Health Services (Waltham Forest) (Hansard, 27 May 1988)

§ Mr. Harry Cohen (Leyton)

I thank the Minister for delaying her Whitsun break getaway to respond to the debate. I am afraid that that is the limit of the pleasantries, as the health cuts in Waltham Forest are not so pleasant. I can tell the Minister a true story, which happened this morning. I was travelling into the House on the train, and about four seats down sat a smart gentleman. He suddenly got out a piece of paper and stated writing a report, and I noticed that it said on the top, "Financial Strategy for Waltham Forest District Health Authority". He scribbled lots of notes that I could not read and then wrote the word "funding". A minute later he scribbled it out. That is appropriate to this debate and the Government's treatment of the health authority.

I pay tribute to the local health workers, the nurses, ancillary workers and technicians. They are dedicated and efficient in the circumstances in which they have to work. I extend that tribute to many in management, who want the best possible for health care, although some seem to be fully prepared to wield the hatchet over Waltham Forest health authority, or sometimes think that managing the cuts means covering up the extent of the crisis in the Health Service and the consequences on local people. This has meant that Waltham Forest health authority has suffered in silence.

Waltham Forest district health authority is a Tory dream health authority. It has done all and more of what the Government have required. The chairman, Mr. Sidney Wayne, in a letter to me on 11 January, said: The Health Authority has already closed hospitals to provide the services more efficiently—the Connaught Hospital in 1976, Harts and Lugano Hospitals in 1984, the Jubilee Hospital in 1985 and the Forest Hospital in 1986. It is hard to see where further rationalisation can take place, although obviously we are continuing to explore all avenues where money can be saved … This year the pressures have started early and my managers have told the Health Authority that routine surgery will be greatly reduced at Whipps Cross over the next 3 months. The reducing of routine surgery follows a period when the hospital was on red alert, which meant that no routine cold surgery would be carried out. That was unprecedented in the length of its duration over the early winter.

The effect on hospital waiting lists as a result of that reduced surgery and the red alert is likely to be appalling, but the health authority has done more than that. Over the years, we have seen ward closures, temporary closures—such as that of the psychiatric ward at present—that drift into permanency without proper public consultation, restrictions on community health provision and lower staffing levels. In the letter of 11 January the chairman of the health authority said that the staffing levels were low in many areas and the staff were poorly paid. He said that there was penny-pinching in, for example, maintenance, decoration and cleaning.

I wrote to the Minister for Health pointing out that the contractors—it is a privatised cleaning service— have difficulty in recruiting staff as their pay and conditions of work are appalling, and a great deal of staff time (nurses and administrators) is spent on "propping up" these contractors. There have also been complaints about the state of the grounds; rats having been seen recently and piles of rubbish surrounding the hospital. The health authority has made all those cuts, yet it will still have a deficit of more than £2 million at the end of this 684 financial year. It is fifth in the list of the top 10 health authorities in England with deficits. There is a serious shortage of funds to meet its requirements in the current financial year. The district health authority does all that, yet its only reward is that the Government and the regional health authority claim that it is efficient. I am sure that, once again, the Minister will bleat how wonderfully efficient it is. The Government have defined efficiency as working well with less, but, in Waltham Forest's circumstances, one can increase efficiency only with more in terms of resources and better working conditions.

I have written to the regional health authority countless times. I received a letter from the general manager, Mr. Hunt, who said: The efficiency savings are dependent on relative performance against a set of performance indicators. As one of the more efficient Districts, Waltham Forest has been required to make relatively low savings". Then he said: The cumulative reduction in resources to Waltham Forest between 1982/83 and 1985/86 was £3.0 million (5.5 per cent.); although above the average for the Region as a whole (2.7 per cent.)". There is a direct contradiction in those two statements. I wrote to the general manager and asked him if he could arrange to recompense Waltham Forest for the severe reductions it has been forced to make in the past and reward the District for its 'efficiency' as you imply should have been done. I shall return to his figures later, because they are wrong. Efficiency cannot be measured in that way.

I received a letter from the community health council dated 23 February which made clear the sort of efficiency that we are talking about. It stated: The CHC hears from people who have been in hospital that services are under a great deal of pressure: indeed they are frequently described as a conveyor belt. We also hear of problems resulting from people being discharged into the community too early and without preparation because of the drastic shortage of beds … Already, Whipps Cross does more complex work than the average general hospital and treats 30 per cent. more people each year than Barts, the London, or the Whittingham, and 75 per cent. more than the North Middlesex or Oldchurch. The Whipps Cross cost per case is the lowest of the Region's London hospitals and the cost per day is also very low. The CHC believes these figures indicate deprivation as much as efficiency, as increasing waiting lists show. One person's efficiency—the highest group call for beds is another person's deprivation—too few beds. There are many problems, such as higher demand, as a result of social factors.

