Patient Referrals (Cumbernauld) (Hansard, 24 July 1985)

§ Mr. Norman Hogg (Cumbernauld and Kilsyth)

This has been a long day, though for Parliament it is still Wednesday — a Westminster eccentricity which must bewilder the outside world. Those of us who have kept the watches of the night, including my hon. Friends the Members for East Lothian (Mr. Home Robertson) and for Jarrow (Mr. Dixon), will be relieved that we are at last reaching the end of the sitting.

It would be appropriate for me to place on record on behalf of hon. Members our appreciation of the staff of the House who, with diligence, patience and characteristic courtesy, have seen us through the past eighteen and a half hours.

I shall not detain the House for long, but I have to raise an important constituency matter that is worthy of the rime that remains. For a number of years, general practitioners in Cumbernauld new town have been concerned about patient referrals from the new town to hospitals administered by the eastern district of the Greater Glasgow health board and by the Lanarkshire health board.

The principle has always been that doctors used their clinical judgment to determine the best hospital for their patients' needs. That principle has come under increasing pressure because of the growth of the new town arid a reluctance by the Glasgow royal infirmary readily to accept emergency admissions. The important requirement for the GPs is that there should be clear and adequate provision both in Glasgow and at Monklands district general hospital. Other hospitals in Lanarkshire, such as Law and Hairmyers hospitals, are not well placed for access from the new town by public or private transport.

The matter came to a head in July 1982, when a Cumbernauld GP received a letter from the eastern district of the Greater Glasgow health board informing him that the substantially open-door policy would continue at the receiving physician's discretion until 5 pm and that at 5 pm or earlier, if there were eight beds or fewer vacant in the medical division, the receiving team would inform the district medical officer or his deputy of the position.

Such was the concern of the GPs that they called a meeting in February 1983 to discuss the future hospital care of Cumbernauld people in view of the reduction in the number of beds at Glasgow. Consultants at Glasgow felt that there would soon come a time when they would be unable to provide a hospital service for Cumbernauld if there were further reductions in the number of beds. Their colleagues from Monklands general hospital said that they could barely cope with the work load from Cumbernauld that they were receiving at that time and would be unable to cope with increased numbers.

The problem is that Monklands general hospital was not built large enough to cope with Cumbernauld's increasing population and cannot cope with more than the numbers that it takes now. If Glasgow stops taking patients, they will have to go to Law and Hairmyers hospitals with increasing frequency.

Doctors asked the chief medical officer for Scotland to their meeting because either Glasgow would have to change its policy of reducing the number of beds, and would have to be given money to provide a service for two 1283 thirds of Cumbernauld's population or Monklands general hospital would be trying to cope with a demand which it was not large enough to satisfy.

The chairman of the Lanarkshire health board and the chief area medical officer were asked how they proposed to care for Cumbernauld's population. They replied that they hoped the situation would remain as it had been in the past. However, the Greater Glasgow health board was not prepared to let patients continue to have freedom of choice, and its cut in finances will affect Cumbernauld patients, who will find it increasingly difficult to get into Glasgow hospitals.

There are only two options for Lanarkshire health board in these circumstances. It either extends the Monklands district general hospital or zones Monklands not to accept patients from certain parts of Lanarkshire so that it can have more beds for Cumbernauld patients. As an alternative, Cumbernauld asks that it should be put into the Greater Glasgow health board area, which would mean that the responsibility for taking patients would be that of Glasgow. This would result in its getting more money, and not having to cut the number of beds that it is being forced to cut at present.

These questions were put to the chairmen of both boards, but it appears that the two chairmen failed to agree. Lanarkshire wrote on 19 September that any action that it took would be simply to take up the same stand that it had taken two years previously.

In theory, a complicated administrative procedure has been devised to keep the Monklands hospital doctor receiving the case informed where the patient may be accommodated. In practice, it never works out. In approximately 50 per cent. of medical cases, admission to Monklands hospital is simply refused. That is perhaps fortunate for the people of Cumbernauld, for the scheme as devised might mean admission to Hairmyers hospital or Law hospital. I stress that I am not criticising those hospitals. It is simply that it is not convenient for the people of Cumbernauld to go there. Only when all beds in Lanarkshire are full does the scheme envisage asking Glasgow royal infirmary for help.

