HC Deb 14 May 1987 vol 116 cc448-57

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peter Lloyd.]

5.21 pm
Mr. Chris Smith (Islington, South and Finsbury)

It is something of a privilege to be able to speak on the Adjournment of the House at such an early hour in the afternoon. I suspect that the hon. Member for Derbyshire, South (Mrs. Currie), the Under-Secretary of State, will riot thank me for this, because I believe that there is a queue of further Adjournment debates to which I suspect she will respond, happily and willing as ever.

In raising the issue of health care for the elderly in Islington, it is worth reflecting for a moment on the background to what has happened to the health services in the borough of Islington, part of which I have the honour to represent in this place, since the Government came into office. For example, we have lost the entire casualty department at the Royal Northern hospital. It is much missed and much lamented by my constituents. Within the Islington district health authority the waiting list in September 1982 stood at 1,098. In March 1986 it stood at 2,410. That was an increase of 119 per cent., the greatest increase over that period of any health authority in the London area.

I fear that the position since 1986 has become worse. It is worse particularly for prospective patients who are awaiting urgent operations. The number of people within the Islington district waiting more than a month for urgent treatment amounts to 83 per cent. of the total. That puts the Islington district health authority in 182nd place out of the 191 health authorities. The figures for the Bloomsbury health authority, which adjoins the Islington health authority, and which has some responsibility for the care of elderly patients in the Islington area, are far and away the worst of any health authority. The hospital waiting list is the worst in England, and Bloomsbury takes 191st place, there being 191 local authorities.

That is the background on waiting lists, and the rhetoric from the Prime Minister and from the Government generally about the Health Service being safe in their hands and about spending more in real terms on it now than in 1979 falls on unreceptive ears among my constituents. Their experience is of a Health Service that is severely in decline. They are waiting longer and they are suffering as a result. The Islington draft operational plan reveals that there is to be a reduction by 1993 in the number of acute beds that are available. From 1983 to 1985 the number decreased from 982 to 812, and it is set to be reduced further to 659 by 1993. That is the draft operational plan that has been established by the Islington health authority. Sadly, it is not alone in facing the prospect of further decline among inner London districts.

Earlier this year the King's Fund, an independent agency, produced a report on the planned health services in inner London. It was called "Back to back planning". It revealed, among other rather frightening facts, that there was no coherent and comprehensive picture on inner London's health needs available from reading the reports, plans and future strategies of the four regional health authorities that between them cover inner London.

Another issue that it raised was extremely worrying, and the 12 chairmen of the district health authorities that cover inner London set out the position starkly in the foreword to the report. They wrote: Regional plans for inner London Districts require a reduction of £109 million"— a reduction of 12.9 per cent.— in the period from 1983–84 to 1993–94; this is equivalent to the combined annual cost of St. Thomas', St. Bartholomews and the Royal Free Hospitals. Those are three major teaching hospitals. The equivalent cost of the three hospitals put together is expected to be taken out of the health budget for inner London over the 10 years from 1983–1993. That is the background against which I raise this debate.

Lengthening waiting lists, reductions in the number of acute beds and future cuts in funding for inner London health authorities affect severely the elderly in my constituency. My constituency has a higher than average number of elderly people, especially elderly people living alone. Many of them need proper and decent health care, but, unfortunately, they are not getting it.

Primary health facilities do not constitute the only problem. There are other areas of the Health Service that cause me to be concerned. The London ambulance service is one of them, and I know that my hon. Friend the Member for Newham, South (Mr. Spearing) will be raising the issue in greater detail later this afternoon. Last summer the London ambulance service cut drastically the number of non-urgent journeys that it was prepared to undertake. It claims now that the number of non-urgent journeys is increasing, and there is some slight evidence of improvement, but last summer there were drastic cuts in non-urgent journeys. The sector of the population most affected by those cuts are the elderly, with their transport to day centres and the difficulties that they have in getting out of their homes. The elderly in my constituency are faced with the problem of a health and ambulance service that is fundamentally in decline.