I said that I would come back to Mr. Hunt's figures. He claimed that the cuts in Waltham Forest amounted to 5.5 per cent. However, the report entitled "Health Trends", published by the Chartered Institute of Public Finance and Accountancy, showed that Waltham Forest has had the largest cuts of any authority in the country inflicted on its resources for its hospital and community health services, amounting to 18.2 per cent. for the years 1982–83 to 1985–86. That is the real level of the cuts, for which the regional health authority does not even know the right figures. I have written to Mr. Hunt, putting his figures right, but still have not had a reply.

What has not been mentioned is the level of dissatisfaction that has grown up. One example is the long waiting times in the accident and emergency unit at Whipps Cross hospital. An article in The Daily Telegraph 685 supplement of 7 February referred to the casualty department at Whipps Cross and quoted a senior house officer saying: The other day someone was kept waiting for seven hours. That just is not acceptable. The hon. Member for Stockton, South (Mr. Devlin) lives in a neighbouring constituency and had the misfortune to hurt his hand. He tabled a question about his long wait at Whipps Cross. He also wrote to the general manager and received the reply: On the particular day when you attended there were 330 patients attending. Each year we see 97,000 people in our department which I understand from the statistics produced is about twice as many as in the Casualty Department in your own constituency, although the staff there report a staffing level very similar to our own. Waltham Forest is, therefore, doing double the amount of work with the same number of staff. The general manager's letter to poor old Tim concluded: The financial position facing this Health Authority next year is so serious that I believe that we will face significant curtailments in services although I have spent the past two years endeavouring to find any economies rather than close beds, although at times this has led to complaints such as yours about at inadequate service. I hope that your hand is better and that you will not require the services of our Accident Department in the near future.

The situation at that accident and emergency unit is made worse because surrounding areas are closing their casualty units and restricting their hours whereas Whipps Cross is open 24 hours a day—almost like the old Windmill theatre—never closing. However, the hospital does not receive recognition of that fact from the Government or the regional health authority. Whipps Cross provides, in effect, the regional casualty service, and should be funded as such.

More cuts are being demanded by the Government. The general manager of the health authority was forced to write a letter on 18 February to all her colleagues in the district management team referring to various cuts, stating: Managers are looking carefully at all costs in areas that are not patient services …The District already has plans to close Leystonstone House and Claybury, and the financial arrangements for this also remain unclear. The letter then proposes that no additional district money is put into the provision of community facilities for our residents who have a mental handicap or are mentally ill … reductions in patient services will have to be considered. The letter refers to the three ways in which those reductions can be made: closure of Claybury hospital—Thorpe Coombe hospital is also mentioned in that section; closures of a service or department; and ward closures at various hospitals. The letter says that family planning services cost £150,000 and community dentistry £320,000 and that they are under threat.

I can bring the Minister up to date. That letter was written on 18 February and since then there have been more closures including the closure of an elderly persons' ward. There have also been cuts in community dentistry, in family planning services and in X-ray facilities at two hospitals. However, at the end of the last financial year, the health authority was £230,000 in the red and we are seeing more cuts now.

An agenda item appeared last week on 19 May stating: The difficulties the Health Authority has experienced this year in trying to resolve its deficit problem are likely to be repeated in future years. 686 That is certainly the case. Acute services are under enormous pressure. The same agenda item states: The number of local Acute beds in 1987 was below the target set in the Regional Strategic Plan 1984/93, and below the bed norm related to the current standardised planning population for the district. The agenda continues: Significantly, the local Acute case load which the Region assumed would fall to 21,000 cases per year in 1986 has in fact risen to 26,000 cases. The region has got its facts completely wrong. The agenda item also refers to increasing pressure on Acute services which was evidenced in 1987 by restrictions on non-urgent admissions to Whipps Cross and a consequent slight reduction in the 1987 caseload. There are fewer patients despite a faster throughput. That is hardly greater efficiency. The agenda item continues: 1987 also saw an increase of 15 per cent. in the waiting lists over 1986 … a noticeably high proportion of non-elective admissions—76 per cent.—to all Acute hospital beds in Waltham Forest in 1987. That clearly shows the excessive strain in the acute services sector in Waltham Forest.

