HC Deb 31 October 1986 vol 103 cc648-57 12.54 pm
Mr. Peter Griffiths (Portsmouth, North)

I am grateful for this opportunity to discuss orthopaedic treatment in the city of Portsmouth.

It is fortunate that I should be able to raise this issue today as it is only three days since I was able to intervene in an Adjournment debate initiated by my hon. Friend the Member for Romsey and Waterside (Mr. Colvin) on the treatment of kidney patients at another of Portsmouth's hospitals—St. Mary's.

I assure my hon. Friend the Minister that my area is grateful for the way in which the National Health Service operates. The Wessex region is one of growth and development. It has experienced considerable improvements, especially during the past seven or eight years. Only today, my right hon. Friend the Secretary of State for Social Services announced an £8 million expansion programme for hospital development at St. Mary's hospital. The Portsmouth and South East Hampshire district health authority is able to assure local Members of Parliament that it has never been faced with cuts. That is the background against which I want to discuss orthopaedic treatment.

The last issue of Link, the regional health authority's newspaper, said that there was extremely good news in the region. It was that waiting lists for operations had been considerably reduced on the previous year and that the reduction was greater in Wessex than in any other region in the country. That was indeed welcome news and I am sure that the Department, area and district health authorities and medical staff should be congratulated accordingly. It was, however, cold comfort for one group of people—those waiting for orthopaedic treatment at the Queen Alexandra hospital in Portsmouth. The orthopaedic department at the Queen Alexandra hospital is especially successful. It has dealt with local people's needs extremely efficiently. Indeed, it is regarded as one of the most efficient in the country. Although the hospital is relatively new, it has suffered serious water penetration around the operating theatres. This fine hospital complex has some 17 theatres, but no fewer than seven have been affected and been taken out of use at some time. Not all 17 are suitably equipped for orthopaedic patients, however, so about half of the available theatres suitable for orthopaedic patients have been out of operation at some time. As a result, the department has had to concentrate on emergency and traumatic cases, and people awaiting elective surgery, especially hip replacement operations, have had the date of their treatment set back. It is the uncertainty about the dates on which elective surgery can be carried out which is most upsetting to patients. Of course they object to having to wait —almost everyone would like to have at once the operation that is necessary—but a wait can be accepted as long as the operation is performed on the due date. However, to be told that there will be a delay is extremely worrying for patients who are already tense knowing that they are to undergo major surgery.

At one point there were six consecutive weeks during which no elective surgery could be carried out. That is the point to which I wish to draw the Minister's attention. The medical staff and ancillary workers have, without exaggeration, worked heroically under those circumstances and they have now achieved the point in their operations programme that they would have reached had there not been the six-weeks' delay.

That is remarkable, but it means that the beds available in the wards supporting the orthopaedic department are now full. To quote the words used by an administrator this morning when I checked on the facts, the place is jammed solid. That means that there is a new restricting factor—not just the limitation on the operating theatre space but the availability of beds for patients immediately after undergoing the operation.

That is a matter of grave concern locally. It may be felt that time alone can bring a solution, but that is not true. Last year, when the waiting lists for orthopaedic operations was growing, it was found possible to arrange for hip replacement operations to take place at the private King George's hospital at Midhurst. I am told that this year space is also available at the Lord Mayor Treloar hospital at Alton. Both those hospitals would have space in their operating theatres and accommodation facilites for orthopaedic patients from Portsmouth to have their hip operations.

I am sure that I need not tell my hon. Friend the Minister that the success rate for hip replacements is high. They are a good investment of NHS money and the improvement in the quality of life which a hip replacement can bring about is dramatic.

The problem is that the regional health authority has not found it possible to provide funds this year to continue the programme of passing patients into the private sector, where facilities remain available. That is extremely sad. I understand the pressures on the regional authority. No doubt it is worried about the cost of the work at the Queen Alexandra hospital, although that, after all, is basically a matter for its capital programme rather than its revenue costs.