Throughout the conduct of this issue, I have had meetings with the doctors. Their representatives and I have met the chairmen and officers of the two health boards. Although these meetings were useful in exploring the difficulties and determining the provisions which exist for my constituents, they did not successfully resolve the central question. In the event, I arranged a meeting with the Minister in an endeavour to obtain ministerial advice to the boards, on which it was hoped they would act so as to resolve the problem.

However, in the last letter which the Minister addressed to me, he merely reiterated that the problem of emergency referrals of Cumbernauld patients was essentially an operational matter for Lanarkshire health board to resolve, in discussion with the Greater Glasgow health board. The Minister stated that Dr. Thomson's letter of 19 September 1984 resolved the uncertainty which had prevailed to that date. He further claimed that the two boards concerned had now clarified the procedure to be followed.

The procedure is, of course, important, but it is not the central issue. The central issue is the capacity of Lanarkshire health board at Monklands general hospital to cope with Cumbernauld referrals, and the willingness and 1284 ability of Glasgow royal infirmary to accept unselected referrals from the new town. This has been underlined by a case referred to the royal infirmary by a doctor from Cumbernauld, which was the subject of correspondence between him and that hospital in May this year. It is clear that, if additional cuts continue in Glasgow royal infirmary then, while it will be willing to accept normal gynaecological complaints, patients requiring termination will not be considered.

It is essential that the Minister resolve the matter between the two boards. I hope that he will feel able to say that funding will be such that patients have a choice of which hospital they wish to attend. I hope that he understands that, if the choice is not given, there will shortly come a time when there are insufficient beds for the care of patients from Cumbernauld.

§ The Parliamentary Under-Secretary of State for Scotland (Mr John MacKay)

I am grateful to the hon. Member for Cumbernauld and Kilsyth (Mr. Hogg), despite the unusual hour, for giving me this opportunity to discuss the particular problem about which he has spoken and to place on record the Government's position on some of the aspects of this issue which are of more general interest and application.

Perhaps it has also given the hon. Gentleman, depending on the decisions of the electorate for the Labour party, a chance to have a say in this House before he takes a vow of silence. But that is something over which Ministers have no control; it is in the hands of the electorate of the Labour party. I shall not say anything about the hon. Gentleman either for or against him in case it damages or even enhances his chances in that election.

However, I will say that the hon. Gentleman has certainly pursued this matter with me both by meetings and by writing and now in this debate.

I think that it is first of all important to establish clearly in a case such as this what are the respective roles of, on the one hand, the Scottish Home and Health Department and, on the other hand, the Health Boards, the Lanarkshire health board and the Greater Glasgow health board. As hon. Members know, the responsibilities of health boards are many and varied, but perhaps the principal reason for their existence is to plan for and provide patient services within the resources which the Government make available to them and in the light of their local requirements and priorities. That latter point is an important one for, provided that there are no national implications, it surely makes sense for the local provision of services to be under the management of a locally-based administrative organisation.

Responsibility for the day-to-day operation and provision of health care services rests with the health boards. In fulfilling that responsibility each health board must, of course, have regard to the requirements of the national policy as laid down by my right hon. Friend the Secretary of State, who is ultimately responsible for securing the effective provision of health services, as well as to the constraints necessarily imposed by the availability of resources, whether finance, manpower or indeed fixed assets such as buildings and equipment. In effect, the Secretary of State fulfils his overall responsibility for the provision of health services through the individual health boards in respect of their designated areas.

1285 The fact that each health board is primarily responsible for providing health services to residents within its own area does not, however, mean that boards can afford to operate entirely independently of each other. While it may be a perfectly reasonable objective in terms of long-term planning for a board to devise its services with the needs of its resident population in mind, the pattern of existing services is to a great extent set by the sizes and locations of the hospital buildings actually available, and, as the hon. Gentleman said, by the travel network in the area. That can impose a very real constraint on the day-to-day provision of services. Where one board may have a deficiency of hospital beds, a neighbouring one may have a relative excess, and the logical solution in terms of achieving the best patient care within existing resources is for patients from the former area to cross the boundary into the second area for hospital treatment.

