§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peter Lloyd.]
12.16 am§ Mr. Jeremy Hanley (Richmond and Barnes)On a point of order, Mr. Deputy Speaker. I rose on both occasions to speak on the Air Navigation (Noise Certification) Order, but I was not given the opportunity—
Mr. Deputy SpeakerOrder. I heard the hon. Gentleman the first time and drew his attention to what is written on the Order Paper. In both cases he will read that these matters are
To be decided forthwith, pursuant to Standing Order No. 79(5).That means that they cannot be debated and that the hon. Gentleman cannot speak.
§ Mr. George Gardiner (Reigate)I am most grateful, Mr. Deputy Speaker, for this opportunity to raise the question of resources for the east Surrey district health authority on the Adjournment of this House. In doing so my purpose is twofold. First, I wish to voice the concern of my constituents about the fact that, despite all the Government's increased expenditure on the National Health Service—by no less than 24 per cent. in real terms since 1979—the actual service available to them over the coming months is likely to diminish; and, second, I shall suggest that some conclusions might be drawn from east Surrey's experience that are of more general relevance to the Health Service, explaining in part why there is such a wide gap between the Government's knowledge of the increased resources being poured into the Health Service and the public's perception of the quality of the end product available to them.
The east Surrey health authority covers the major part of my Reigate constituency, the major part of the Mole Valley constituency to the west and all of the east Surrey constituency. It serves a total population of 180,000 and it has a management record or which we can be proud. By reorganising patient services and selling surplus property, it has made possible the construction of a new district hospital of the highest standard, which was opened by my right hon. Friend the Prime Minister nearly two years ago. In some instances there was public opposition to the closure of small local hospitals, but there can be no doubt that the quality of medical care provided by the new east Surrey hospital is of a far higher order, one example being in ophthalmology.
Since that hospital was completed, the authority has raised nearly £5 million from the disposal of surplus properties, and planning consents have been obtained on further land and buildings. That should yield an additional £6 million. These capital receipts open the way to a number of exciting new developments. Construction of phase two of the east Surrey district hospital, effectively doubling it size, is scheduled to start next year. Work has already begun on a residential unit for the young severely disabled at Harrowlands, in Dorking, which will be the first of its kind in Surrey, sharing its facilities with patients from the neighbouring mid Surrey health district.
There is already a new day unit at Caterham Dene, and new day hospital facility for the elderly at Oxted. In Redhill, facilities for elderly long-stay patients have been 1333 upgraded. I cite these simply as examples of significant improvements in Health Service provision that have been and are being made possible through skilled management of the district authority's capital resources. Meanwhile, in an older hospital building at Dorking, we have a regionally funded orthopaedic unit that has won international acclaim for its hip replacement work, and where one surgeon performs 25 per cent. of the hip replacements in the 13 health districts of the south-west Thames region.
I turn next to the authority's management of its current resources, with particular reference to acute hospital services. For some years it has been evident that the east Surrey district was, and would continue to be, a loser under the RAWP system for securing re-allocation of Health Service resources throughout the United Kingdom. I shall return to that matter in greater detail in a moment. The obvious conclusion to be drawn form this was that, if an acceptable service was to be maintained, much more efficient use would have to be made of the modern hospital facilities to which I have just referred. That greater efficiency has undoubtedly been achieved.
Over the four years from 1981 to 1985, the number of beds in our acute unit hospitals decreased by 20 per cent. and the number of staff serving them decreased by 13 per cent. Yet the number of in-patients treated increased by nearly 10 per cent. while the number of out-patients treated increased by 8 per cent. Thus, over these four years the east Surrey authority can point to a productivity gain approaching 33 per cent. This faster throughput of patients and more efficient use of available beds has had its effect on the authority's in-patient waiting lists.
On 31 March last year the Secretary of State published the numbers on the waiting lists for every district health authority, which revealed that east Surrey's lists were among the shortest in the country. Today that total on its waiting list is easily the lowest in the entire south-west Thames region, while all our major surgical specialties achieve throughput levels above the regional and national averages. Thus in the efficient management of acute hospital resources the story from east Surrey is one of success. Yet, as I shall show shortly, for that success we are having to pay a bitter price.
