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§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)I am grateful for the opportunity afforded to me and my right hon. Friend the Member for Tweeddale, Ettrick and Lauderdale (Sir D. Steel), should he seek to catch your eye, Mr. Deputy Speaker, to discuss the important question of long-stay care provision in the Borders.
I know that the Minister would prefer to be elsewhere, but I make no apology for asking the House to consider this issue, which is not only important locally, but urgent, because the local area health board published a consultation document "Changes in Health Care Services" at the end of February. It has solicited comments on that document to be returned by 3 April for consideration at the next board meeting on 11 April or at the subsequent meeting on 7 May. One of the important issues behind this debate is the local concern that the time scale over which the decisions are to be considered and the consultation undertaken is far too short. I wonder whether the Minister could say something about that later.
I know that profound changes will be made to the way in which the national health service is structured and financed after 1992, when an internal market is established. I know that that means that some changes must be made, but to what extent is it absolutely necessary to work to the time scale to which the board seems determined to adhere? Is there any scope for flexibility in the time available?
The board's financial circumstances are peculiar to the extent that, in 1989, it completed a substantial capital project—the Borders district general hospital. That work involved £4 million of additional expenditure, a substantial sum given the size of the health board. The Minister will also be aware that, in 1989, the board borrowed £500,000, which it is required to pay back. However, the NHS management executive has also decreed that it should eliminate its deficit by 1992–93. I understand that that requirement has been placed on the other Scottish health boards, but certain circumstances in the Borders argue that special mitigating factors should be taken into account.
If the NHS management executive and the Scottish Office Home and Health Department insist on the board's carrying out those financial cuts within the time stipulated, the task will be too demanding to be undertaken sensibly. The damage that may result could be well in excess of any savings, financial or otherwise, that may be made.
I know that in 1991–92 the board has been allowed a net income of £36.95 million—an increase of £4.45 million on the 1990–91 budget. Much of that money has already been hypothecated to developments insisted upon by central Government, for example Project 2000, the extra money needed for the treatment of AIDS, the junior hospital doctors allocation, as well as money needed to deal with the abolition of Crown immunity.
All those issues, though important, will take a large proportion of the extra money that has been made available to the board. Indeed, the board calculates that it has only about £1 million of new money that is not already committed. Is there any hope for the Borders health board of additional help, in terms of the SHARE formula, 1157 bearing in mind that we have not yet reached parity in money due to that board relative to that given to other boards in Scotland?
Suffice it to say that the board needs to make efficiency savings of £650,000–2 per cent. of its budget—if income and expenditure are to be in balance by the end of March 1992. In addition, it must make efficiency savings of 1 per cent. All that represents an extremely tall order. It seems unreasonable, and the Government should pay more attention to the requirements of some boards.
The Borders health board has been extremely prudent in its expenditure. It has played the game by all the rules set by St. Andrew's house, and in its present hour of need it would be proper for the Scottish Office to look with more sympathy on the claims that the board is making.
The changes that the consultation document proposes, in terms of long-term care and provision in the Borders, mean that there could be a substantial move of long-stay patient care out of NHS provision into the private and voluntary sector. I have nothing against that sector. There are examples in the Borders of exemplary homes, which are run to a high standard by dedicated people.
I have nothing against that sector in principle, but great concern is being expressed lest, if the board's proposals and the ideas in the consultation document are put into practice, there will be difficulty guaranteeing and overseeing the standards of care that long-stay patients now enjoy in the NHS in the Borders. We must not overlook the wishes of patients. If a patient in, for example, a ward in the district general hospital in Galashiels is opposed to having private or voluntary sector care, his or her wishes should be respected.
The professional health care teams are worried lest the result of the changes will be a fragmentation of the multi-disciplinary approach and team work that they have built up over many years. Their efforts have resulted in a high standard of care of geriatric and long-stay patients locally.
There is also concern about the morality, so to speak, of seeking to use Department of Social Security income support payments to support long-stay patients locally. There are 385 private nursing home beds in the Borders, but, by definition, they are provided in an unplanned and incoherent way and are not related to local demands.