That is recognised in the operation of the Scottish health authorities revenue equalisation mechanism, and this cross-boundary flow is compensated for in the financial allocations we make to the boards. It does not absolve the board from taking primary responsibility for all its residents, nor from devising a strategy for developing its existing services to cater for that resident population. But it does allow a practical solution to be reached where there are imbalances of supply and demand. In each case such a solution depends crucially, however, on the respective boards working together in close co-operation to achieve the best and most practicable service to meet the needs of their residents. Such co-operation is extremely important to the co-ordinated planning and provision of hospital services and I know that nearly all who work in the boards fully appreciate that.

The boundaries of a health hoard are therefore purely administrative in the sense that, subject to the availability of hospital resources, a patient in one area can be treated in another. It has long been held to be an essential freedom for the general practitioner to be able to decide as he thinks appropriate the best hospital to which to refer his patient. Health boards do their utmost to accommodate that, but the constraints of availability of hospital resources inevitably mean that that freedom cannot be entirely uninhibited. That is not to say that cross-boundary flow is undesirable, but that health boards, for reasons of practicality, may not in all cases be able to provide the full choice of options of hospital care which a general practitioner might ideally wish. Instead, and I am sure that the vast majority of them accept this, the options may be restricted. But the overriding principle of greatest importance is that wherever possible hospital care should be available somewhere with the minimum of delay and with the interests of the patient in mind. That must be the goal to which health boards must strive, and, although we will never be rid of waiting lists entirely. I am sure that boards are continuing to make important progress in that direction.

I turn from that general principle, which is important, on cross-boundary flow and the relationship between adjacent health boards to the particular case of Cumbernauld raised by the hon. Gentleman.

There has been a tradition for patients from Cumbernauld to be referred to Glasgow hospitals and, in particular, to the Glasgow Royal infirmary. Cumbernauld is, of course, in the area of the Lanarkshire health board and it was because of the needs of the Cumbernauld area, 1286 as well as those of the Airdrie-Coatbridge area, that a new district general hospital in Airdrie, the Monklands DGH, was built.

Whereas previously there had been substantial cross-boundary flow from Cumbernauld to greater Glasgow, the position has changed somewhat. In 1976, some 88 per cent. of non-emergency, and 73 per cent. of emergency, acute patients from Cumbernauld were treated in Glasgow hospitals mostly at Glasgow Royal infirmary. Following the opening of Monklands DGH, however. these percentages have gradually fallen. The figures for 1982 were down to 72 per cent. for non-emergency cases and only 41 per cent. for emergency cases.

Part of the reason for the trend being gradual is that it takes time for GPs and patients to adjust their referral preferences and practices in the light of new hospital developments. It is inevitable that, for a time, people will continue to rely on the older hospitals. But it appears from the figures that the reputation of Monklands DGH among the people of Cumbernauld is growing. I am glad of that, for Monklands is an extremely efficient and well- run hospital, as I found when I visited it.

The hon. Member approached me about potential problems in the referral of Cumbernauld patients to Monklands in 1983 as he mentioned. We had a useful meeting at the beginning of 1984, when he explained to me that there were fears among the general practitioners in Cumbernauld that the capacity of Monklands to absorb more patients from Cumbernauld was now very limited but that there were signs from Greater Glasgow that they might not be in a position to continue to provide the existing level of service to Cumbernauld.

There was an even more pressing problem, as the hon. Member explained, namely, that Greater Glasgow was now unable to take emergency referrals from Cumbernauld, reversing previous practice, whereas Monklands, it was claimed. could not cope with the additional demand.

As I said at the time when we met, real as these problems were, they were essentially operational matters for the two health boards involved. I remain of that view. As I said, the responsibility for the operation and provision of health services locally lies with the health boards arid, provided that they are prepared to work together over common problems in providing those services, this is the best way to overcome them.

I placed emphasis earlier on the importance of cooperation and planning between health boards, and this case illustrates a good example of that. Following my meeting in January 1984 with the hon. Member, I arranged for the Lanarkshire and Greater Glasgow health boards to get together and address the two problem areas outlined, the one being the general admission of acute but non-emergency cases, the other being the specific issue of emergency cases where the situation was more difficult. I am glad to say that after the necessary discussions arid consultations, a solution was found by the boards to these problems.