To add to that difficulty, for many years we have not known precisely where the responsibility for the planning of health services for the population of south Islington has lain with the Bloomsbury district health authority, which has supposedly been responsible for planning hospital services for the elderly. Sadly, althouth it has had that responsibility, and although supposedly within the funding that has been made available to it by central Government some account has been taken of that responsibility, it has not been exercising it.

It was nonsense in the first place for a portion of the health responsibility of one area to rest in the hands of a health authority for a different area. It may be adjacent, but none the less it was not a health authority that covered that part of the population. The people of Finsbury and the southern part of Islington were falling between two stools. Primarily they looked to Islington district health authority for support and assistance, but that health authority was not funded to provide it; Bloomsbury health authority was funded to provide it, but unfortunately it did not do so. To make matters worse, much of the population, especially in Finsbury, expected St. Bartholomew's hospital to provide hospital care for them, but St. Bartholomew's is run and administered by the City and Hackney health authority, which was yet a third health authority involved in the confused picture in the provision of hospital services for the elderly in south Islington.

For several years I have been endeavouring to establish exactly where the responsibility lies, who is prepared to take it up, and where the funding should be directed. It seems that some small amount of progress is being made. I wrote to the Minister some weeks ago specifically about where the precise responsibility for hospital services for the elderly in south Islington lies, should lie and where, in the Government's view, it should lie in the future. Should it lie with Islington district health authority, which is presumably the logical place to put it? Should it lie with the City and Hackney health authority because St. Bartholomew's hospital is run by it and is the hospital that is immediately adjacent to the boundary? Should it lie with Bloomsbury health authority, which has had the responsibility for funding up until now?

I received a very helpful letter, not from the Minister, but from the chairman of the North East Thames regional health authority, who the Minister had asked to reply on her behalf. I was pleased to read the first sentence of the second paragraph of that letter. He said: I acknowledge that Services for the Elderly in South Islington are inadequate. It is extremely good to have received that clear statement of the problem in writing from the chairman of the regional health authority. He went on: I am delighted that some progress has now been made and that there is agreement between Bloomsbury, Islington and City and Hackney Health Authorities about how to deliver improved services. The Regional Health Authority has also agreed to allocate some resources to ensure the planned improvements. I shall return to that point, because the information that I hope the Minister will give us this afternoon is exactly what planned improvements there are and what funds are coming from which authority.

The chairman continued: The Health Authorities acknowledge that GPs refer elderly, acutely ill patients living in South Islington to St. Bartholomew's Hospital and City and Hackney District, with capital support from the Regional Health Authority, has agreed to provide an acute assessment ward designated for this purpose which should be available in 1989. So far, so good. What happens—this is my first specific question to the Minister—between now and 1989? A specifically designated ward in St. Bartholomew's hospital in 1989 is welcome, but between now and then where should GPs refer elderly patients who come from south Islington who are acutely ill and require hospital treatment?

The chairman continued: There is agreement also that longer stay health service provision should be provided by Islington Health Authority to complement the range of services provided by the London Borough of Islington. I am glad to receive that assurance from the chairman of the regional health authority, but I suspect that he has forgotten that the London borough of Islington is a rate-capped authority and therefore will find it impossible to devote additional resources to assist in this process. He also seems to have forgotten that with the impending closure of Friern Barnet hospital many patients from that hospital will be returning into the Islington community over the next five or six years and for whom joint provision by the health authority and borough will have to be made. That will be a major drain on resources and funds, and to envisage, at the same time as that is occurring, provision being made for the longer stay health needs of the elderly is stretching credulity. It will require a major injection of funding into the health authorities and the borough to ensure that those needs are properly met.

My second specific question to the Minister is in relation to the longer stay Health Service provision. What funds will be made available to enable Islington health authority and Islington borough council to provide between them the sort of service that the chairman of the regional health authority envisaged? What funding will be available to enable that to happen in full and proper form?

My third specific question to the Minister relates to the agreement between Bloomsbury, Islington and City and Hackney, which is referred to in the earlier paragraph of the chairman's letter. Obviously, that agreement is welcome. It is long overdue and it is about time that the three district health authorities and the region agreed a strategy on what to do about patients who need proper hospital provision, proper planning of their health needs and a way of meeting them.