There are some important staffing issues involved in all this. There are potential redundancies on a not inconsiderable scale, so the staff are confronted with uncertainty about their future, but to be fair to them, they are less worried about themselves than about the standard of care available to their patients.
In my experience, the staff of the NHS are the service's most valuable asset. Locally in the Borders, they are committed and dedicated people. Their morale is suffering as a result of the changes that are being considered. They are asking why the elderly are carrying the brunt of the cuts. Is it because they are a soft target? They believe that the changes will result in privatisation by the back door, and that is causing them much distress and uncertainty.
I urge the Minister to take an urgent and fresh look at the financial provision available to the Borders health board and the time scale that it is asked to observe. The issues at stake are important, particularly to the patients whom we all seek to serve. I hope that his comments will relieve some of the anxiety felt in the Borders health board.
§ Sir David Steel (Tweeddale, Ettrick and Lauderdale)I congratulate my hon. Friend the Member for Roxburgh and Berwickshire (Mr. Kirkwood) on his initiative in securing this Adjournment debate, even though, like the Minister, I had planned to be elsewhere. I wish to reinforce my hon. Friend's general comments and to outline the way in which the proposals will affect my constituency.
Whereas my hon. Friend spoke of a substantial shift from the public to the private sector in his constituency if the proposals are implemented, such a shift would not take place in my constituency. Rather, national health service provision for long-stay elderly patients would be totally eliminated and replaced by a series of private sector proposals. Is that the Government's intention? If so, I have never understood why, on the one hand, the Government are screwing down the expenditure of all health boards—they call it careful control and budgeting, but it is a constraint on their finances—while, on the other, DSS payments to the private sector for long-stay patients are increasing at an unprecedented rate. I do not understand why the Treasury imposes careful controls in one Ministry while another picks up the tabs and seems to have an open budget. Will the Minister clarify that?
If the proposals are adopted, will patients in the private sector have the same access to NHS facilities, such as physiotherapy and chiropody, as they enjoy at present? Like my hon. Friend the Member for Roxburgh and Berwickshire, I pay tribute to the private sector. Indeed, opened the only purpose-built private nursing home in my constituency, and it is a good one. However, there is no guarantee that, if the private sector suddenly expands into all hospitals, as envisaged in the Borders proposals, the same standards will be maintained. We all know of examples in other parts of the country where the private sector has fallen down.
It would be wrong to suggest that general practitioners in my constituency are totally opposed to the idea of independent community trusts, but they are certainly not enthusiastic about them, for one obvious reason: they would turn GPs into business managers and that is not why they trained for the medical profession. They feel that the Government want to secure care of the elderly on the cheap by turning GPs into business managers and perhaps then paying for staff. The same staff may find employment elsewhere but under worse pay and conditions than they enjoy in the NHS.
The proposals will mean a sudden dislocation of staff and patients. I would welcome the re-opening of the Galashiels and the Selkirk cottage hospitals. They are suitable places for GP beds and for care of the elderly. Indeed, they are more suitable in the long run than the more distant hospital at Huntlyburn. How they are to be reopened—under what authority, control and budget—is extremely important.
A letter from GPs in Galashiels said:
The need to abandon the long-established principle of NHS provision for continuing medical care of the elderly in such a precipitate manner to satisfy short-term political/ financial expediency seems to us to be difficult to justify. We feel this demand by the Government should be resisted by the Board.That is important, and I am glad that the Minister now has the opportunity to clarify what lies behind the proposals.
§ The Minister of State, Scottish Office (Mr. Michael Forsyth)I am grateful to the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) for raising this subject, as it allows me to put on record important facts about the funds available to the Borders health board and the interesting and exciting changes proposed for long-stay services.
I hesitate to question what the right hon. Member for Tweeddale, Ettrick and Lauderdale (Sir D. Steel) said about his constituency, but I understood that Hay Lodge hospital in Peebles was in his constituency. It had 48 beds for long-term care of the elderly, and I do not believe that there are proposals to change that. I was a little puzzled by the right hon. Gentleman's statement that there would be no provision in his constituency.
§ Sir David SteelI was referring to Ettrick and Lauderdale.
§ Mr. ForsythThe right hon. Gentleman must not forget Peebles.
