§ Motion made and Question proposed,That this House do now adjourn.—[Mr. Lennox-Boyd.]
9.35 am§ Mr. Fred Silvester (Manchester, Withington)The outstanding feature of Adjournment debates is that the answers are always written before the questions are heard, but perhaps today will be an exception. Debates on specific hospitals and problems in the Health Service are usually answered the easy way and we all have on our files interesting letters from the predecessors of my hon. Friend the Parliamentary Under-Secretary of State, including my right hon and learned Friend the Member for Rushcliffe (Mr. Clarke) and my hon. Friend the Member for Oxford, West and Abingdon (Mr. Patten), which take the straightforward line.
There are three lines of defence in such matters. The first is to quote the global sums spent on the NHS, which are remarkable but not always relevant. The second is to refer to living within our means, about which we have several letters on file. The third is to suggest that Ministers have no power to intervene in regional decisions. The case of ministerial detachment is unsatisfactory because, although Ministers cannot intervene in every local decision, they cannot escape from the casual connection between policies devised at the Elephant and Castle and their effect in the field.
Not everything can be answered by generalities. We have got into the procrastinating habit of assuming that general principles worked out by the Department must be applicable to each local circumstance and if we have to stretch the hospital or chop off its legs to make them fit, we shall do that. Until my right hon. Friend the Member for Brentford and Isleworth (Mr. Hayhoe) came to the Ministry, the central problem facing us was not being tackled. General principles do not apply in every case.
Today I want to talk specifically about the Christie hospital. It is no ordinary hospital, but is the largest single cancer-treating hospital in Europe and is linked with one of the leading cancer research institutes. Its origins go back to 1893 when the first of the two elements was founded, and it was brought together on its present site as a combined hospital known as the Christie in 1932. Cancer research has been pioneered there since the mid-1940s when Dr. Edith Paterson, an expert in radiation biology, was at work. The Paterson institute is almost entirely sustained by public subscription and has carried on the work of cancer research in conjunction with the hospital. The hospital undertakes many drugs trials and there is a regular interchange of personnel with centres overseas. For those reasons the Christie is a national asset and an undisputed centre of excellence.
I decided to bring the questions arising from the hospital to the House today because I wanted to summarise what we were able to tell the Prime Minister on her visit last Friday and to ensure that her words found a place on my hon. Friend's agenda and were not forgotten. We were delighted to welcome the Prime Minister and she saw the hospital, which is working well, its several new facilities, enormous dedication and considerable efficiency. The Prime Minister was told of some of the things that I will the House. She told us how important it was for the country to preserve and encourage centres of excellence. I emphasise that my comments are 1487 not a begging letter or a bellyache. To suggest that the Christie is going downhill and depriving people of treatment is a travesty of the truth. It depresses and sickens me when hospitals are used as pawns of political propaganda.
First, as an aside, I draw my hon. Friend's attention to a card which is going around which was published by the Labour party in support of its "Save our health service" campaign. The card shows a child's drawing. It says:
My grandad is the fittest person I know. 2 years ago he was very poorly and when he went into Christie's Hospital they cured him.The card is from a child aged eight called Ruth. That card, which was made in London and made its way to Manchester, has caused great offence to some in the hospital because it implies that the Labour party gives official backing and credence to the proposition that the sort of help available to Ruth's grandad would not be available unless a particular political party was elected. I find that offensive, as do some others.I do not want to fall into the same trap of making political mileage one way or another about the Christie. We must deal with an important point of principle and fact if we are to get it right. In the past six years, the Christie has had much new building and it treats more people than ever. The Christie has a problem of success, because its success is paid for despite rather than because of the NHS system of resource allocation. In brief, the Christie's excellence continues to attract patients for whom there is no allocation. The Christie copes. It raises huge sums through voluntary effort. The Christie is the most efficient cancer hospital bar none. It has squeezed a quart, even a gallon, into a pint pot. All those qualities—excellence, voluntary effort, efficiency and hard work—are precisely the virtues which the Government seek to promote, but the reward has not followed the endeavour.