It cannot be argued that because the operating theatres are out of use for a period there is a financial saving at the district level which could be used to send patients elsewhere. The orthopaedic department remains where it is. The staff are there. There is a need for a once-and-for-all relatively small injection of cash to the regional health authority, specifically and immediately earmarked for one purpose only — for hip replacement operations during the period that we are awaiting the restoration of the full operating capacity of the Queen Alexandra hospital.

I shall not stand up again in 12 months' time and repeat this demand. The cause of the problem is completely outside the control of the NHS. It is a matter of grave concern that doctors and others who are able and willing to carry out the operations simply lack the space in which to do it. Each time the sum, which is as little as £2,500, becomes available an operation can take place. A relatively small sum provided once and once only would allow the orthopaedic department of this highly-regarded hospital to continue to reduce the waiting list for elective surgery.

I hope that my hon. Friend the Minister will feel able to draw this one substantial problem to the attention of our right hon. Friend the Secretary of State, who has shown direct interest in the length of waiting lists. The problem could be solved with a relatively small injection of extra cash. That would bring untold benefits to my constituents and others in the Portsmouth and South-East Hampshire district health authority.

1.6 pm

Mr. John Butterfill (Bournemouth, West)

I should like briefly to support the remarks of my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) about the importance of orthopaedic treatment in the NHS, especially in the Wessex region. The region has been fortunate in that the revisions in the RAWP formula have improved our previous position. We were worried that too great a proportion of NHS funds seemed to be concentrated in London and that our region did not receive an adequate share of the national resources for the NHS. We hope that the present trend will continue and that any review of RAWP will continue to give the Wessex region a high priority.

The region has a higher than average proportion of elderly and retired people. More than 30 per cent. of my constituents are of retirement age or above. That high proportion of elderly people gives rise to special problems, not least problems affecting the NHS.

Orthopaedic surgery is important in treating the elderly. Too often we become seduced by the high-technology areas of medicine, about which we hear so much in our national newspapers. I fear that some of the London teaching hospitals, which may be more involved in those areas than any others, grab both too much of the headlines and too great a proportion of the cash available, leaving areas such as orthopaedic surgery out in the cold. That is undesirable and unfair because, although nobody would deny that saving life is important, the quality of life is equally, if not more, important. I recollect a member of my family who was terminally ill saying to me that what mattered to him was the quality of life. Certainly for people in Wessex, especially the elderly, it is vital that we ensure that in the latter part of their lives they can enjoy comfort, mobility and freedom from pain.

In those areas orthopaedic surgery can play an important part. Consequently, I hope that my hon. Friend the Minister can confirm that the Wessex region will receive high priority and, if possible, an improved allocation of the national cake, particularly in relation to orthopaedic surgery.

1.9 pm

The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I have been asked to respond to the debate.

I congratulate my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) on his assiduity in securing a debate on such an important subject. He will realise from my remarks that the debate is very timely for the Portsmouth area. I know that there are immediate concerns in Portsmouth, particularly over the repairs at the Queen Alexandra hospital. I shall come to that shortly, but I must first thank my hon. Friend the Member for Bournemouth, West (Mr. Butterfill), who put the argument for RAWP very succinctly. We have just debated services in Essex, yet we can see that there is also a need for services in other parts of the country to be improved. My hon. Friend has also shown how RAWP has helped people in those parts of the country that have been underfunded.

I have not yet had an opportunity to visit any of the facilities run by the Health Service in or around Bournemouth, but during the party conference I had an opportunity to visit my uncle who was resident in a home for physically handicapped people, run by a voluntary agency in Bournemouth. He has been an orthopaedic patient for some time, and is now slowly recovering. I should like to put on record my appreciation of all the staff at the Carlton Dene home in Bournemouth, as they have given my uncle and the other residents there excellent care. I thoroughly enjoyed my visit, and it helped to remind me that we are really talking about individuals in discussing the Health Service.

Great speeches were made at Bournemouth, and I shall come later to the speech made at the conference by my right hon. Friend the Secretary of State for Social Services, but ultimately we are talking about individuals and their families. However, I was pleased to note the remarks made about the area by my hon. Friend the Member for Bournemouth, West.