What are the precise terms of that agreement? How much funding will come from each of the three district health authorities, and how much funding will come from the regional health authority to provide these improved services? What improvement will occur? At present, many elderly patients from south Islington are dealt with at St. Bartholomew's hospital, but from where will the improvement come? Some improvement may be coming with the new ward in 1989, but what will happen between now and then?

A rather ominous note was set in the middle of an appendix to one of the recent reports to the district health authority meeting in Islington, which referred to possible cuts in provision for the elderly in southern Islington. A number of figures were set out beside the figure for possible cuts. The figures related to the three district health authorities. I should dearly like to know from the Minister exactly how much funding will come from the three district health authorities, and how much will come from the region, to cope with the health and hospital needs of elderly people in the southern part of my constituency. They need and deserve better treatment than they are getting at the moment.

I look forward to hearing the Minister's specific replies to my questions and also her commitment to a rather better future for my constituents' health needs and health facilities than they have had for any of the past eight years. I look forward to hearing what the Minister has to say. I hope that she will give some comfort.

These are the dying days of the Government. The Government will shortly be replaced by a Labour Government who are determined to support the Health Service, particularly in inner areas such as Islington, to a much greater extent and with much greater care for the needs of people'than the present Government have shown. I hope that the Government, even in their dying days, will relent and that we will have a deathbed conversion to the principle of proper funding for our health services and a proper way to meet the needs of elderly people—my constituents—who deserve a much better deal than they are getting at the moment.

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

I congratulate the hon. Member for Islington, South and Finsbury (Mr. Smith) on his efforts to publicise the needs and concerns of his constituents. He wrote to me on 25 February 1987. I am deeply hurt that he failed to acknowledge that I wrote back. Indeed, I have a letter dated 18 March, which I shall read. As a result of that correspondence, I have a great deal of progress to report on some of the specific issues that he has raised. Indeed, since this debate is a little earlier in the evening than usual, I shall have the opportunity to report some progress in a wider area of interest; that is, the care of and the level of services for the elderly that the Government have been able to provide, and some aspects of care, particularly in the Islington health authority.

The hon. Gentleman is quite right: the number of acute beds has been reduced. Even now, however, the total number of acute beds in London for its population runs at twice the national average and about two and a half times the level of acute beds for the population of outer London. That is for the obvious reason that the population of London has shifted. Indeed, about 2.5 million people have left central London in the years since the war. However, on the whole, the health services have continued to maintain the pattern that was established 100 years ago and subsequently. Therefore, in any calculation of acute services for the population, London has been substantially over-provided. I am not the first Minister who has said it, and it has not been only Conservative Ministers who have said it. It has been said for some time.

The plan to lose some 1,500 acute beds over the 10-year period from 1984 to 1994, which was actively debated a short time ago in the regional health authorities and the district health authorities, has been put into operation rather faster than anybody expected. Three years into a 10-year programme, 1,100 beds out of the 1,500 beds have already gone. It is realistic to state that that rapid changeover has brought some of the problems that the hon. Gentleman has described.

However, there are two aspects. The first is that, in many cases, acute beds have been replaced by geriatric services, and some of the developments that I shall describe are of exactly that kind. Our elderly people fill half the acute beds in the country, but it does not automatically follow that they are getting the best service that they need by remaining in the acute side of the service. Where, as in much of London, the geriatric service has been inadequate and the acute service was over-provided, the switch from acute to geriatric has been widely recognised as necessary and sensible. The problem has been the speed with which some of it has happened rather than the pattern of change.

Mr. Chris Smith

indicated assent.

Mrs. Currie

The hon. Gentleman agrees. Since he entered the House, he has taken a keen and intelligent interest in the subject. He would recognise that to have gone in the opposite direction—to have diminished geriatric services and to have increased acute services—would not have been sensible.