The Pat Seed scanner was provided by a fund in honour of the brave lady who fought cancer and gave so much encouragement to others. The fund raised £1 million for the scanner and the building. The Jubilee out-patients suite and the day ward were provided by voluntary subscriptions which raised £1.5 million. The adult leukaemia unit was subscribed by the Leukaemia Research Fund, the Cancer Research Campaign and the Women's Trust Fund at a cost of £800,000. The Pat Seed appeal committee has agreed to provide a developmental linear accelerator at a cost of a further £1.2 million. The Kay Kendall Foundation will provide a new laboratory in experimental haematology costing £900,000 and the Women's Trust Fund is providing £100,000 for the medical oncology department's research laboratories. I am sure that my hon. Friend is a mathematician. If she adds all that up, she will find that during the past six years about £5.6 million has been raised by voluntary effort. Not a penny of that has come from public sources.
The Christie is the most efficient cancer hospital bar none. If one considers the cost comparisons available for hospitals providing a similar service in the United Kingdom and the summary tables one finds, for example, that the cost per in-patient case at the Christie is £678. Those are the 1984–85 figures. The hospital with the nearest total is in the Trent area. Its cost per in-patient case 1488 is £738. The royal Marsden in London has a cost per in-patient case of more than £1,000. The nursing cost per in-patient case in the Christie is £88. The next nearest figure per in-patient case is twice as expensive and the royal Marsden is four times as expensive. Those comparisons may be carried out in the domestic service, too, and in catering and building maintenance. Whichever yardstick one applies, one finds that the Christie is in the most efficient section.
Secondly, I shall dwell briefly on the comparison with the royal Marsden hospitals in the Fulham road and Surrey. I shall try to avoid paranoia in this matter, because I know that my hon. Friend the Minister is not altogether sympathetic about some comparisons between the north and the south. But these comparisons are extraordinary and they cause raised eyebrows, if nothing else. The basic figures which I have already given to my hon. Friend show that the average cost per patient is four times as great at the royal Marsden in London. If one considers the expenditure tables for 1985–86, one finds that the royal Marsden in Surrey gets approximately £10 million a year from public funds for a case load of 5,895. The royal Marsden in London gets another £10 million for a case load of roughly 5,989. The Christie gets approximately £11 million, some of which is earmarked, for a case load of more than 10,000. Similar sums of public money are being spent on double the number of patients.
Whichever way one looks at it, the figures are highly unsatisfactory. The cost per in-patient day at the royal Marsden on medical and surgical equipment is £6.50 and is £1.37 at the Christie. In pharmacy, the figure is £13.95 at the royal Marsden and £8.27 at the Christie. In radiology, it is £2.33 at the royal Marsden and £1.31 at the Christie. The drugs bill at the royal Marsden is £1.5 million. At the Christie it is £900,000. The staffing facilities are much better at the royal Marsden, not only in numbers but also because the royal Marsden appears to have no nursing auxiliaries and many senior nurses, while much work is done at the Christie with nursing auxiliaries.
If there were only one or two discrepancies one would not make much of it, but the fact is that the cumulative evidence of the difference of treatment at the royal Marsden and at the Christie provides continuous aggravation and no one has yet given a satisfactory explanation. We have investigated whether the type of case treated at the two hospitals is different, but apart from a certain amount of highly intensive neck surgery there is little difference between the two provisions.
Thirdly, I said that the Christie gets a quart into a pint pot. It serves a region, as my hon. Friend the Minister knows, which has the third highest cancer incidence in the country and a population with many elderly people who are coming up to the age when cancer is likely to develop. But if one considers the figures from 1980–85, one sees that the number of patients is up by 15 per cent. The throughput per bed is up by 28 per cent. The day cases are up by 43 per cent. The number of days that people spend in the hospital is down from 10.1 to 8.5. The hospital is squeezing more and more people through. That is not uncommon, of course, in the Health Service, but the record of the Christie in that respect is superlative. One can continue to do that for so long, but after that the cracks begin to show. The Christie has achieved all that with the cards stacked against it. There has been no major capital expenditure on X-ray by the region since it bought a piece 1489 of ultra-sound machinery in 1979 for £40,000. As a regional specialty, the Christie can bid for traditional funds for development, but little is forthcoming.