This brings us face to face with the RAWP system, which is intended to secure a fairer distribution of Health Service resources between the different regions of the United Kingdom, ending the former concentration on London and the south east. This in itself is not an unworthy objective, and it is apparent, even within the south east, that many of the cases which at one time would have been referred by GPs to consultants at the London teaching hospitals are now treated within their own districts.
In view of the political capital that some seek to make from the consequent cuts in hospital provision in the south east, it is worth reminding ourselves that the RAWP system was introduced in 1976 by Mrs. Barbara Castle, when Minister of Health, and that it was advocated enthusiastically by her Parliamentary Secretary, the right hon. Member for Plymouth, Devonport (Dr. Owen), who is now, of course, leader of the Social Democratic party.
The RAWP system has been continued by the present Government, though it is now under review. I can only comment that such a review is long overdue, and I hope that the east Surrey experience that I now describe will be 1334 taken on board by those conducting the review. The evidence is that the operation of RAWP, while increasing the health resources in many regions, is at the same time penalising increased efficiency in the "loser" districts.
Until early this year the authority was working to a planned £450,000 per annum reduction in its revenue allocation under RAWP — which, as I have already indicated, represented a very considerable constraint. However, in May it was informed that this saving or "cut" was being increased to £700,000 per annum — a horrendous additional burden to be imposed on what was already a decreasing expenditure programme. In the acute unit alone, £442,000 had already been trimmed from the budgets over the past year, and this sum withdrawn from the allocation available for this year. Yet, unless services were curtailed further, there would still be a substantial overspend by the end of the current year. Immediate further economies had to be effected while consideration was given to more radical long-term options.
Accordingly, on 4 July, a letter was sent to all GPs in the district detailing a rolling programme of overlapping acute unit ward closures for a month at a time during the summer. At the East Surrey hospital, three wards handling cases of general surgery, urology, orthopaedics, general medicine and rheumatology are each closing for one month; at Redhill hospital, two wards providing gynaecology and ophthalmology; at Dorking, one ward handling general medicine; while at Oxted surgical specialties are being withdrawn for a month while the operating theatre is upgraded. Throughout the summer, cases coming under these headings will he able to be treated elsewhere in wards that are open, but the inevitable result of these temporary closures will be to increase waiting lists and postpone for many patients the day when they had expected to get the treatment or surgery they require. Meanwhile, at Netherne psychiatric hospital a ward closure has been brought forward. All these, of course, are short-term measures, while the authority investigates what more severe economies will have to be made.
Thus, the east Surrey authority is paying a high price for its own success; for the fact is that the RAWP system makes no allowance for the increased total of per patient costs that accrue from achieving a faster throughput of patients and making more efficient use of the system. Yes, of course, with faster throughput the bed costs and nursing costs per patient are lower, but the total cost of what we might call the fixed overheads per patient rise—the costs of X-rays, pathology, drugs, blood and so on. The sad conclusion facing the east Surrey administrators is that their authority would be in a better financial position today if they had not increased efficiency in the way that they have, but simply allowed the waiting lists to grow. I ask my hon. Friend the Minister to consider also the effect that this must have on staff morale.
In our case, it is already difficult enough to recruit staff, especially those with professional qualifications, on the same nationally approved salary scales as apply in other parts of the country with significantly lower housing costs than we encounter in Surrey. In east Surrey's case, there has been until now the stimulus of joining a team that is improving performance in patient care and making a significant impact on waiting lists. But when that goes, what is left? What incentive is there for a young person 1335 trained in medicine to join an authority in which his or her scope for securing improvement must continually be curtailed?
