HC Deb 05 July 1991 vol 194 cc622-8

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

2.40 pm
Mr. Clive Soley (Hammersmith)

I am grateful for this opportunity to raise the case of my constituents, Mr. and Mrs. Brown, and of the Parkside health authority. On 15 August 1990 my constituent, Ian Brown, wrote to me saying that his wife had been the victim of a medical accident at Charing Cross hospital, which is in the Riverside district health authority area. That accident resulted in severe scarring of Mrs. Brown's right arm and restricted use amounting to disability. It is not the purpose of this debate to go into the details of the accident; that is a matter for attention elsewhere and I do not intend to refer to it further.

What happened afterwards is, however, a matter for this debate and it is a matter on which I seek some answers from the Minister. A number of corrective operations were to be carried out on Mrs. Brown. One operation was carried out, and helped to ameliorate the immediate problem to give more time for further repair work to be carried out which would deal with the worst of the scarring and improve the functioning of the arm to some extent. The corrective surgery was to be done at St. Mary's hospital in the Parkside health authority area.

Four attempts have been made to carry out that operation and all four have been cancelled. The first was due in autumn 1990. Then, in December 1990, the second operation was cancelled. To set my remarks in context, I should explain that all the operations were cancelled at the very last moment. Mrs. Brown and her husband prepared themselves for her admission to hospital for an important operation—of particular relevance because the NHS had created the problem, albeit by accident, in the first place —and Mrs. Brown was emotionally ready to go into hospital, only to discover on the day itself or the previous day that the operation had been cancelled.

After the second cancellation I wrote to Neil Goodwin, general manager of St. Mary's hospital. I quote from his reply of 17 January 1991 because he puts the problem in context. He wrote: The poor availability of beds for booked admissions was as a result of a greater than expected number of admissions being accepted via the Accident and Emergency department who must take priority and whose number cannot be accurately predicted. This unfortunately resulted in the cancellation of some of the elective admissions. Five elective orthopaedic admissions were scheduled for 12 December 1990. Of these two had malignancies of the bone, two were booked for total hip replacements and the fifth was Mrs. Brown. All patients scheduled for admission are assigned a priority and, on this occasion with only two beds available for elective admissions, the bone malignancy patients were admitted. With regard to future admissions for Mrs. Brown, I am pleased to inform you that from 7 January an additional 14 orthopaedic beds will be opened and, since she has been cancelled more than once, she will be given priority as an elective admission. Needless to say, those last words are relevant to the rest of my comments.

Mrs. Brown's next appointment was for 13 March 1991. Again, it was cancelled because of a lack of beds. Mr. Brown then tried to have his wife transferred to a hospital list outside London, although he and his wife were obviously upset at having to do that given that they felt that the accident had taken place as a result of an NHS operation in the first instance.

On 9 April I wrote to the Minister for Health saying that the operation had been cancelled and I was told in what I understand was a verbal statement that there was little prospect of treatment at St. Mary's. On 7 May I received a reply from Baroness Hooper saying that she had passed the letter to Michael Hatfield, chair of Parkside health authority.

This is one of the most important complaints that I have on behalf of my constituents. When we encounter such a problem, which is clearly one of underfunding of bed spaces, traditionally and quite appropriately hon. Members can write to the Minister who must answer to the House for the state of the health service. However, consistently over the past few years, hon. Members—myself included—have found that their letters have been passed on with a one paragraph sentence from the Minister claiming that it is a matter for the health authority. In other words, the Minister avoids having to answer the key question and the buck is passed to the local health authority.

Michael Hatfield wrote to me on 13 May 1991 saying: It is obviously highly regrettable that Mrs. Brown's surgery has had to be cancelled on several occasions. Every effort is made to ensure that patients previously cancelled are given priority admission". One could forgive Mr. and Mrs. Brown thinking that that priority admission was not happening. Mr. Hatfield continued: however bed availability remains subject to the number of emergency admissions, which must always take precedence over less urgent treatment. St. Mary's currently has an extra 12–20 emergency admission patients occupying medical beds as a result of increased demands on their emergency care service, and this unfortunately does compound the problem. There are indeed plans to open a 14-bed day ward at St. Mary's in the next few months which will provide facilities for orthopaedic surgery. This will be very valuable in helping to reduce the number of orthopaedic cancellations, and as the revision of Mrs. Brown's scar could very easily be undertaken as a day case, the consultant in charge of her case would consider it suitable for this facility. The chairman of the health authority is clearly claiming that the problem is a shortage of beds. A new admission date was given, this time for 19 June 1991—just under a month ago—but again it was cancelled, and again the reason was lack of beds.