The needs are clearly apparent. In the case of radiotherapy, the present complement of treatment machines is six plus a cobalt 60 unit. The calculation of requirements over the next seven years is that nine linear accelerators will be needed. Even if that is achieved, the hospital will have only half the number of machines in relation to population served compared with the national average. In the case of diagnositic radiology, it has relied entirely upon Pat Seed money. There is an urgent need for a second scanner and the movement into nuclear magnetic resonance imaging will impose further requirements on the hospital. None of this has come from regional funds. It is all very well to rely on voluntary funds, and we approve of it, but there has been no matching provision from the regions.
It is not only capital, but running costs. The Christie takes in patients from all over. Five per cent. come from Wales. The cost of that to the hospital is estimated at £300,000 because there is no provision for the transfer of resources from one region to another. No fewer than 16 per cent. of the patients come from outside the north-west area. If one calculates that on the same basis, it costs roughly £1 million. I do not say that that is an accurate figure, but it is not far off. There is also a problem of calculating the number of patients, which is done two years in arrears and which is worth perhaps another £300,000.
This is all done within South Manchester district, which is suffering from similar pressure. In 1984, it is estimated that the district alone had a net inflow of 34,000 patients from other districts and the cost is valued at £27 million. The district wants to help the Christie, but it is under extreme pressure and it cannot sustain the burden which the Christie imposes upon its general finances.
One can see that in the drugs bill. We have been trying to cut the bill by negotiating prices, but that is limited by what the DHSS will permit. I do not argue about that. There are reasons for it, but it means that the hospital has a limited ability to act alone in this respect. In 1980–81, the Christie's drugs bill was £586,000. In 1985–86, it was £1.1 million. My hon. Friend will know that the reason is that, in cancer treatment, the joint use of chemotherapy and surgery as well as the use of chemotherapy alone has developed dramatically. Some of the drugs are very expensive. Indeed, taking account of inflation, the drugs bill is an increase of £350,000 in real terms over that five-year period. We calculate that, of that sum, £100,000 has come from the region and £250,000 has had to be found from the resources of the district. The position is neither tolerable nor reasonable.
Most dramatic has been the effect upon nurses. It is now accepted that the hospital is 50 nurses short of what it needs to maintain the service at this level of patient throughput. The region has just said that it will allow 20 more nurses, but that is for 1987–88 and will not begin until April 1988—
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)April 1987.
§ Mr. SilvesterI am pleased to hear that. My information was that they would arrive in April 1988. We have sent people to examine the nursing problems in the 1490 hospital and the strain is intolerable. Everything that we can do to speed the provision of additional nurses is essential.
Finally, because I wish to give my hon. Friend time to give a sympathetic reply, I refer to my right hon. Friend the Member for Brentford and Isleworth, the former Minister for Health, who in 1985 set up the review of the RAWP formula. It covers several of the matters that I mentioned, such as cross-boundary costing, the time lag, teaching and research and development. But I was a bit put off by a letter from Victor Paige, the former manager of the Health Service, who said:
The review will not cover sub-regional resource allocation to districts.Such a limitation would be absurd because some of the most acute problems arise in sub-regional allocation. But I took comfort from the fact that he went on to say:Information on sub-regional experience…would be welcomed.Too right it would. Unless we tackle the problem of dealing with centres of excellence such as the Christie within the overall funding of the Health Service, we shall get nowhere. But it will take time. The Department has asked for answers from that study by the end of this year, and it will have to chunter through the system, so it will be some time before anything is done.May I end by explaining the present needs of the Christie? As I said, these are not moaning complaints but expressions of the urgent needs of people who are doing a fantastic job and meeting demands which are made upon them. They are not going out touting for business. They need 20 nurses immediately, and I shall be glad to hear more about that. They need a revaluaton of the drugs bill, especially the regional contribution. Why does the royal Marsden have a drugs bill twice the size of the drugs bill at the Christie? We also need some matching help on capital expenditure. After all, if the hospital raises £5.6 million and gets nothing but a smile, it is a bit depressing.
