HC Deb 08 February 1991 vol 185 cc588-94

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

2.41 pm
Mr. Bernie Grant (Tottenham)

I have asked for this Adjournment debate following the leaking to The Guardian of a letter sent by Mr. Terry Hunt, the regional manager of North East Thames regional health authority, or NETHRA as it is fondly known, to district managers in the region.

In the letter, Mr. Hunt addresses the problems of NETHRA's huge waiting list, which is the worst for its size in the country, on which no fewer than 65,744 people are waiting for operations. More than 22,109 people have waited for more than a year, which in itself is scandalous.

Among Mr. Hunt's proposals for reducing the waiting list is one that deserves the attention of the whole country as it marks a departure from the principles on which many of us had believed our national health service is based. He proposes that a list of medical conditions are to be deemed inappropriate to place on waiting lists in the future. In other words, those medical conditions will no longer be available for treatment under the national health service.

The conditions to be excluded include varicose vein operations, lumps and bumps, wisdom teeth without symptoms and in vitro fertilisation, unless, he says, there is an overriding clinical need. We are told that other conditions may be added to that list.

The Government repeatedly assure us of their support for the founding principles of the NHS, yet, because of a lack of funding, the principle of a universal and comprehensive health service available to all is being formally abandoned in NETHRA.

I want the Minister to tell the House whether that is Government policy and, if not, what she intends to do about it. Is she prepared to see the NHS become merely a first-aid service or does she believe, as I do, that it should be a comprehensive service? Other questions need to be asked about this decision. Who made it? Who was consulted? Were the community health councils consulted about this major change in policy? Would we have known about it had there not been a leak to a national newspaper?

On the face of it, the decision appears to have been made secretly by an NHS bureaucrat. Bureaucracy in the NHS has largely been abandoned, but it cannot be right that a decision of such significance can be covertly concocted and carried through without scrutiny and behind the closed doors of NHS management.

There are several clinical and social concerns about the list of excluded treatments. Let us consider the example of non-malignant lumps and bumps. A doctor has written to a national newspaper about his concerns. He asks: How will anyone know that lumps are benign if they are not to be treated—and will people cease to seek medical opinion on life threatening conditions once they hear that lumps will no longer be treated by the NHS? Furthermore, there are many lumps and bumps which might not need removing or treating for medical reasons but which are socially and physically disabling nonetheless. I am reminded in particular of one of my constituents who has a lump on her foot. It causes her considerable pain and she had hoped to have it removed. She is a carer. Her husband is suffering from cancer and it is making life even more difficult for her. When her GP referred her to North Middlesex hospital, she was refused treatment because of that new policy, which is quite disgraceful.

Had I the time, I could run through the other prohibited conditions to show that there are similar good, preventive and social reasons why they should remain available through the national health service. However, I shall confine myself to saying how cruel it is to deny women the right to IVF treatment on the NHS. I should like the Minister to visit my constituent Mrs. W. and explain to her why she cannot have IVF treatment. She has been trying to have a child for seven years and had finally begun pre-treatment for IVF. After many months of taking pills she is distraught because she has been told that she will not now receive the treatment.

Mr. Hunt's decision also raises the issue of the relationship between the NHS and the private health sector. It is no coincidence that the private hospitals are thriving on exactly the sort of work that North-East Thames regional health authority is now abandoning. Is it part of Government policy to encourage the private sector by starving the NHS? That is what it is beginning to look like to my constituents.

The trouble is that very few of my constituents can afford to pay £1,000 to have their varicose veins treated or the thousands of pounds involved in having private IVF treatment. To them, Mr. Hunt's ruling means that they will never be able to have the treatment that they need. Frankly, I shudder to think what other treatments will be added to the list. We are going down a very dangerous road when income is the determinant of whether one receives treatment.

I have no doubt that the Minister will reply that the NHS is not funded from a bottomless purse and that priorities must be established. No one would quibble about that or with the need to find constantly more efficient ways to run the NHS. However, Mr. Hunt's decision is a panic measure taken against the background of chronic starvation of funds by the Government to the health authority. It is bringing the NHS in the region to its knees. As elsewhere, managers are struggling to run an underfunded service and at the same time responding to political pressure to keep the waiting lists down by manipulating the figures—in time, no doubt, for a general election.

In the North East Thames regional health authority areas people will not be deceived. In 1989–90, 28,514 operations were cancelled, with a record 8,095 operating sessions not taking place. We have lost 31 hospitals since 1979 and a further 16 have been partially closed. 1[n the same period we have lost 3,295 acute beds.