Only last week the district authority decided to cut two acute wards at Wanstead hospital. One of them, the Jubilee ward, had just received a £150,000 upgrade. The other ward was used in the recent methicillin-resistant staphylococcus aureus outbreak. Those cuts come in addition to the cut of 37.8 per cent. in available beds ror acute and elderly cases between 1975 and 1988. That represents a decrease of 27.5 per cent. since 1979 and the figure is declining every year. High throughput is the sole claim for efficiency yet that has been achieved as a result of too few beds. That leads to premature discharge and cancelled admissions. There is an example in the local press of a man who had five admissions cancelled. Waiting lists are longer and many people give up waiting for the treatment that they need.

In-patient waiting lists for all specialties have increased. Waiting lists for general surgery rose in the year ended September 1987 from 458 to 618. Ear, nose and throat waiting lists increased from 2,177 to 2,664. Orthopaedic waiting lists rose from 349 to 498. Gynaecology lists rose from 408 to 567, and urology from 217 to 460. The Government are even in breach of their own DHSS guidelines on how long urgent and non-urgent patients should have to wait for treatment.

Maternity services have also been cut and are under enormous pressure. A report "London's maternity services in crisis" states: Maternity units cannot cope with the growing number of births while bed numbers shrink, except by keeping women in hospital for shorter periods, and by maintaining dangerously high bed occupancy rates. The report refers to Waltham Forest hospital as a maternity unit already reaching the limits of efficiency where standards of care are suffering. The position has become worse with the closure of nearby maternity hospitals.

Waltham Forest is an area of severe deprivation. It has one of the highest levels of deprivation in the region and is among the highest in the country, on the 1981 census figures. Many people live in poor housing. The area has the fifth highest number of pensioners, the sixth highest number of children under the age of five and the sixth highest number of large families. Its birthrate and infant mortality rate are higher than the national average. It has the highest overall death rate in London, according to 687 1977 figures, including causes ranging from pneumonia, bronchitis, emphysema and hypertensive heart disease. However, that deprivation is not recognised. Neither is there proper funding for the reprovision from Leytonstone house and Claybury by the early 1990s. Together, that represents a massive injustice to the people of Waltham Forest.

There have been rumours of a secret report that there will be no more capital for reprovision. I hope that the Minister will, make it clear, if not today, at some future time, what the situation is. Waltham Forest's health service is in crisis. It is caused by the highest level of cuts in resources in the country, and yet Waltham Forest has some of the highest levels of health need. It is no longer appropriate to talk only of efficiency; we want to hear from the Minister about resources and money.

There has been a place for the leech in the history of medicine and now it has returned in a new form. The DHA takes a bite, as is its bounden duty to the Government; the RHA is enormously sluggish and complacent in not admitting the scale of the cut; but the Government, as the biggest bloodsuckers, are draining away the lifeblood of the NHS. I hope that that damage will be reversed and that the people of Waltham Forest will get the health service that they want and deserve. I demand proper funding for Waltham Forest's health service.

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

This bloodsucker is more than content to take the stage with the hon. Member for Leyton (Mr. Cohen). It is always a pleasure debating with him. He reminds me so strongly of my brother; he shares the same name and has very similar handwriting. As my brother made me an auntie yesterday, I feel even more disposed towards the hon. Member for Leyton than usual. I congratulate him on his success in winning the ballot for this debate on health service provision for Waltham Forest. I thank him for his kind thoughts about my holiday. I am sorry that it will not be starting yet because I shall shortly be on my way to Chester, to meet Mersey district and regional health authority chairmen.

The hon. Gentleman has obliged me to make a brief reply. I hear what he says about deprivation and poor housing in Waltham Forest. However, in Waltham Forest the standardised mortality ratios for the main preventable diseases are very good. Not only are they better than the national average but they are better than the regional averages. The death rates in Waltham Forest from cancer and from heart disease are lower than the national average. Whatever else the hon. Gentleman's constituents and the health authority may be getting up to between them, it is evident that the people of Waltham Forest look after themselves. The death rate there from preventable diseases is one that I should like to see in other parts of the country. It is certainly much better than in my own constituency of Derbyshire, South. I remind the hon. Gentleman that the whole object of the exercise is to have healthy people and not necessarily to have full hospitals. The objective is to have people enjoying a full life and good health at the same time.

688 The hon. Member for Leyton bombards Ministers and regional and district general managers with letters, some of which make his points well and some of which do not. The hon. Gentleman mentioned particular major changes, and he will know the statutory situation. Any major changes in provision of service have to be put out by the health authority for consultation. If the community health council disagrees, it has the right to say so and to make alternative proposals. If the health authority continues to press forward with its plans, it must apply to Ministers for agreement or refusal. Therefore, I stand in a statutory relationship to the particular issues which the hon. Gentleman mentioned.