If my hon. Friend will make some helpful remarks on those three points this Christmas time, she will have made a good start in helping the Christie hospital.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)I congratulate my hon. Friend the Member for Manchester, Withington (Mr. Silvester) on being successful in Mr. Speaker's ballot and on giving us the opportunity to discuss the Christie hospital. He began his remarks with four hints to Ministers: that we should not prepare all our answers before hearing the questions; that we should not quote global sums for health services nationally, which he thought were irrelevant; that we should not blather on about living within our means; and that we should not say that we have no powers to intervene locally. I would dispute all those points, but perhaps not on this occasion. May I offer him one hint: that he listens carefully this morning because my voice will not last until the end of the sitting unless I can speak more or less in a whisper. I apologise to him for that.
My hon. Friend has been a staunch advocate of health services in the region, and, indeed, in the district. Recently, he brought some members of South Manchester health authority to meet Ministers and to share with them his concern about funding. The Christie hospital is run by South Manchester health authority which, in turn, receives 1491 its funding from the regional health authority. I hope that my hon. Friend accepts that it is relevant to consider, almost as an end-of-term report, the north-west region from which the Christie draws many of its patients.
During the past month or so, considerable progress has been made. On 1 December, approval was given for a £21.5 million development at Chorley general hospital. On 12 December, approval was given for a £14.7 million development at the royal Lancaster infirmary. My hon. Friend the Minister for Health laid the foundation stone for the £30 million development at Manchester royal infirmary on 12 December, the day when my right hon. Friend the Prime Minister visited Christie hospital. In that sense, the north-west region has made considerable progress recently.
It is worth pointing out that, during the years of this Government, considerable change has taken place. In 1978–79, the North-West regional health authority received just under £380 million a year in revenue. This year, it has received £904 million in revenue. In addition, this year, it is receiving about £72 million in capital moneys, which is the second largest allocation in the country, the largest being to the West Midlands regional health authority. My hon. Friend's academic skills will enable him to do the calculation for himself, but he will see that there has been a considerable allocation of extra money to that part of the country—well above the extra money that has been allocated to regions in the London area, which have remained much closer to their targets for much longer.
The results can be seen in the numbers of patients treated and in the number of direct care staff. In December 1978, the north-west region was looking after 512,000 inpatients. Last year, that had risen to 614,000. The number of people attending out-patient clinics had gone up from 3.1 million to 3.6 million, and the number attending as day cases had gone up from 68,000 to 116,000. The number of direct care staff employed by the North-West regional health authority has gone up from just under 40,000 to 48,000. It is worth pointing out that some patients who might once have been treated at the Christie may now be treated in other centres simply because the first class work of cancer researchers has shown that some treatment can be delivered in more ordinary surroundings, and the same standards achieved.
There has been the £72 million provided this year for the north-west region, and 58 major capital schemes, costing over £1 million each, have been completed since 1978. Some 14 schemes are under construction, including the Manchester royal infirmary, and 18 are approved to start. This represents a total investment in hospitals in Manchester and Lancashire of more than £320 million since 1978. Whatever the local Labour party may be claiming, it could not begin to claim that any Labour Government had put that kind of money into any part of the Health Service, north or south, and that is an acknowledged record.