In this country, orthopaedic services, and particularly waiting times for out-patient appointments and in-patient treatment, were studied in great depth in a report published in 1981, which has become known as the Duthie report. It is the report of a working party chaired by professor R. B. Duthie, Nuffield professor of orthopaedic surgery at Oxford university. I shall therefore take much of the medical information that I have on this important subject from the report.

Orthopaedic surgery is mainly concerned with the repair and reconstruction of the skeletal system. Much of the work used to be mainly concerned with tuberculosis in children. Many of the existing orthopaedic facilities are in old sanatoria that were used for that purpose. But today tuberculosis in children does not cause the orthopaedic problems that it once did, and paediatric work has developed substantially, and is normally found in paediatric specialty facilities, such as children's hospitals.

Thus the problem mainly occurs among people in the older age groups. Among them, the skeletal system fails most drastically, because it suffers from the effects of degenerative diseases of the joints and fractures of weakened long bones such as the femur. The number of elderly people, and the percentage of the population that they represent, has increased over the past few years, and is expected to increase until the end of the 1980s. In the 1970s, the 65 to 74 years age group made the biggest contribution to the rise, but from 1980 onwards the continuing increase in the number of old people has been due to an enlargement in the group aged 75 and over. About one fifth of them are over 85, although the number of those aged 65 to 74 is decreasing slightly.

We estimate that about 3 million people in this country are aged between 75 and 84, and perhaps soon there will be about 750,000 people aged over 85. You and I, Mr. Deputy Speaker, hope, in time, to join them, and we also hope that all the necessary services will be laid on when that time comes. But that change towards a more elderly population has been reflected in the use of orthopaedic beds, and, indeed, of beds in other specialties which treat large numbers of old people. For example, in 1977 the elderly accounted for 5 per cent. more admissions than 10 years before and on average they occupied 11 per cent. more beds. By 1977 about half the available beds were occupied by elderly people and that continues to be so.

In Portsmouth we believe that nearly 70 per cent. of all acute beds are occupied by people aged over 65. The National Health Service is increasingly and substantially a service for the elderly. The increasing numbers of elderly people treated is a reflection of the success of medical treatments for the younger age groups. Our success breeds its own pattern of demand and we must ensure that we can adapt to it.

The increase in the load of illness and disability placed upon the orthopaedic services by the larger number of old people is only part of the explanation. The availability of new and effective measures to meet some of the needs has led to new demands for orthopaedic services. There is no doubt that the radical changes in the surgical treatment of arthritis which followed upon the development of total hip replacement in the early 1960s has led to an enormous demand for orthopaedic resources. Prior to that date osteotomy and arthrodesis operations had a much more restricted application to arthritis and were particularly unsuitable for elderly patients with advanced conditions of the disease. The total hip replacement is one of the most outstanding surgical advances in recent years. From its early restriction to one or two specialist centres, its use has spread to every orthopaedic unit. Knee and other joint replacements follow much the same course.

I was amused and delighted to read paragraph 3.34 of the Duthie report about a promise made 10 years ago. It states: In 'The Challenge of Arthritis and Rheumatism"', a report on problems and progress in health care for rheumatic disorders, which was published in 1977 and edited by Dr. Philip H. N. Wood of the Arthritis and Rheumatism Council's epidemiology research unit at the university of Manchester, it is said: Hip and knee arthroplasty arc rapidly becoming accepted as standard procedures. No joint is safe from the ravages of the disease though, and much research is being directed to replacement arthroplasties that would help the considerable numbers of patients with damaged shoulder, elbow, ankle and finger joints. Moreover, in polyarthritis it is now possible to undertake programmes of principal joint replacement to restore some degree of independence and activity to patients who previously would have become totally crippled. I have seen the truth of that promise in my own area. It was a joy to see. The Southern Derbyshire health authority covers six constituencies, including mine. One of my first visits after being appointed Minister was to the Derbyshire royal infirmary's rehabilitation unit in Derby. It was set up in 1973 at the initiative of my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph) when he was Secretary of State for Social Services. The two units have become internationally known.