I submit that all this points to a major defect of the RAWP system—that it gives no incentive to increasing efficiency within those health districts that are "losers". Ministers say a lot about getting value for money within the NHS—an objective that I entirely support—yet the manner in which RAWP operates has precisely the opposite effect. I must in all honesty relay to my hon. Friend the Minister a theory put to me by one hospital administrator in the course of my inquiries—that the most prudent way to proceed was to avoid glaring inefficiency on the one hand, while eschewing notable efficiency on the other. As he put it, somewhat sadly:
The best way to survive in the Health Service today is through mediocrity.I therefore ask my hon. Friend the Minister to ensure that the current review of the operation of RAWP takes this serious flaw into account; and that it considers the merits of a system whereby "the money follows the patient", wherever he or she happens to be treated. Furthermore, I ask my right hon. Friend the Secretary of State, through him, to ensure that significant changes are made soon, before many more of the achievements of health districts such as east Surrey's are destroyed.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. Ray Whitney)I am grateful to my hon. Friend the Member for Reigate (Mr. Gardiner) for raising this matter. I should like to offer some general remarks, but if, on studying his comments, I find that I should provide more details, I shall write to him. I shall carefully study his points about the RAWP formula.
Nationally, regional targets are set which aim to give a fairer distribution of the available resources between regional health authorities, based on such factors as age, morbidity and patients' movement across health authority boundaries for treatment. At regional and district level, the emphasis of the redistribution of resources is to provide equality of access to services. In essence, this means enabling those parts of the country which have inadequate facilities to look after the health care needs of their population to build these up. On the other side of the coin, some districts which have until now enjoyed a much more favourable level of provision are asked to take part in a fairer sharing out of the cake. I hope that my hon. Friend will accept that as a general principle, albeit taking cognisance of the problems of the policy to which he referred.
The Government have a duty to make sure that the way public money is divided up in the NHS works as well as it possibly can. Although we firmly believed in the RAWP process, we recognised the feeling that the methodology used in the calculations was ripe for a critical review. My right hon. Friend the Secretary of State for Social Services therefore announced last December that he was setting up a review of RAWP which would include an examination of the appropriate factors to be considered. Requests have been made that a report of the review should be with Ministers before the end of the year.
The effect of resource redistribution at the district level means that some districts have to face the fact of lower 1336 expectations. East Surrey is indeed one of South-West Thames' "losers". I hope that my hon. Friend agrees that, put in context, the picture may not be as bad as it appears.
When the South-West Thames regional health authority produced its 10-year resource assumptions for its 13 districts in 1985, East Surrey was considered to be over target and expected to take a drop of £4.5 million in annual revenue relative to other districts by 1993–94. So far, the district's rate of movement towards its long-term revenue target has been as originally planned. It is no worse off than it expected and has an additional £22.5 million pay an price uplift this year — no more than other districts in the region got, but certainly no less. The recent recalculations look at first sight to make East Surrey worse off, but the fact is that some corrections which were done to the calculations of the district's longterm commitment for providing care for old long-stay patients from outside its boundaries showed that it would have fewer patients than had earlier been thought. An appropriate amount was therefore deducted from its revenue target, but this was fully compensated for by a real reduction in the amount of care it would need to plan for. In fact, I understand that the district will be slightly better off in real terms.
East Surrey has not missed out on new developments. As my hon. Friend said, only two years ago the Prime Minister opened a new district hospital in Redhill, built at a cost of £17 million, and I was glad to hear my hon. Friend's remarks about the high quality of service being provided in that hospital. A further phase of development is now under consideration, costing about £12 million, arid the regional health authority has agreed to try to bring forward a start on this block to allow the district to achieve more savings through rationlisation. All this is helped by Government injections of capital resources and our policy on land sales, which gives districts the benefit of proceeds from sales to develop their services in the best way for the local population.
South-West Thames regional health authority has calculated that the East Surrey district is over-targeted in revenue terms, and will give it a slightly decreasing share of the region's resources over the next seven or eight years. This, in turn, will allow those parts of the region which are under-provided and below target to build up services for their local populations. We acknowledge that this causes problems in districts such as East Surrey, and we understand the pressures, especially where the district is already efficient, and my hon. Friend gave examples of the district's efficiency.