Temporary closures are a different matter. If the health authority cannot staff a unit, it may have to take what amounts to emergency action. Recently, the courts clarified the law on consultation and on the term "temporary closures", and we expect local authorities to observe that legislation. That firmly applies also to the "secret report" to which the hon. Gentleman referred, which I understand has been circulating. In other words, if there are proposals for major changes, those affected must be consulted in the usual way.

As the hon. Gentleman said, the MRSA ward at Wanstead hospital was set up when there was a high incidence of MRSA in the district. Recently, it has had a low occupancy, with an average of seven patients, and it is therefore wise for the health authority to consider whether it still needs a separate ward, or whether the patients could possibly be nursed in side rooms.

Similarly, the health authority has sensibly examined the occupancy levels of beds allocated for general practitioner use. In some parts of the country, GP beds are extremely well used and a valuable asset to the community. In others they are allocated but the GPs do not use them. I understand that there is a proposal to close the GP beds at Wanstead and to provide alternative respite and terminal care facilities elsewhere in the district. The patients would not suffer, and the money previously allocated to the resource—which appears not to have been used very fully—could be used in other ways, perhaps to help clear the waiting list mentioned by the hon. Gentleman.

The hon. Gentleman probably knows that an option appraisal is being developed on Wanstead hospital. However, as he is well aware, it is not in Waltham Forest but in Redbridge. The object of his exercise must be the same as the obligation on Waltham Forest health authority—to provide services for people in the district. That is how the service operates.

On 14 April the hon. Gentleman wrote to Terry Hunt, regional general manager of North East Thames health authority, quoting a number of figures. I listened hard to what the hon. Gentleman said, but I am not sure whether the figures that he quoted were exactly the same. On that occasion the hon. Gentleman used figures from the Chartered Institute of Public Finance and Accountancy. He is nodding vigorously. I have got him. Those figures were published last year and compared the revenue expenditure in the health authority in 1985–86 with that in 1982–83, which is a long time ago.

The figures appear to show a real terms decrease of over 18 per cent. in the district allocation. The hon. Gentleman may have noted from volume 1 of the recent publication "Health Service Trends"—I do not see him nodding—that that apparent decrease is substantially accounted for by 689 changes in the way the regional health authority made allocation for the service provided at Claybury hospital, and the transfer of services and associated expenditure from Langthorne hospital to Newham health authority. The decrease was not represented by reductions in service. It is a transfer of cash, and there is a good reason for it.

The expenditure was transferred in that way so that the health authorities providing services in the large mental illness and mental handicap institutions, but providing them to people from outside, should have the money transferred to the user authorities. The idea is that the user authority will pay the provider authority. It is partly intended to encourage the user authority to start developing community services for those people so that they can be cared for at home or locally, and good prevention and rehabilitation services can be provided. We hope to see that happening. This greatly distorts the comparisons made by the hon. Gentleman.

As the hon. Gentleman will know, the regional health authorities decide allocations to districts. This year North-East Thames regional health authority's initial net revenue allocation is £1,084 million—over £1 billion. That is a cash terms increase of 8 per cent. over last year and represents a real terms increase of more than 4 per cent.—way above inflation—and, therefore, substantial growth in revenue funding.

In the last year Waltham Forest appears to have been very prudent, managing to stay within its limits, and in the current year it will receive more money. First, it will receive £300,000 from the Department's special fund, which is intended to compensate the health authorities which will not be gainers under the RAWP formula—which was set up by the right hon. Member for Plymouth, Devonport (Dr. Owen) when he was Minister of Health. I understand that the money will be used for the introduction of a community management computer system and other projects. Secondly, £100,000 has been allocated to the authority from the waiting list fund to enable extra cases to be treated from the ear, nose and throat and general surgery lists.

Thirdly, as I am sure the hon. Gentleman is aware, there is a £9 million scheme under way at Whipps Cross, which will provide three new wards, four new operating theatres, a new out-patients department and rehabilitation facilities at the hospital. That will be a considerable improvement for his constituents. We are receiving reports that the health authority, which is very hard working and competent, is successful in delivering services to local people.

The hon. Gentleman is quite right that the accident and emergency department of Whipps Cross hospital is very busy and that it is the hardest working in the whole region. I understand that it deals with about 260 patients a day, of whom 45 are admitted. I hope that this does not reflect on any weaknesses of or lack of accessibility to local general practitioners. There are more than 200 general practitioners in the Redbridge and Waltham Forest family 690 practitioner committee area. It is for the clinicians concerned to decide who is an emergency and who is not, and emergencies take precedence. It is a very busy hospital and a very busy casualty department and it is not supposed to be providing an alternative service to GPs.