I saw the full range of diagnostic, surgical and rehabilitation facilities for patients suffering from a variety of chronic conditions, of which arthritis is probably the most well known. I saw occupational therapy, physiotherapy and hand surgery facilities. That specialty is affected equally by the rising numbers of elderly.

I was particularly moved to meet a lady of about my own age who had spent nine years in a wheelchair. She was walking around happily having been repaired in numerous places. She said that she now needed her ankles repairing because after many years of being in a wheelchair they had become weak. Now that she is walking with the aid of only a stick the ankles are showing signs of the degeneration that had necessitated earlier operations. She is now looking forward to having her ankles fixed.

That is a modern miracle but it involves an enormous amount of time, skill and effort. If one joint is affected in a patient, the probablity is that others will be. As skills to help these patients improve, pressures on orthopaedic facilities increase quite sharply. The number of patients awaiting treatment may change very little, but the number of interventions that can be made per patient may increase sharply. Therefore, the facilities can rapidly become overstretched.

I have seen the work that is being done in conjunction with the Derby royal infirmary at Bretby hall orthopaedic hospital, which is my constituency. There we see, perhaps, part of the answer. The 60 beds at Bretby hall are entirely for planned surgery and are retained only for the purpose in accordance with recommendations made in the Duthie report. Bretby hall is now able to do full hip replacements in an hour and a half in the operating theatre instead of the four or five hours that used to be necessary to perform the operation. Patients go home in 12 days. I am told that that is not quite a record, but it is standard procedure at Bretby hall. I hope that the expertise and skills that go into that sort of speedy and effective use of resources can be examined and perhaps copied elsewhere.

We must be aware that our elderly population my be much more adaptable than we think and may find it much easier to cope with some interventions than perhaps we were ready to give it credit for in the past. On one occasion recently the league of friends at Bretby hall was asked to make money available for a set of Sony Walkmans. The league asked why this equipment was needed and the explanation was that knee joint replacement operations and the replacement of similar joints can be done under local anaesthetic. When this is done the patients are alert and awake and it is quite a noisy procedure. It was therefore suggested that patients might prefer to listen to Elgar or whatever while the operation takes place.

At a later date I visited the hospital and met a number of my constituents, including one elderly lady who had had an operation to replace a knee joint under local anaesthetic. She had thoroughly enjoyed the experience. I asked her whether she had made use of a Sony Walkman, to which she responded with a firm "Of course not". She added, "I wanted to hear what was going on and I asked for a running commentary."

Demand is increasing sharply because the possibilities of successful interventions are increasing. As my hon. Friend the Member for Portsmouth, North has said, over 80 per cent. of these operations are now successful. People are queuing up for them and each patient may find it is not only the most serious joints that can be dealt with. It may be that other joints can be assisted. We might expect that in future patients will come forward several times for work to he done. If the intervention is no longer an unpleasant experience and if, as my elderly constituent suggested, it is becoming an interesting experience, we can expect that demand will continue to increase. On the other hand, my own experience suggests that by judicious use of existing facilities we can ensure that we are able to respond to demand. Indeed, we are determined to do so.

I shall give the House some of the overall figures that will put my general remarks into perspective. The trauma and orthopaedic specialty nationally covers a wide range of work and in 1978 it handled fewer than half a million patients. In that year it dealt with 441,000. By 1985, 527,300 were dealt with by the specialty. That is an increase of 19 per cent. In other words, for every five patients dealt with in 1978, six were dealt with in 1985. In the light of the circumstances that I have described, that is an amazing achievement. In March 1979, the number of cases on the waiting list was 133,500. By September 1985, the most recent date for which I have figures, the figure was 129,300, representing a 3.2 per cent. fall. In March 1979, there were 13,500 urgent cases on the waiting list. By September 1985, the figure had dropped to 9.623, representing a fall of 14.2 per cent.

Mr. Butterfill

Can my hon. Friend confirm that the waiting list figures would have been considerably better had it not been for the health workers' strike?