I should like to go back to the 50th report of the Public Accounts Committee on the use of operating theatres in the national health service. The Committee, chaired by my right hon. Friend the Member for Ashton-under-Lyne (Mr. Sheldon), produced a useful report which was widely welcomed by many people. It gave a helpful description of the problems and of what should be done about them. The chairman of the theatre sub-committee of St. Mary's hospital, the hospital which we are discussing today, wrote to my right hon. Friend—I shall let the Minister have a copy of that letter in due course because I am not sure of the procedures or whether he will be able to get one from the PAC—stating: I think it is clear from those two tables that the chief reason for cancellation of operating sessions is lack of availability of beds and that not one session was cancelled"— I emphasise "not one"— for lack of medical staff during the period studied. The relevant period covered eight months in 1988. The letter continued: It also seems that a chief reason for cancellation, at very short notice, of admission of patients for planned operations was that there was no bed available for them, that bed being occupied by another acutely ill patient… The report from your Committee does show concern about the provision of service of patients admitted through the Accident and Emergency Department and this concern is shared by many of us who feel that the provision of emergency services in this country is not as it should be. It seems to me that the distinction between emergency and elective work is over-simplified. I think it best to regard emergency admissions as those in which life is threatened and which required treatment or operations within hours. Next, inevitable cases where operation must be done within twenty-four to forty-eight hours and a good deal of fracture work comes into this group and finally, those cases where admission is truly elective and can be planned well in advance. I certainly do not take the view—I am sure that Mr. and Mrs. Brown would not do so either—that an accident and emergency admission should not be given priority over Mrs. Brown's operation. That is not what is central to this argument. It is not a matter of Mrs. Brown's operation being postponed because of a greater emergency, but of insufficient beds being available when there are sufficient surgeons and sufficient theatre time to carry out both the emergency surgery and the elective surgery of the type that Mrs. Brown needed—and needed as a result of an NHS accident in the first place.

The figures attached to the report sent to me and to the Public Accounts Committee show that in April 1988 a total of 81 beds were not available to surgical patients, and that 60 planned surgical admissions were cancelled. The number of beds not available for surgical patients varies from the low figure of 15 to a cancellation rate of 105. Perhaps more relevantly, the overwhelming reason for the cancellation of theatre sessions is given as a lack of beds. In April 1988, 27 operations were cancelled because of a lack of beds; in May, the figure was 17; in June, 30; in July, seven; in August, 21; in September, 19; in October, 36; in November, 36; and in December, 25. I am told that the position has probably worsened since then.

It is interesting that very few cancellations were made for other reasons. Statutory holidays probably accounted for the next biggest cause of cancellations. Another reason sometimes given for cancellations is that the patient does not turn up, but the figures show that there were never more than seven such cancellations and usually only one or two. There is no example of an operation not being carried out because no surgeon or anaesthetist was available. In other words, the operations could have taken place if the beds had been available. Bed availability is fundamental to the debate.

I am not using the opportunity to raise these matters as a way of knocking the Government's running of the health service. None the less, I think that the Government run it badly. We all know the general view of the public on the issue. I am here to speak for Mr. and Mrs. Brown, and specifically for Mrs. Brown, who suffered from the accident to which I have referred. If more beds were available at St. Mary's hospital, the operation could have been performed.

I asked someone at St. Mary's hospital—someone in a position to know—how many beds would be needed, and whether as many as 100 beds would be needed. I was told that the number would probably be significantly less than that. The staff and the necessary operating theatres are available, so why can we not provide sufficient beds— perhaps another 30 or 40, possibly fewer, I am not in a position to know—to enable an operation to take place on Mrs. Brown's arm and to permit the many similar operations which in the past have not been performed, thereby causing the sort of distress and anger that Mr. and Mrs. Brown have experienced. We know from the figures of 1988 that the number must be considerable.