Secondly, in many parts of London much better general practitioner services are reducing some of the pressure on hospitals. We are particularly pleased to see that, in one or two places, better GP work is resulting in far fewer requirements for people, particularly elderly people, to be admitted to hospital. In other words, they are getting better care and service from their GPs. I am sure that they welcome that—I certainly do. We hope to see rather more of the same, not just in London and not just for elderly people, but all over the country.

We recognise the special difficulties in London—I say that as a Member from the Trent health authority area. Two important studies are under way. They should bear fruit in some of the directions that the hon. Gentleman and his colleagues would want. We recognise that simply comparing London's needs with its population does not work for London because its population swells with commuters. One is attempting, in many parts of the London region or regions, to provide two lots of health services because people want them at home in Kent, Sussex, Bedfordshire, or wherever they live, and also in London, where they work. If someone collapses with a heart attack at Waterloo station, he will not promptly be taken back to his district hospital 30 miles away, but will be treated in one of the main London hospitals, and he will get good service. That fact is recognised. Detailed studies are under way as to how that might properly be calculated. I am sure that the hon. Gentleman realises that they are far-reaching discussions. That matter is now being looked at with some care.

The other major study that is under way is about patterns of nurse recruitment in London and the difficulties in recruiting and retaining nurses in London, which might be rather different from some of the problems in the rest of the country. I think we now recognise how serious a problem accommodation is in some parts of London. The results from some studies will come to us shortly. We hope that we shall be able to make some announcements on that matter.

The hon. Gentleman might care to look at the Official Reportof last Friday's Adjournment debate about Newham health authority. He may find that it is not only a problem about nursing but that there are one or two problems in a wide range of services. We are aware of the problems and we are determined to ensure that we have adequate information and some decent long-term studies on which sensible decisions can be made.

I turn now to services for elderly people in the country as a whole. There are now about 10 million pensioners. We now have a higher proportion of pensioners than any other major country except Sweden. Our pensioners are living longer—we are all living longer. The life expectancy of a baby girl born today is 81 years. That is a tribute to the Health Service and the quality of services provided by it. It is a tribute to better housing and better prosperity all round, much of which, thank goodness, pensioners are also able to enjoy.

In regard to the Health Service and local authority services for the elderly, I am glad to report some substantial improvements since 1978–79, when last there was a Government of the colour that I suspect that the hon. Gentleman might prefer to see after the election. Under our Government very substantial improvements have been recorded and it is worth putting them on record. My figures are for England. The number of elderly people treated in geriatric units has increased substantially, as in-patients by some 60 per cent. and as out-patients by some 40 per cent., between 1978 and 1985. Nearly 400,000 elderly people are treated every year as in-patients in geriatric departments. They are therefore getting the service that they particularly need. Day hospital attendance has risen by nearly 20 per cent. in the same period. Indeed, some 1.6 million old people regularly attend day hospitals.

We have seen increases in hospital staffing. The number of consultant geriatricians rose by nearly 50 per cent. between 1978 and 1986, and we now have nearly 500 whole-time equivalent consultant geriatricians in a sphere that used to be the Cinderella service in which very few people wished to work. Similarly, the number of nurses caring for geriatric patients between 1978 and 1985 increased by 22 per cent. We now have nearly 45,000 such whole-time equivalents working for the elderly.

Of course, the vast majority of the elderly are cared for in the community. The community health services have also seen improvements. The number of district nurses has jumped by 18 per cent. The number of elderly people treated in their own homes by district nurses is 1.6 million every year. That is a remarkable achievement. That figure has increased by 28 per cent. under this Government. About 74 per cent. of district nurses' time and nearly 90 per cent. of auxiliaries' time in the community is spent caring for elderly patients.

We do not neglect either the problems of mobility. The number of chiropodists treating the elderly has risen. The total number has gone up by nearly 24 per cent. and the number of elderly people treated by National Health Service salaried and sessional chiropodists is up by 25 per cent. to 1.5 million a year. That is a remarkable tribute to all the staff concerned.