This year figures will certainly be far worse. Of 28 districts in the regional authority, 13 are making cuts in excess of £1 million this year, including 10 inner London districts, as a result of the foolish insistence of Ministers that they clear all debts before the start of the remodelled NHS in April.

In my district of Haringey, 75,149 people were waiting for operations in March 1990, 31 per cent. of whom had been waiting over a year. That is quite appalling. Yet by August the district was overspent and it has had to find ways of containing a projected £1.8 million overspend in the current year. That meant the closure of the orthopaedic theatre at St. Ann's hospital before Christmas and the closure of the orthopaedic ward at St. Ann's at the beginning of January this year. The work has been moved to the North Middlesex hospital, and the operating time reduced to one half-day session a week, with beds having to be shared with general surgery, which is severely limiting the progress of the general surgery waiting list. The 18-bed infectious diseases ward at St. Ann's has also been closed, to be replaced only by six beds at the North Middlesex. In all, three wards have closed, one operating theatre has been lost, and the building that was supposed to replace the facilities at St. Ann's has been cancelled due to capital shortages.

In October surgeons were told to reduce operations by 50 per cent. and then on 1 December they were told to halt all non-elective surgery altogether until 1 April 1991. I suggest that it will take some skilful manipulation of the figures to disguise the massive increase in the waiting list which will result.

Figures are one thing, but the effect on patients and their families is another. I receive scores of letters from people who are affected by the problem. Let us take, for example, the case of Mr. James Breslin who lives in my constituency. He is 63 and needs a hip replacement badly so that he can continue to work to pay his exorbitant mortgage. After waiting many months he was finally given a date of 16 March 1991. He has now been told that the operation has been cancelled, and that he must expect at least another six months' delay. Mr. Breslin's daughter wrote to me last month and I quote from her letter: He doesn't know yet—we are afraid to tell him. He is in constant excruciating pain. It is terrible to watch him, his face contorts with agony when he tries to get up or sit down, and when he tries to walk. I am afraid of what this news will do to him—the only thing keeping him going was the fact that 16th March was growing nearer. Please help my father. When I wrote to the surgeon, he could only explain that Mr. Breslin was one of 52 of his patients who would not be operated on until next year and many of them had had their operations cancelled twice. He said that it was impossible to plan elective surgery.

In NETHRA, there are thousands of people like Mr. Breslin, who are being short-changed by the NHS. According to the Greater London Association of Community Health Councils, which does such excellent work to represent the views of health service users, with such limited resources, the situation in NETHRA is approaching chaos in many parts of the region.

Districts such as Haringey can no longer look to other neighbouring authorities to tide them over difficult periods, for they are all in the same boat. The picture is one of wards being closed and beds being left empty while people are crying out for the treatment that they so badly need. I am reliably informed of an instance recently when cardiac patients at Bart's were put in armchairs for the day, because emergency medical admissions needed their beds. In the region as a whole, emergency admissions are rocketing and patients are being denied operations until their condition necessitates their admission to hospital on an emergency basis.

I began by expressing my concern about the abandonment of the fundamental principles of the NHS, as exemplified by the decision by the managment of NETHRA to abandon certain kinds of treatment. I should like the Minister to state the principles on which the NHS is currently operating. I hope that she will not attempt to pull the wool over our eyes by quoting bogus statistics to demonstrate that matters are improving. They most definitely are not.

The NHS was created in the spirit of universalism which followed the second world war. I end by quoting from another letter which I recently received, from a pensioner in Tottenham who has also had his operation cancelled and who fought in that war. He wrote: I am now wondering what the hell I fought for. Does the Minister intend to allow our service men and women now fighting in the Gulf to be left asking themselves the same question?

2.53 pm
The Minister for Health (Mrs. Virginia Bottomley)

I congratulate the hon. Gentleman on securing this opportunity to discuss the position in his health authority and, particularly, to clarify several important points causing great anxiety in the North East Thames regional health authority. The hon. Gentleman has raised questions about the health service on several occasions in the House. We respect and understand his interest and anxiety. That anxiety is shared by the Government. The hon. Gentleman will be aware that we are determined to ensure that we use the record resources going into the health service and the record number of people working in it to provide a high standard of care of the people of Britain.