It should be made clear that Borders health board has sufficient resources to provide excellent services. The board is funded no differently from any other in Scotland. It does not have a persistent financial problem; nor is there any evidence that it is mismanaging the funds allocated to it. For the financial year 1991–92, Borders has been allocated nearly £38 million—an increase of 11.1 per cent. over the previous year's allocation and the highest increase of any health board in Scotland. In real terms, the increase in the revenue allocation mode to Borders health board since 1979–80 has been 63.7 per cent.
What the board has not yet done fully is to adjust the pattern of its services to take into account the opening of Borders general hospital in 1988. The board recognised from the outset that that hospital would be more expensive to run than the facilities that it replaced. That is not surprising, because the new hospital was designed to provide many more facilities locally so that the people of the borders did not have to travel to Edinburgh for relatively routine health care. It was also designed to provide facilities to a much higher standard than the cottage hospitals which it replaced.
Part of the cost of the new hospital was met from closing a number of small hospitals and part was met from adjustments made to the revenue allocations of the Lothian and Borders health boards to reflect the fact that people are now treated locally. In addition, Borders health board stands to benefit from the different arrangements that we are gradually introducing for distributing funds to health boards—it is called moving to share parity and was mentioned by the hon. Member for Roxburgh and Berwickshire. However, even taking all those factors into account, Borders health board needed to adjust the pattern of its services to ensure that the new facilities of Borders general hospital were used most appropriately and that in the long term the resources required to operate them were generated by the board.
Another factor to be taken into account is the introduction of the internal market. With effect from this April, health boards, as the hon. Gentleman said, will become the purchasers of services for their community. Their task is to assess the health needs of the populations they serve and to arrange to meet those needs in the most effective—including cost-effective—way by contracting to 1160 purchase services from a variety of providers. With effect from April 1992, those contracts will be based on real money. Clearly, for this system to work properly, health boards need to have their incomes and expenditure in balance.
We have therefore told health boards generally that they should aim to have their incomes and expenditure in balance by the end of the 1991–92 financial year. This applies to all health boards and not just Borders. Health boards generally understand and accept the need for this and are working towards putting themselves in that position. Like all other health boards, Borders health board needs to do that.
All that is by way of background to explain that the board's proposals are not a sudden response to an unexpected crisis, but are the next logical step in a long-term pattern of adjustments to services to take into account what is required and what is now available.
Three principles underlie the proposals of Borders health board. The first is that its facilities should be used in the most appropriate fashion—in other words, Borders general hospital should not be used to provide long-stay care for the elderly.
Secondly, associated specialties should be located together so far as is possible. An example of that is the desirability of bringing psycho-geriatric assessment facilities into the Borders general hospital alongside the existing geriatric assessment facilities. Finally, it is also important that long-stay care facilities for the elderly and for psycho-geriatric patients should be provided as close as possible to the local communities. Borders health board has a long tradition in the field of mental handicap of providing local facilities rather than institutional care, and that needs to be continued and developed.
Therefore, the board proposes to create long-stay accommodation for psycho-geriatric patients in Kelso by upgrading Kelso cottage hospital and transferring general practitioner beds from there to the Inch hospital in Kelso. It also proposes to recreate long-stay accommodation for the elderly in Selkirk and Galashiels. This would fulfil the commitment that the board gave some time ago to reopen these facilities. It also provides an opportunity to transfer long-stay accommodation for the elderly from Borders general hospital, where it is inappropriately located, to local communities. This in turn offers an opportunity to use more effectively the accommodation at Borders general hospital.
The board has a variety of proposals in mind for this. First, it is considering transferring the psycho-geriatric assessment facilities, which are currently housed in poor-quality accommodation at Dingleton hospital, to the Borders general hospital. That would mean that all the board's geriatric and psycho-geriatric assessment facilities were located alongside one another. This is a much better pattern of provision and one which I think would be generally welcomed. The board is also considering an expansion of ophthalmology at Borders general hospital, which is one of its major priorities and which would consolidate and improve on the progress that the board has already made in reducing waiting lists for this specialty. To bring about these changes, the board plans capital investment at Kelso cottage hospital, at Inch hospital and probably also at Galashiels.