People prepare themselves emotionally and physically for operations, whatever those operations may be. In Mrs. Brown's case, it will be a restorative operation on her arm. People make themselves ready to go into hospital, only to be told at the very last moment that the operation cannot take place because a bed is not available. Other arguments can be advanced. For example, if the Government had accepted the no-fault compensation Bill—the National Health Service (Compensation) Bill—that might have helped Mr. and Mrs. Brown, who are caught up in what is for them a personal nightmare.

My central question for the Minister is directed to bed availability. Why cannot additional beds be provided in a hospital such as St. Mary's? No one is arguing that the hospital needs hugely increased resources for additional surgeons and operating theatres—it merely needs additional beds to enable it to carry out elective surgery so that no one has to suffer four cancellations in one year. Indeed, it is still not known, and cannot be known, when Mrs. Brown's operation will be carried out. For all I know, she might be in the same position 12 months from now. That must be deeply unsatisfactory and deeply distressing to Mr. and Mrs. Brown. I hope that the Minister will address himself to these matters.

2.57 pm
The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell)

The hon. Member for Hammersmith (Mr. Soley) has raised an issue which perhaps can be debated at two levels. First, there is the case of Mrs. Brown and, secondly, there is the issue that is illustrated by her sad and unacceptable position.

I shall begin by dealing with Mrs. Brown's specific case. As the hon. Member for Hammersmith said, for the purposes of the debate we need not concern ourselves directly with how she came to need the treatment that she now requires, which is being discussed in the context of St. Mary's hospital. In the context of the debate, the salient points are clear. Mrs. Brown was referred to St. Mary's to receive treatment that she clearly needs. I saw photographs of her on the lunchtime news on television and no one would dispute that she needs treatment and is entitled to receive it from the national health service if it is possible to improve the condition of her arm.

Mrs. Brown was referred to St. Mary's to receive treatment. On four occasions she expected to be admitted to receive it and on four occasions there were cancellations. That is the issue which the hon. Gentleman raised and he has sought to expand it into a discussion of bed availability, which he sees as the principal cause of cancelled operations.

The hon. Gentleman quoted a letter from Parkside health authority. It is important that it should be clearly on record that the unit general manager of St. Mary's has offered his apologies to Mr. and Mrs. Brown for the delay in Mrs. Brown's treatment, and an admission that the management of her treatment in hospital is not such as to satisfy the hospital managers. His apologies and admission do not treat Mrs. Brown, but they make it clear that no one thinks that the record is satisfactory.

I shall go a stage further and say that the Government wish to state clearly that repeated cancellations, even of non-urgent admissions to hospital, are not regarded by us as an acceptable managerial technique. Some cancellations are the inevitable consequence of a commitment to use national health service resources effectively.

It would be unrealistic for any Minister or Government to give an undertaking that there will never be a cancellation of a non-urgent admission. However, repeated cancellations for the same patient are not acceptable and I assure the hon. Gentleman that the Government do not regard that as acceptable. The records of individual NHS hospitals on repeated cancellations for the same patient requiring non-urgent treatment is one of the measures of the quality of health care delivered by a particular hospital and we look to health authorities to measure and monitor that through the contracting system.

It is important that the House understands why non-urgent admissions inevitably will be cancelled on occasions if we are to maintain our commitment—which I believe is shared across the House—to use the resources available to the NHS as effectively as possible. Non-urgent admissions are planned into a hospital's programme as and when beds and other resources become available. It is important not to regard beds as the only resource; they are one of many resources available to a hospital, all of which must be marshalled to treat a particular patient. There is no magic about beds—

Mr. Soley

I understand the Minister's point in general, but my understanding of this case is that the problem is specifically a lack of beds.

Mr. Dorrell

We must examine why, sometimes, beds are cited as the reason for a particular operation not being carried out. Bed unavailability can be caused by a number of factors. It can be because of emergency admissions—the example cited by the hon. Gentleman—or it can be because of an unexpected length of stay required by an existing patient. It is not just the admissions that determine bed availability, but whether a patient is discharged from hospital within a reasonably expected time. It involves the patient load in a hospital at any one time.

Bed availability is also affected by staff availability. There may be an epidemic in winter months and hospital staff—like staff in any organisation—are susceptible to illness. Often we are told that operations are cancelled because beds are not available, but the reason could be that there have been too many admissions for the bed capacity or because there have been too few discharges. It could also be that there is an inadequate number of people to staff all the physical beds in a hospital, "Beds" is simply a useful tag to hang on all those different sets of circumstances that can lead to a bed space not being available at the time that the patient needs it for a non-urgent admission.