The South Manchester health authority, which manages the Christie hospital, is a teaching district and its hospitals are linked with Manchester university. The main hospitals are the Withington, the Wythenshawe and the Christie, which is the smallest, with 347 beds. The total funding of the health authority in 1982–83, the first year of its establishment as a district health authority—we 1492 cannot go back any further because it did not exist in that form before—was £68,757,000 and in 1985–86 it had gone up to £80 million, which is an improvement in real terms, despite the fact that one of the aims of the regional health authority is to shift money, as far as possible, to match population growth. That growth has tended to be outside Manchester rather than within it. Other districts, such as Bolton, have seen an increase in population and have a reasonable claim on the moneys of the north-west region. Nevertheless, south Manchester has still had a small increase in real terms.
The number of patients treated in south Manchester has gone up from 513,000 in 1982 to 550,000 in 1985. My hon. Friend may call that an irrelevant generality, but it refers to real patients and is worth putting on record.
§ Mr. SilvesterDoes my hon. Friend understand that the regional plan wants the Christie to treat fewer people? It is getting more patients because doctors will not send them somewhere else, but it is not getting the funding for them.
§ Mrs. CurrieMy hon. Friend will realise that there is the dilemma of the hump, which is that good doctors will not send their patients somewhere else until good facilities are provided somewhere else. At the moment, we spend large sums of capital money while we are not yet able to open the facilities in places such as Bolton. I have no doubt that that is broadly the right way of going about things. It is always good to be able to point out that the number of patients treated is rising and is, I suspect, adequate.
The Christie hospital and Holt Radium Institute, with the separately administered Paterson Laboratories on the same site, serve a large part of the United Kingdom. They serve the north-west region, south Cumbria, which is in the northern region, Cheshire which is in the Mersey region and, as my hon. Friend has said, north Wales. There is an out-patients clinic in Wrexham. As my hon. Friend said, the Christie was founded in 1893 and moved on to the present site in 1932. I understand that it is one of the largest specialist cancer hospitals in Europe, but my hon. Friend has said that it is the largest, and I defer to his local knowledge. I take my hon. Friend's point about matching capital offers from the voluntary sector, but it is worth pointing out that £10.5 million comes from the Health Service, and that is a substantial contribution.
There are some 850 staff, measured in whole-time equivalents, and the number of patients treated, both discharges and deaths, in 1985, at 10,735, was 22 per cent. higher than in 1979, when fewer than 9,000 patients were treated. The waiting list is 327, but I am sure that my hon. Friend will agree that we do not mind what the number on the waiting list is as long as waiting lists have the same sort of waiting times as they do at the Christie. It takes the hospital only 12 to 14 days to clear the waiting list, which is highly commendable.
My hon. Friend mentioned recent capital developments, which are both voluntary and NHS-funded, such as the new aseptic suite, which was completed in March 1986 at a total cost of £142,000 and the new radiotherapy linear accelerator, which was also provided in March, at a cost of £450,000 and the adult leukaemia unit, which was completed in October at a cost of £817,000.
My hon. Friend's words give me the opportunity to express our heartfelt thanks and appreciation to all those who have raised such enormous sums of money. The Health Service is, and always has been, a partnership.
1493 Voluntary funding and effort were there long before the Health Service was even thought of. It is good to see it functioning well in a hospital such as Christie, where voluntary funding can be put to such good use. I am sure that my hon. Friend will join me in giving our warm thanks to all concerned and in encouraging them to continue. He may know that I was involved in a small way in helping to set up the leukaemia research fund activity in south Birmingham when I was a councillor there, and I was involved with it for 10 years. I have always felt that we should tap into people's willing generosity in that way and encourage them to help. It would be a sad day for all of us if voluntary activity disappeared, and we were totally reliant on state funding.
The Christie has one or two activities to which we should draw attention. I was particularly interested to notice that it is treating over 350 cases of cervical cancer a year and is at the heart of the region's preventive effort on this detectable and curable cancer. It is worth noting that, by March 1988, every one of the 19 north-west districts will have a cervical cancer call and recall system. We hope that the clay will come when the death toll from cervical cancer will drop sharply.
