not an additional allocation from central funds. On the other hand, the region receives some benefit in that the amount is excluded from the calculations when decisions are made about future allocation levels for the region's general services or, to use technical language, which is perhaps not the best thing to do at this time of night, when it is disregarded, to use the deathless prose of NHS administrators through the ages, when calculating the region's distance from its regional allocation working party target, which is used in redistributing health services within the country so that areas which historically have been under-funded and under-provided, such as East Anglia, now experience substantial rates of growth that are far more substantial than other parts of the country.
East Anglia has been, and will remain, one of the fastest growing regions in the development of medical services. The picture is rosier for East Anglia, despite the problems that it faces, such as the Addenbrooke problem, than it has ever been. I am sorry that no Labour Members are in the Chamber to hear me say that East Anglia suffered terribly between 1976 and 1978–79 from cuts in NHS funding, which affected adversely capital expenditure on new hospitals and hospital building and revenue allocations to East Anglia. The Government have worked hard since 1979 to ensure that East Anglia catches up. It is worth while getting that clear.
The region benefits also in the method of calculation that I have described, in that it is relieved of the responsibility of finding any additional money to finance any expansion of the service that may be required. It is open to the supra regional services advisory group to recommend that additional money be allocated from central funds if it decides that the service should be expanded.
I will summarise that aspect because it is crucial to the debate. Money already being spent on the provision of a service is protected within the region's general allocation and is disregarded in calculating the region's future 563 general allocations, whereas money for the expansion of the service beyond its existing level is found from central funds.
After that general and, I hope, clear exposition of the present situation of funding, I come to the specific case of liver transplantation, from which I can proceed to the Addenbrooke's issue, which is uppermost in my hon. Friend's mind.
In the case of liver transplantation, applications for the service to be designated as supra regional were received early in 1984. The supra regional services advisory group then asked the Royal College of Physicians for its views, and the Royal College set up a working party which reported in the autumn of 1984.
The report advised that liver transplantation met the criteria for supra regional designation and that four units — Birmingham, the Royal Free and King's College hospital and Cambridge—should be designated as supra regional centres for its provision.
The advisory group endorsed that advice and made recommendations as to the amounts of money that should be allocated to each of those centres. Those recommendations were made on the basis of financial and workload information obtained from the four regional health authorities responsible for the four centres. We accepted the advisory group's recommendations.
For the liver transplant unit at Addenbrooke's, it was estimated that the amount of money being spent on the service during 1984–85 was £567,000, and this was the sum that was protected and earmarked within the region's allocation specifically for the unit.
Although that estimate had to be based on data received in the middle of the financial year—not always the best time to obtain accurate data — we have no reason to believe that it is substantially wide of the mark. In addition, the advisory group recommended that the work of the unit be expanded, and a further allocation of £292,000 was made from central funds, making a total according to our calculations—calculated in the way in which I explained—of £859,000 available to the unit for the coming financial year, 1985–86.
We greatly regret that there have been misunderstanding about the nature of the funding arrangements for the Addenbrooke's unit, and to be frank, the Minister of State and I were rather surprised, too. The arrangements that I described at some length—anxious, as I was, to explain the position to my hon. Friend and his constituents—were set out in a health notice which was issued in 1983.
That type of notice is well understood. It set out the procedures that I had understood were well established and well known in the National Health Service. They have been applied to all the other designated supra regional services without giving rise to any difficulties; no other unit in the country has complained about the situation in the way in which Addenbrooke's has complained.
In other words, all other hospitals and units seem to have understood the method of funding set out in the health notice and the way in which the recommendations of the group were being applied.
564 My hon. Friend referred to the text of a letter written by the Minister of State about the Ben Hardwick bed I must make it clear that that letter was primarily concerned with the financing of the Ben Hardwick bed, and that was not an appropriate context for spelling out in full the way in which the central funding of supra regional services works. That letter was concerned with the Ben Hardwick bed—nothing more and nothing less.
On the key issue which so radically concerns my hon. Friend it is perhaps worth noting that an officer of the East Anglian regional health authority is a member of the supra regional service advisory group and was party to its recommendations. The East Anglian region was represented at the regional chairmen's meeting in November last year, and thus there was a clear opportunity for the region to comment on the recommendations before they even got to my right hon. and learned Friend and to me. I understand that no comments were made.
However this unfortunate set of misunderstandings has come about, it is particularly to be regretted that a substantial increase in the funds allocated to the unit, amounting to almost £300,000, should have been reported locally as a savage cut. That seems to us to be an unusual interpretation.
That having been said—and I am sure that my hon. Friend appreciates that I must set out as clearly as 1 can the facts as I and my right bon. and learned Friend see them — of course we have the welfare of this unit at heart. The die is cast for 1985–86, but we shall continue during the course of the year to keep the work and the needs of the unit under review.

§ Sir Anthony Grant
I appreciate what my hon. Friend has said, and I have been listening to him very carefully. I am anxious that he should not close the door on this. I want him to be absolutely clear that he will follow the course of this vital unit and that a chink of hope can be given to it for the future if this is a success.

§ Mr. Patten
We will certainly keep the work of the unit under close scrutiny. Together with the advisory group, we shall keep the situation continuously under review during 1985–86.
I should like to end as I began by paying a tribute to the unit for the work it is doing at Addenbrooke's. This is something which unites my hon. Friend and myself tonight. The unit carried out a substantial number of liver transplants in 1984 and is the only unit to have developed expertise in liver transplants in children.
The additional money that we have allocated for 1985–86 is clear evidence of our commitment to the unit, whose future we shall keep under review. I hope that our support will enable its work to go forward on a firm footing.