Turning to local authority provision, we find a slightly more mixed pattern and perhaps not quite as much growth, but local authority provision is not entirely under our control in the way that the Health Service is. Local authority provision for the elderly has to compete with other interests in many local authorities. Islington is one with such important bodies as a peace committee, a women's committee and other such committees. In some parts of the country local authority provision has not risen quite as fast as the health care provision——

Mr. Chris Smith

I must intervene momentarily to correct the hon. Lady. For a start, there is no peace committee or any such entity in Islington borough council. There is a women's committee which does extremely good work on health and safety issues which worry many women in the constituency.

Mrs. Currie

I suspect that the elderly women in the constituency might prefer more home helps, but that is an opinion from one who was a Birmingham city councillor for 11 years.

I noticed last week, following the hammering that the Labour party got in the city of Birmingham when its majority was slashed by some 10 votes on the city council, that the first thing the Labour leader of the council, Mr. Dick Knowles, did was to abolish the women's committee and the race committee and take issue strongly with those who felt that it was wise to have them. He said that he had intended to abolish them anyway; it was just pure coincidence that he did so the day after a disastrous election.

On local authority provision for the country as a whole, I am delighted to report that between 1979 and 1985 the number of places in day centres went up by 15 per cent. and nearly 22,000 elderly people can go to day centres each day. Since people do not go every day, obviously that provision is available to more than 22,000 people over a week.

The number of meals served through the meals on wheels service has risen to 43 million a year; 70 per cent. of the meals are served to people in their own homes. The number of home helps has gone up by 14 per cent. There are now some 53,000 full-time equivalents. As most home helps are part-timers, that is a substantial army of people helping the elderly to stay in their own homes. We have also seen overall an improvement in residential care, not through the local authority service but mainly through the increased provision of excellent residential care in the private sector.

Islington district health authority, as the hon. Gentleman knows, is chaired by a former Member of the House, Mr. Eric Moonman, and a very good job he is doing. If we look through some of the funding and other developments in that health authority, evidence may be called in aid against the broad case that the hon. Gentleman tried to put. The gross revenue expenditure of the health authority in 1985–86, for example, was a shade under £45 million. This year the initial cash allocation for that health authority has risen to nearly £51 million. That is a substantial increase in a period of barely two years. I know that the authority will use it wisely under Mr. Moonman's guidance.

Between 1985–86 and this year the authority has had some million in capital. The result is that it is looking after more patients. Between 1982 and 1985, the most recent year for which I have figures, the number of in-patient cases treated in Islington went up from 26,900 to 28,200 and the number of cases treated on a day basis went up from 2,500 to 3,500. I have examined the performance indicators for similar authorities and it may be possible to look after more patients on a day basis. In some parts of the country surgeons find that 25 per cent. to 30 per cent. of the kind of cases done in Islington can be carried out on a day surgery basis. In Islington the percentage is still small. The most popular area of day surgery is still less than 20 per cent. of the total. So that there is scope for doing more.

In one branch of particular interest to the elderly, trauma and orthopaedics, there has been a substantial increase in the number of cases that the authority is able to look after. In 1982, the number of in-patient cases was 1,700. In 1985 it was up to 2,100. Therefore, many hundreds of additional elderly people in Islington have been assisted in that way.

The number of people being treated at home has remained steady. Health visitors and home nurses can give a good service. I suspect that the hon. Gentleman is right in saying that the proportion of elderly in the neighbourhood is high. Perhaps it is slightly higher than the average because the death rate from ischaemic heart disease and cerebral vascular disease is lower than the national average. Islington is doing well on prevention, and I congratulate it on that.

As for the responsibility for the care of the elderly in Islington, and particularly in the hon. Gentleman's constituency, he is right in saying that there is a frightful muddle. In addition to community services, Islington health authority is responsible for hospital services for the elderly in north Islington and also in Hornsey within the boundaries of Haringey health authority. Responsibility for hospital services for the elderly in south Islington and the Finsbury area lies at present with Bloomsbury health authority. But because of the proximity of the hospital For acute admissions many patients are sent to St. Bartholomew's hospital, which is within the City of London and Hackney health authority. I count four health authorities so far, with the regional health authority taking a close interest in what goes on, of course.