The board's consultation document rightly recognises that its role for the future is to assess the needs of its population and to purchase the best pattern of care to 1161 meet those needs. However, the facilities that the board secures for its population do not need to be owned or managed by the board itself. That is particularly true in the case of care for the elderly, where there is often a fairly even balance between the need for medical care and the need for social care.
Therefore, I welcome the fact that the board's consultation document proposes the establishment of local trusts in a variety of areas. The trusts would be voluntary bodies, which would operate under the terms of the Registered Nursing Homes Act 1938. The board would be responsible for registering and inspecting the facilities provided by the trusts and would by that means, and through the contracts which it would negotiate, be able to specify the standards of care which it requires and to monitor that they are being achieved in practice.
§ Mr. KirkwoodI am listening carefully to the Minister, and there is much substance in what he says. However, model trusts offering voluntary or private sector care will take a long time to set up, and the time to do that sensibly does not seem to be available.
§ Mr. ForsythAs I have said, that cannot be done out of the blue, but it will result from the strategic approach of the board. I know that the hon. Gentleman is keen to see that there is no disruption of services as a result of the changes. He should appreciate that all health boards are in the same position and that it is important for them to move towards the policy objectives. I would not agree to any changes because of financial imperatives if they resulted in a reduction in patient care which could be avoided if the matter were to be considered over a longer time.
I cannot give the hon. Gentleman an assurance that the Borders, any more than any other health board, will be off the hook. These matters are addressed to getting the best value for patients and the best patient care—something which the board has not made a lot of progress towards achieving. I hope that that will reassure the hon. Gentleman to some extent.
Before the hon. Gentleman intervened, I was discussing the establishment of the local trusts. I believe that the proposal will build on the wide range of voluntary and private sector facilities that already exist in the Borders, and have for some time. I hope that it will receive a positive response from the communities concerned.
The hon. Gentleman also asked about the timetable to which the board is working. The measures that it is proposing could have been taken some time ago. It is important that the board's income and expenditure are in balance by the end of 1991–92. It would be too early to conclude that it was beyond the capability of Borders health board to achieve that. However, once the consultation process is over, the board may conclude that some of its ideas require further consideration before they 1162 can be pursued, and others may take longer to determine than had previously been thought. The board needs to make an assessment of the alternative steps that it might take, at least in the short term, to ensure that it is living within its means.
I should be keen to ensure that my officials keep in close touch with the Borders health board, and continue to do so throughout the financial year. If problems arise, they would be ready to discuss them with the board. I know that the hon. Gentleman and the right hon. Member for Tweeddale, Ettrick and Lauderdale are assiduous in looking after the interests of their constituencies. I should be happy to receive representations about any constituency difficulties.
The board's proposals are not a panic response to a crisis, but a step along the road to implementing the board's long-term strategy for its services. There are many positive aspects to the board's proposals. Long-term geriatric care and psycho-geriatric care will be provided locally. It will be possible for geriatric and psycho-geriatric facilities to be located together at the Borders general hospital. That represents a major improvement in services. Furthermore, no closures are proposed.
§ Sir David SteelWill the Minister deal with my points about who will be running the trusts, and whether general practitioners are expected to do so?
§ Mr. ForsythIt would not be helpful for me to express a view on that, because the board will need to reach its own conclusion—the proposal has come from the board—and is still consulting. Although the board has not yet reached conclusions, I am sure that the general manager or the chairman of the board would be happy to discuss the matter with the right hon. Gentleman.
§ Mr. KirkwoodWill the Minister say a word about the use of Department of Social Security money? We are concerned that the use by health boards of income support to provide health care on the cheap for the elderly should not be done without proper consultation and discussion.
§ Mr. ForsythI noted the points made about the topping-up of provision through the DSS. I share the hon. Gentleman's concern and I should be happy to consider the matter in the future. It is important that resources are deployed in a cost-effective way that provides the best standard of care. Our proposals for community care, which will come fully into operation in 1993, will mean that assessment and financing will be in the hands of the local authorities, and the resources will be transferred from the DSS to deal with that. The right hon. Gentleman and the hon. Gentleman were pointing to an apparently anomalous position which is worthy of further consideration. I am happy to give an undertaking to give that consideration.