My hon. Friend raised a number of other issues. In particular, he went into detail in his comparison with the royal Marsden hospital in London. The consultants at the Christie are arguing that the hospital is underfunded and draw unfavourable comparisons with the major national hospital in London. My hon. Friend said that he felt that the Marsden was several times more expensive in its treatment of patients, and was good enough to provide some detailed examples of that. However, he will know from an answer to his parliamentary question on 26 February this year that the Marsden's costs per patient day are not several times higher but 80 per cent. higher. My predecessor was able to tell my hon. Friend that the cost per in-patient day at Christie was £76 and that for the royal Marsden £138, while the cost per in-patient case at Christie was £657 and that at the royal Marsden £1,181. Those are the figures on which we should rely.
My hon. Friend knows that these matters are under careful consideration, and broadly there are three reasons why the royal Marsden appears to be more expensive than the Christie. The first is that the royal Marsden is the national centre and receive patients from all over the country. Although the description of the work may be similar, at least some of its cases may be more complex, and may prove to be more expensive, wherever they might be treated.
The second reason is that London is more expensive. Neither my hon. Friend, who represents a northern seat, nor I probably like that, but it is a fact, and we are keen to investigate why London costs should be higher and how they can be reduced to more average levels.
The third reason seems to be that, whatever one might say about the royal Marsden, the Christie is highly efficient in its use of resources. At 89 per cent., the average occupancy rate at the Christie is very high. As I have said, the waiting list clears rapidly, the throughput of patients seems to be good, and so on. Two things come out of the comparison. First, whenever we review what is happening in London, we push hard on the question of the royal Marsden's costs and compare them with those of the Christie. We ask the royal Marsden why, if the Christie can 1494 operate at that sort of cost, the royal Marsden cannot. That is not an easy challenge for a good hospital to meet, but it is nevertheless an appropriate challenge. Secondly, as my hon. Friend will know, the north-west region has been investigating the Christie's fears about funding. In other words, these matters are taken seriously and, indeed, it has been looking at the funding of all the regional specialties.
I understand from Sir John Page, the regional health authority chairman, that the regional medical officer, Dr. Stephen Horsley, has been having discussions with the consultants at the Christie and that that should lead to an agreed workload so that the work that can be devolved to districts is so devolved, and the same high standards can be maintained while ensuring that the Christie's special qualities and talents are effectively used for more serious or difficult patients.
It has been mentioned that on Wednesday, even while the review is going on, the region agreed to provide an extra £170,000 in order to fund 20 extra nurses in the year beginning April 1987–88. That means that those nurses can be taken into consideration from April. In the intervening three months advertisements must be placed, applications will be received and interviews will be carried out, if appropriate. The staff involved may have to give notice somewhere else and so the beginning of April is probably just about as close to "at once" as one can get. That would seem to be satisfactory.
The other points raised by my hon. Friend are being taken on hoard in the region's broad review of what is going on. I include in that the Christie's complaint that the number of beds that it has for radiotherapy is well below national guidelines. However, I should point out that the excellent work done at the Christie may help us to revise those national guidelines and to see whether we can provide our cancer patients with a service which is both effective and efficient.
My hon. Friend mentioned charging for patients from other regions and from Wales. My right hon. Friend the Secretary of State wrote to another regional Member of Parliament on this issue on 28 November 1986, and I should be glad to make a copy of that letter available. He broadly said that we were prepared to look at any system of cross-charging. However, we bear in mind that those patient flows are taken into account in the resource allocation working party programme and have been looked at again recently. We are also extremely wary of setting up yet more bureaucracy, as that may well mean that money is absorbed into administration instead of going into patient services. However, in principle we are prepared to look at any system.
I do not have time to deal with the valuation of the drugs bill or with some of the questions that my hon. Friend posed. But the very fact that those issues have been raised today will no doubt mean that they are taken into account. I am glad to have had the opportunity to join in my hon. Friend's praise for this first-class, outstanding hospital which serves the north-west and local people so very well. With my hon. Friend, I thank those local people who have raised voluntary funds. We are ensuring that the hospital has the right resources, and we are investing more in the north-west region. I hope that my hon. Friend will continue to help us in spreading that good news.