Improvements in activity rates in recent years are clear, and I acknowledge them. The staff involved deserve recognition of their hard work and dedication. A few striking examples are patient throughput rates in trauma and orthopaedics, which are in the top 10 per cent. nationally; they have high levels of district nurses to attend the elderly and a high rate of contact with these patients; they are doing well in providing mental handicap community unit beds and community mental handicap nurses; and the ratio of direct care staff—those involved in treating and caring for patients—to indirect care staff is well above average.
But East Surrey is not the only health district in South-West Thames—let alone in the country — which is making improvements and achieving higher levels of performance. Every district has been asked to review its efficiency levels and to use the available resources in the 1337 most cost-effective way it can. They are using performance indicators to show up areas where improvements can be made, and their cost improvement programmes are helping to release cash to pay for service developments.
Whether a region or district is set to gain or lose, it is vital for the health authority to make every penny count. The purpose of the NHS is to treat and care for patients. The more economy and efficiency measures that can be introduced, the more money will be available and the more patients can be treated.
While I congratulate my hon. Friend's local health authority on its fine achievements, I must stress that there are fields where there is room for improvement, such as savings from competitive tendering for house-keeping services, where as yet less than half of the services have been put out to tender. Progress has been made, but it has some way to go with its laundry services and it must make a start on the catering. There is need to look at the use of day care treatment, which seems lower than elsewhere. In some specialties, day case rates are less than one-fifth of the national average. The length of stay of elderly patients also seems high, and that, too, could be looked into.
I wish to place the situation in east Surrey against the background of what this Government are doing for the NHS nationally, efforts to which my hon. Friend paid tribute. The Government have recently added an extra £50 million to health authority cash limits in England, following decisions on this year's pay awards. Of that money, more than £16 million will go to the Thames authorities and to the special health authorities in London; £7 million will go to the north western and Mersey regions; £5 million to the west Midlands; and over £3 million to the Yorkshire and Northern regions. Those are substantial additions.
That has been achieved in a year in which we have already allocated about £650 million more to hospital and community health services in England. That represents a 6.7 per cent. increase nationally on revenue to the NHS. With the extra £50 million, we are talking about growth in real terms of well over 3 per cent., the highest figure since 1980–81.
Health authorities throughout the country plan to release a further £150 million this year, with more planned 1338 increases in activity and productivity within existing resources. Health authorities are benefiting also from the fall in general inlation that has been brought about by the Government's policies. There will be a real increase in spending of 24 per cent. after allowing for inflation. That is the Government's proud record since coming to office. I know that my hon. Friend recognises that, and I hope that he will accept that the public's perception is that there have been improvements in the service. My hon. Friend —who better than he?—will understand the difficulty of putting across the achievements of the Health Service. I remind him of a recent study that was carried out independently of the Government which showed that about 87 per cent. of those polled were very satisfied or fairly satisfied with the treatment that they had received within the NHS. It is important to remind ourselves that those who have experience of the Health Service, as opposed to relying for their knowledge of it on the media, understand that significant improvements have been achieved since 1979.
Capital spending programmes and improvements in hospitals continue to be undertaken, and it is right that we should claim credit for using the public's resources wisely and effectively. We recognise, however, that the policy of redistribution causes strains, especially for RAWP losers such as East Surrey. I hope that my hon. Friend will recognise that East Surrey has enjoyed a higher level of provision than some of its neighbours. It has shown already that it is capable of rising to the challenge and finding ways of saving money which do not reduce patient care. I hope that it will be encouraged to believe that still more can be done in that direction on the lines that I have suggested. There is still scope for cost improvements within virtually every health authority and I am sure that all authorities will want to exploit them to the full. I do not believe that East Surrey is an exception and I hope that the authority, with the co-operation of the staff, to which I pay full tribute, will be able to continue to use the resources which are being made available to ensure that the health care that is delivered to my hon. Friend's constituents will continue to improve and not deteriorate.
Question put and agreed to.
Adjourned accordingly at twenty-two minutes to One o'clock.