Mr. Soley

I must press the point. Mr. Hatfield said that the problem was caused by emergency admissions. In his letter he said that bed availability remains subject to the number of emergency admissions, which must always take precedence over less urgent treatment. I understand that argument. The case that I have raised relates not to patients having to stay longer than expected in hospital, but to emergency admissions.

Mr. Dorrell

The hon. Gentleman must think about the position of a hospital manager. He may want to admit Mrs. Brown or another patient for non-urgent treatment in the following week. In order to tell Mrs. Brown that that treatment will be possible, he must ask, first, whether the necessary number of staff are available to give Mrs. Brown the treatment that she needs. The second question that he must ask himself is whether a bed will be available. He must make a judgment about the number of beds needed for emergency admissions and in the case in question, that factor may have been underestimated. He must also estimate the rates of patient discharge, because over a given period, a hospital will discharge as many patients as it admits.

Mr. Soley

If we are arguing a general case, I would agree with the Minister, but in the case in question, beds were unavailable as a result of emergency admissions. There is no suggestion by anyone, anywhere, that insufficient staff were available to undertake the operation. I have been clearly told that if the extra bed had been available, the operation would have been done regardless of other emergency operations—and that they, too, would have been performed.

Mr. Dorrell

I was seeking to analyse the different factors that lead to cancellations in general. It seems that the variable underestimated in that instance was the extent of emergency admissions, but the following day it could have been one of the other variables. Bed availability could have been quoted as the factor in any of the three instances, arising from different underlying factors.

It is not necessarily right to conclude that all problems can be solved by increasing bed space. However, it must be said that St. Mary's management, in order to meet the contract standards required by its health authority since 1 April, concluded that the hospital's bed space is inadequate. Although the chairman's letter said that the committee was then proposing to commission an additional 14 beds, it intends over the next few weeks to commission a further 20 beds. Bed capacity must be regarded by any sensible manager as a resource element, but the important question is not how many beds or doctors are at his disposal but the quality of service provided to patients.

Mr. Soley

rose—

Mr. Dorrell

I have given way to the hon. Gentleman three times and I want to move on to echo one of the themes that he sought to develop.

The Government do not apologise for pressing home their policy that NHS hospitals must use their cash as effectively as possible. There should be a clear steer to all health service managers that they are expected to use all their resources—beds, clinical skills and staff—as effectively as possible. However, I reiterate that the Government do not regard repeated non-urgent cancellations as an acceptable managerial practice. However, efficiency and effectiveness are not purely accounting concepts and the optimum use of resources tends to lead to cancellations for the reasons that I explained—although the hon. Gentleman may not accept that argument in respect of his specific constituency case.

We must ensure that all health service hospitals match high standards of service as well as keeping within narrow measurements of cost efficiency. Under the contracting service that we put in place on 1 April, we require health authorities to speak to provider units, and particularly to hospitals, to agree standards of service that the authorities, using health service resources, expect their hospitals to provide to the patients on whose behalf the authorities purchase the service.

One of the standards of an acceptable service should be a limit on the number of times—apart from in exceptional circumstances—a hospital should be allowed to cancel non-urgent admissions. The new purchasing function of the health authorities should be used, through the contracting system, to limit this type of management action by health service hospitals even though it arises from an entirely laudable commitment to using the resources of the health service as efficiently as humanly possible. Sometimes in their enthusiasm to do that there is a danger that managers do not adequately consider other vital quality factors from the point of view of the patient.

The hon. Gentleman was right to invite the House to dwell for a moment on the plight of his constituent, who four times prepared herself to come into hospital and four times—on the same day or immediately before it—found her operation cancelled. To secure the efficient use of resources, once or twice is perhaps unavoidable, but repeated cancellations should be deprecated and limited —and we look to health authorities to do that. We have given them the weapon, in the contracting system, to limit such occasions and to insist that provider units—hospitals —are held to account and given management objectives not only of cost efficiency but of improving the quality of service, so that NHS patients in future will not have to suffer the sort of treatment that Mrs. Brown has suffered in the past few months.

Question put and agreed to.

Adjourned accordingly at ten minutes past Three o'clock.