Before I describe those solutions, I will comment on the question of the accident and emergency department at Monklands, which the hon. Gentleman raised in passing. This department has been under some pressure because of unforeseen demand, and the Lanarkshire health board is in the advanced stages of planning the building of an extension to the outpatients' department. The problem of the capacity of the department to deal with those who 1287 attend it, largely instead of going to their general practitioners in the first instance, does not bear on the Cumbernauld problem, which is not one of self-referrals. The solution to the general question whether Greater Glasgow will be able to continue its present level of service to residents of Cumbernauld is bound up with Greater Glasgow's plans for future developments in its acute hospital services.

The Greater Glasgow health board is well aware of the financial pressures that it is likely to be under if it does not take steps to reduce its total provision of acute beds to match the rapid decline in the population of its area in recent years and the emergence of hospitals like Monklands outside the area of the Greater Glasgow health board. These hospitals are now taking up patients which traditionally went into Glasgow for their hospital care. These matters are under discussion between the board and my Department but the present assumption is that Glasgow will continue to accept and treat Cumbernauld residents.

In the discussions which followed my meeting with the hon. Member, the Greater Glasgow health board confirmed that despite the speculation to the contrary, it expected to be able to provide the present level of service to Cumbernauld for the foreseeable future. I am glad that the boards were able to clarify the situation in this way and to their mutual satisfaction.

The issue of emergency referrals was more difficult because the Greater Glasgow health board was unable to offer a return to the situation before 1980 when it accepted responsibility for emergency patients from Cumbernauld. Instead, however, Lanarkshire health board was able both to state that it now accepted this responsibility in the first instance itself and to reiterate established procedures which were designed to fulfil that responsibility. These procedures provide for Cumbernauld patients to be referred initially to Monklands DGH. Should there not be accommodation there for them, arrangements are immediately set in hand to find alternative accommodation elsewhere in Lanarkshire, which is primarily at the two large hospitals at Law and Hairmyres. Only in the unlikely event of no suitable bed being available in these main Lanarkshire hospitals is the Glasgow Royal infirmary approached when, with the full agreement of the chairman of the Greater Glasgow health board, maximum help will be given. If the procedures are properly followed, the doctor who is looking for the bed should be doing a lot of 1288 telephoning. The procedure should be undertaken by the Monklands DGH by keeping a note of the availability of emergency beds — that is something that every large hospital has to do in any event—whether or not it is receiving from Cumbernauld.

Once again, I should point out that these were operational solutions to an operational problem and were sorted out by the two health boards together. I wrote to the hon. Gentleman in October 1984 to explain these solutions and, so far as I am aware, the procedures have operated to the satisfaction of both health boards and no problems have arisen.

I am aware of what the hon. Gentleman has explained, namely, that the general practitioners in Cumbernauld may not be wholly convinced that this is the best service for their patients. It is not always possible to provide every GP with the facility to refer patients to whichever hospital he wishes. There are cases where, as here, the provision of an appropriate service depends on a clearly understood procedure to be followed.

I appreciate that GPs in Cumbernauld and their patients have historically looked to Glasgow, and especially to the Glasgow Royal infirmary, for their health care. However, Cumbernauld is within the Lanarkshire health board area and with the opening of Monklands district general hospital in 1977 the situation changed. The bulk of the non-emergency admissions are still made in the Glasgow Royal, although the proportion has reduced from 88 per cent. in 1976 to 72 per cent. in 1982. For emergency admissions, the proportion has declined from 73 per cent. in 1976 to 41 per cent. in 1982. Lanarkshire health board and Greater Glasgow health board have agreed procedures for Cumbernauld and this must be matched by a willingness on the part of the doctors to follow these agreed procedures. I believe that if that is done there should be no problems for the patients in Cumbernauld, whether they are treated in Monklands district general hospital or in the Glasgow Royal infirmary.

I am happy to reiterate that it has been made clear by the Greater Glasgow health board that despite some of the rumours, which the hon. Gentleman brought to my notice with the doctors he took to see me. it is prepared to say clearly that it is able to take patients from Cumbernauld for the foreseeable future as and when the need to do so arises.