The hon. Gentleman began by asking me about the principles of the national health service and whether we held to the essential founding principles. I can give him an unequivocal assurance that the national health service is, and will remain, available to all, free at the point of delivery, financed largely out of taxation and funded to a record level that many would have thought inconceivable only 10 years ago. That is so, with regard to not only the numbers of people working in the service and the way in which they are paid, but the knowledge, the pharamaceuticals and the technology available to the hon. Gentleman's constituents and to mine. However, it is precisely because of the growing and developing nature of medical care that we cannot avoid change. We need to rationalise and to develop the ways in which we provide care.

The hon. Gentleman referred several times to bed closures and to hospital closures. It is a simplistic view of the health service to regard it as primarily concerned with beds. It is primarily concerned with patient care. We must always get the balance right between the provision of acute care and operations, which are enormously important to those who need them, and the broader care—the community care—and the services for the priority groups, such as the mentally ill and the mentally handicapped.

A distinguishing feature of our national health service, as the hon. Gentleman is aware, is the family doctor service. I hope that he will set the way in which that services has developed in recent years in his constituency alongside his concerns about acute care, with which I shall deal in a moment. In the hon. Gentleman's family practitioner committee area—now the family health services authority area—there are now three times as many practice nurses as there were three years ago. Over the past 10 years, there has been a fall of more than 100 in the number of patients on the average GP list in his constituency. There has also been an increase of 13 per cent. in the number of GPs in his family health services authority area and there have been great developments in the care provided by the hospitals in his area.

I will give an example about which the hon. Gentleman will wish to tell his constituents. Between 1988 and 1990, the number of day cases undertaken by the major hospital in his area increased by nearly 50 per cent. That is an achievement of which to be proud. Only recently, the Audit Commission took a number of health authorities to task for the lack of speed with which they had moved towards day cases. There has been an increase of about 60 per cent. in London as a whole, which is excellent, but the hon. Gentleman's area has done particularly well.

It is not our intention to put people into beds and leave them there indefinitely, but to use the resources to the full to provide better care. That certainly applies to operating theatres. The recent Bevan report dealt with the essential need to use operating theatres to the full. The hon. Gentleman said that operations had been cancelled, but "cancelled" is not the right word. Some have been postponed for a variety of reasons, the lack of validation of a list and the lack of proper planning to ensure that staff would be available. Sometimes emergencies have occurred and the non-urgent cases have been put back. Alongside that, about 10 per cent. of patients do not show up for their appointments.

We must ensure that the national health service manages its services effectively and that the public and the patients realise that it is not a cost-free service. It may be free at the point of use for our constituents, but next year costs will approach £30 billion. The onus is on all of us to ensure that we understand the range of resources brought together through the work of the district health authority and the family health services authority and integrated under the umbrella of the region. We must ensure that we evaluate and monitor our work to continue to push forward the frontiers.

The hon. Gentleman has centred the debate around a letter sent out by the regional general manager of the North East Thames regional health authority. I welcome the opportunity to clarify the matter. The idea that the letter was leaked is fanciful. It was a routine letter, which I have with me, and there is no question of its being confidential or private. I am sure that the hon. Gentleman can confirm that there is no mention of its being secret, confidential or private. I appreciate the opportunity to clarify the issue. Duncan Nichol, the chief executive of the national health service management executive, has written to all regions to put the position more clearly. In order that there should be no misunderstanding, I intend to place a copy of the letter in the Library of the House. Misunderstanding and mischief often lead to unjustified anxieties among patients.

Waiting lists and waiting times are important in terms of the length of time an individual waits, rather than the exact number on the waiting list. We have made it clear that we want action to be taken on the long waits. Our health service treats patients according to clinical priority so that 50 per cent. of patients are admitted immediately because they are urgent or emergency cases. Of the 50 per cent. of patients who are not admitted immediately, half are admitted within five weeks, so three quarters of all patients are admitted immediately or within five weeks. We share the hon. Gentleman's concern about those who are not admitted within that time scale and for whom there are sometimes unacceptable delays. Inevitably, there are the ones who do not require urgent, acute operations. The hon. Gentleman will know that it causes anxiety and uncertainty to the patients and their families if it is not certain when they will be admitted.

The number of patients waiting more than a year reduced by nearly 7 per cent. in the year to 31 March 1990, and provisional figures show that that downward trend is continuing. The North East Thames authority has bettered those figures—there has been a reduction of long-wait patients of 28 per cent. In the year to 31 March, provisional figures show that the region's figures are continuing the downward trend. I am pleased to see the great strides being made in the region in terms of dealing with long-wait patients especially since, as the hon. Gentleman is well aware, the North East Thames authority has had a particular problem with the number of such patients.