I therefore wrote to the hon. Gentleman on 18 March 1987, in response to his letter, saying: As you say, this would seem to be a matter for agreement between the various District Health Authorities concerned. I have therefore written to David Berriman, Chairman of the North East Thames Regional Health Authority, asking him to reply to you direct about this matter at the same lime as reporting to me. I am therefore happy to recognise that perhaps the Department had some small role in encouraging the progress since February.

It is accepted that the provision of health services to the elderly people of south Islington is unsatisfactory. Discussions have been taking place for a short time now between officers of the three district health authorities mainly concerned—that is, Bloomsbury, City of London and Hackney and Islington—and the regional health authority about the provision of hospital services to the elderly of the area. Progress is being made in these discussions and there is now agreement in principle about how improved services should be provided in south Islington.

The hon. Gentleman asked me specifically what funds there will be in future for the health and local authorities. I shall give him some detailed figures for the health authority schemes that are under active discussion right now.

For local authorities as a whole this year I per cent. additional funding has been given for community care of all kinds, and that has amounted to some £27 million. How they spend it is up to them, because most local authorities resist being told specifically what to do. It is a convention that Ministers do not commit the Government too wildly about future funding in the weeks leading up to a general election. It will therefore depend, I suspect, on the outcome of the coming election. I have no doubt that whoever is the Member for Islington after the election is likely to be invited to the opening of some of the establishments and wards that I am about to describe. I hope that the hon. Gentleman may also have the opportunity of attending.

First, there will be £180,000 for community services in south Islington. I understand that the North East Thames regional health authority is permitting the Islington health authority to retain half the efficiency savings that will be developed this year, and that will be about £180,000. The emphasis will be on community services for the elderly in south Islington. I am sure that the hon. Gentleman will be in touch with the chairman of the health authority and will hear from him in some detail precisely how that additional money is to be spent.

Since, as the hon. Gentleman said, many elderly, acutely ill patients living in south Islington are referred to Bart's, which is in the City of London and Hackney health authority, the regional health authority has allocated £250,000 capital for an acute geriatric assessment ward at Bart's, which I have no doubt will give his constituents some of the finest care and treatment available in this country and possibly in the world. The ward will have up to 25 beds and it is planned to open it in 1989.

However, I take the hon. Gentleman's point and I will ask the regional health authority to give further consideration to the care of these patients in the intervening period. It may he possible to look after these patients in existing facilities that might be not quite as acceptable as the most modern facilities while the additional money is being spent. I undertake to ask the regional health authority to take a look at that.

In addition, the North East Thames regional health authority will be providing £400,000 for Southwood ward at the Hornsey central hospital, which should also be of assistance to elderly people in the neighbourhood. This is subject to detailed agreement on the content of the scheme.

There is also an urban programme bid in for a day hospital of which perhaps the hon. Gentleman is aware. I understand that the Islington health authority has made an application to the Department of the Environment for urban programme funding for a 20-place geriatric day hospital at the Whittington hospital, at a capital cost of some £750,000—they do not come cheap in London—and I understand that this bid is currently being considered. The urban programme funding would provide day hospital facilities in the Archway wing at Whittington, where associated geriatric wards are already sited, so it would be a good location.

I was very interested to hear of Islington's joint policy on the care of the elderly and I know that a great deal of detailed work has gone into that. I have read the joint policy, and I hope that as much as possible will come to fruition. It is very encouraging to see evidence of such close co-operation between a district health authority and a local authority and such commitment to the development of community care services.

We think that in taking that work forward the district health authority could make rather more use of the performance indicators now available for services for the elderly and also of the balance-of-care planning system which has been developed by my Department and was made available from 31 March 1987. What I am saying is that there are now management tools available that may assist health and local authorities in the planning of their services, particularly when they are going into new areas, as these are hoping to do. I am willing to make officials' time available to the local health authority and the local council to ensure that they are able to plan their services along the best possible lines.

I am glad to have had the opportunity to debate this subject tonight. I look forward to seeing the hon. Gentleman once again in the House, perhaps not for Islington—that will be for the voters of Islington to decide—but I am quite certain that it will be a Conservative Minister answering him.