Mrs. Currie

Absolutely. I am willing to confirm that. There have been two significant NHS strikes in the past decade—one in 1978 and one in 1982. The 1982 strike had devastating effects on waiting lists. We have endeavoured to recover from that. However, in most specialities we have not only recovered from 1982 but, as in the cases I have described, we are now showing a considerable improvement, even on the 1978–79 figures. We have not finished yet. The estimated waiting time, in median terms, in 1979 was 13 weeks. In 1984, it was 12 weeks. The figure has been sticky. It has not dropped in the way we should have liked.

The first hip replacements were done in the late 1940s. I was reminded recently, after I made an injudicious comment that they were unknown 20 years ago— they were very much known 20 years ago — that the most effective ones were beginning to be done about 38 years ago. In 1978, the number of hip replacements stood at about 28,000. In 1983, the figure was 37,000 and, in 1984, it was 38,000. My hon. Friends will be aware of the promise made by my right hon. Friend the Secretary of State during his speech at Bournemouth in which he said: We have raised that number to 38,000 today. But I aim to do more. By 1990 I want to see that number approaching 50,000. A figure of 50,000 would be almost double that which existed about 12 years ago. We are determined to achieve that objective. In 1978, the waiting time for hip replacements was about 23 weeks. After the NHS strike in that year, the waiting time rose to 25 weeks. By 1983, we had got it back down to 24 weeks. It is still at that level nationally. Obviously, the figure Varies a great deal. The target time for non-emergency treatment is one year. Nationally, on average, the hip replacement programme is within that target.

I hope that my hon. Friend the Member for Bournemouth, West will bear with me if I direct much of my attention to the Queen Alexandra hospital in Portsmouth. I listened with great care to what my hon. Friend the Member for Portsmouth, North said. Much of what he said was right. I suspect that in his position I should have used much stronger language. The major part of the Queen Alexandra hospital was completed eight years ago, although there has been a hospital on the site since 1908. The new hospital was built by John Laing. Two major repair jobs have had to be undertaken, and that has had a drastic effect on patient services. All 14 of the main operating theatres closed for five weeks from 11 August so that badly defective concrete floors could be replaced. It is estimated that the repairs will cost £200,000. The theatres are on two floors in two groups of seven. It was hoped to open some operating theatres on the bottom floor while later work continued above. Only six other main theatres are available for use—five at St. Mary's hospital, which is the other district general hospital, and one at Gosport war memorial hospital.

About 600 non-urgent operations were delayed, and only essential surgery was possible. The possibility of using two neighbouring private hospitals on an agency basis was explored. I am glad to report that since these events began the hospital dealt with all emergency and trauma cases without any problems. There was not a problem for emergency work or for anyone brought in off the street, but there was a continuing serious problem for all planned work.

The defective floors were laid about 10 years ago by subcontractors to John Laing which have since gone out of business. Talks are continuing between John Laing and the Wessex regional health authority, and the legal implications are being considered. My hon. Friend will understand if I say very little more on that matter.

In addition, as my hon. Friend mentioned, 75 beds on the top floor of the hospital have been put out of commission for three months because of extensive water damage to the hospital's flat roof. Repairs will cost an estimated £300,000. The flat roof construction of the hospital was a recommended technique for all major public buildings when Queen Alexandra hospital was designed. However, the method has been discontinued. The life expectancy of such flat roofing appears to be about 10 years. The regional health authority considers that there is no liability on the part of the contractor.

Those of us involved with the National Health Service and with other public building matters, such as municipal housing, in that period might well have wished that flat roofs were banned a long time ago. But they were not; they now are. We have to pick up the tab for the repairs that should have been unnecessary. The circumstances in Portsmouth fully bear out my hon. Friend's remarks.

Work on the first major repairs began in August and will not be completed until February 1987. My Department accepts that this is unfortunate. It is essentially a matter for the relevant health authorities to resolve, but Ministers are taking a close interest, as we are concerned about the effect on patient services. We are assured that the decision to close the beds and to reduce surgical services was not taken lightly. The health authorities concerned have been making every effort to ensure that the impact on patient care is kept to a minimum.