In the district health authority covering the hon. Gentleman's constituency of Haringey, the period from March 1989 to 31 December 1990 saw a 35 per cent. decrease in the total number of in-patients waiting, so the authority has done particularly well in recognising and meeting that challenge. In the year ending March 1990, Haringey reduced the number of in-patients waiting more than a year from 842 to 385—a 54 per cent. reduction. I am sure that the hon. Gentleman will want to join me in congratulating Haringey health authority on so clearly and strongly identifying that problem as one needing action. However, there is room for more action. That is why the management executive and the Secretary of State have identified long waits as a special priority in the health service.

We have been working with the special waiting list fund. During the past five years we have spent £154 million to enable hundreds of thousands of extra patients to be from the waiting lists. Next year, £35 million will be allocated to health authorities from that fund, and the regions will supplement that with a further £25 million from their own resources. The North East Thames authority, which covers the hon. Gentleman's area, will be allocated £2.63 million from the fund, which the authority will match, making a total of £5.26 million.

It is not just a case of increasing resources, but of increasing efficiency. I have spoken about the importance of validating the lists, of some of the administrative tasks which need to be undertaken and also of clinical validation.

The aspect that the hon. Member for Tottenham (Mr. Grant) mentions applies to clinical validation. It is important for clinicians to examine the list, to check and to satisfy themselves that the people on it are in need of surgical treatment. I think that the hon. Gentleman will agree that there is the world of difference between a varicose vein which may be unsightly, but is not troubling a gentleman who wears long trousers all day and causes him no pain or difficulty, and a varicose vein which is extremely unsightly, possibly ulcerated, or causing great difficulty. Similarly there is a difference between a tattoo which can be seen by no one and, although disliked by the patient, cannot be said to be causing distress or pain and a tattoo which causes great psychological distress and is a source of great concern. Wisdom teeth can be in need of clinical attention and can cause pain and difficulties to the patient, but patients may also simply wish that they did not have wisdom teeth although there is no clinical need for their removal.

North East Thames regional health authority was seeking to identify a range of operations where districts and, especially, clinicians would wish to satisfy themselves about the clinical aspects. It would be quite wrong to think that that list constituted a prohibition on those operations—on the contrary—but a need has been identified to check on the clinical need for such operations.

Mr. Bernie Grant

If the Minister is saying that this is not a definitive list, has she instituted some sort of appeals mechanism so that if, for example a clinician says that an operation is not urgent, the patient's doctor and other evidence can be brought before some sort of appeals committee?

Mrs. Bottomley

In our national health service patients are always admitted to hospital on the basis of clinical need. We do not have a waiting list in the formal sense that the first person on the list is the first person seen. That is why 50 per cent. of people are admitted to hospital immediately and a further 50 per cent. within five weeks. Some of those patients admitted immediately, or within five weeks, will get to hospital much sooner than people who have been on the list for longer. However, their clinical need and priority are greater. They are in need of urgent attention and have a deteriorating or a life-threatening condition.

The key point about the letter from the general manager of the regional health authority, spelt out even more clearly by the letter from Duncan Nichol, which I hope that the hon. Gentleman will read carefully, is the requirement to establish clinical need in those areas. I quote briefly from the letter: It is important that we do not create the impression that the NHS is seeking by blanket managerial declaration, to rule out whole categories of treatment … without reference to the clinical priority of individual patients. I hope that the hon. Member for Tottenham will be at pains to explain that to his constituents and more widely.

It is important to continue to validate lists and to ensure that we provide the sort of pioneering health care which is a feature of our national health service. For example, last weekend we were all concerned about the well-being of the child Tamara Rainey at Addenbrooke's hospital—a child in acute need. Our national health service is able to provide treatment at the frontiers of science. We can continue to provide such treatment, free and available to all, if we use our resources effectively and well.

We must see, for example, whether GPs can undertake some minor treatments because GPs are now increasingly involved in minor surgery. We must ensure that the family health services authority and the district health authorities work together effectively and comprehensively. We must ensure that we do not think only in terms of acute medicine and the importance of tackling waiting lists. We must also remember those, such as the mentally handicapped and geriatrics, who require care in the community. Although it is costly, we all want to see better standards of care for such people.

The constituents of the hon. Member for Tottenham have seen the establishment of the North Middlesex hospital as a first-wave NHS trust. The hon. Gentleman will find that to be a centre of excellence able to provide better care and to inspire great confidence among his constituents. I hope that I have reassured the hon. Gentleman and his constituents and I thank him again for allowing me to explain these matters.

Question put and agreed to.

Adjourned accordingly at ten minutes past Three o'clock.