For the purpose of the debate, I checked the current situation. I shall endeavour to give my hon. Friend as much informatin as I can. The 14 theatres were indeed closed, as I mentioned. Seven theatres were opened on 22 September.I understand that five of these theatres are available for orthopaedic work. The total in-patient waiting list on 1 April 1986 was 1,136. By 30 September 1986 it had risen to 1,403. However, I am told that only 11.6 per cent. of patients waited for more than a year. It is worth reflecting that the equivalent figure for the rest of the country is about 30 per cent. Although there has been a substantial diminution in services, Portsmouth, until that date, had received a relatively better service than many other parts of the country. I am sure the people of Portsmouth appreciate that and indeed have come to expect it, as, of course, is their right.

Last year some hip replacements were done privately at the King Edward hospital at Midhurst. At least one orthopaedic surgeon has been trying to persuade the health authority to release more money for hip replacements to be done at Midhurst, where a good service was provided for local people. Another orthopaedic consultant has let us know that his waiting list has grown so fast that he cannot take on any more people for elective surgery, which is a very sad reflection on the circumstances in Portsmouth. I am told that that consultant is immensely hard-working and does as much as might be expected of him and that his patients respect and appreciate his work. We are conscious of the accuracy of my hon. Friend's remarks.

In June, the Portsmouth health authority asked the Wessex regional health authority for extra non-recurring revenue so that hip replacements could be contracted out to the private sector. I understand that at that time the answer was no. The authority asked again in September and has put it on the agenda for its district review in December. The authority also said that it was prepared to forgo for two years capital money that it has allocated to other services to reduce hip replacement waiting lists. We appreciate the efforts made by this district health authority to come to grips with the problem. I hope that it will not be necessary to damage or postpone plans for other services. However, if that is the only way we will be able to improve the waiting lists for hip replacements, it is for the district health authority, in consultation with the regional health authority, to decide what it wants to do.

I mentioned that the debate is very timely. My hon. Friend the Member for Portsmouth, North may not be aware of the fact that the district general manager is meeting clinicians on Monday 3 November to consider a possible reorganisation of orthopaedic surgery, with a view to expanding in-house facilities. Serious and urgent consideration is being given to the ways in which existing facilities could be utilised in order to get waiting lists down.

The health authority is looking at doubling day surgery facilities when the next stage of repairs is complete. Given the remarks I made earlier about the changes in anaesthesia and the techniques of orthopaedic surgery, it may be possible to do more of the work on a day basis and release other resources for more serious cases in orthopaedics or possibly for cases in some other specialties, which may otherwise have to wait if orthopaedics is to be advanced. The possibility of expanding day surgery is very worthwhile.

My hon. Friends will know that nationally the number of day surgery cases has doubled in the past six years and now about one million cases each year are being attended to in that way. I have had treatment of that kind. It is nice to be able to go home when one has finished, provided that adequate arrangements are being made at home to prepare for the patient and that that is what the patient wants to do. It is marvellous to think that people may have full hip replacements and major joint operations that turn them from complete cripples into walking people in a matter of weeks and that it may be possible, subject to the most stringent controls over the assessment of the patients, for them to get some of the work done on a day basis and be able to pop in from time to time to get the next bit done. That would be an adequate use of resources.

I hope that what I have said has shown sufficiently that we are taking the problems being put to us by colleagues in Portsmouth very seriously. It is a serious matter. In my judgment, it should not have happened. The problems we face with this building now require to be put right properly. It is no good simply wringing our hands over what has happened in the past. An eormous amount of money, nearly £500,000, is now being spent on putting those construction problems right. We are assured that the region and the district are taking seriously the effect that that has had on waiting lists, especially in orthopaedics, and that every effort is now being made to get to grips with the problem. I am confident that, within a short time, efforts will have been made, and I hope that funds are found locally, to ensure that the waiting lists can now be reduced.

In orthopaedics we have a service that never used to exist and was not possible and we have a pattern of disability among a section of the population that never used to be a problem because few people reached such old age. We now have both. It is a challenge to the Health Service which my right hon. Friend the Secretary of State, other Ministers and those whom we have appointed to the district and health authorities are taking seriously. I am grateful to my hon. Friend the Member for Portsmouth, North for giving us this opportunity to discuss these matters.