§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Andrew MacKay.]
§ 8.3 pm
§ Mr. Eddie McGrady (South Down)I am grateful for the opportunity to raise in this Adjournment debate a matter of grave concern to my constituents—the provision of health and social services.
The Minister responsible sits in another place, but I am pleased that the Minister replying this evening has a deep knowledge of the subject, as he surrendered the portfolio only last spring. My constituents and I are concerned about an apparently concerted attack on hospital provision in South Down, which has two minor hospitals and one major hospital. One—the Gowan Herron hospital in Dromore—has already closed. The Mourne hospital in Kilkeel is about to be reduced to the status of a glorified general practitioners' clinic.
The centrepiece of hospital provision in South Down is the Downe group, and its future is of fundamental importance to the people of the Down and Mourne districts. I refer not only to the continued existence of proper hospital provision but to the quality of future services. While the debate must primarily proceed on medical and health grounds, there are strong and important undertones in respect of the entire district's economic and social future.
That debate has continued a long time. I remember attending public meetings and protests as long ago as 1966. The only criterion should be the proper provision of medical and health care, allied to a reasonable assessment of the cost of those facilities. It appears that decisions will be taken purely on a bookkeeping basis, financial restrictions, and cutbacks. The submissions of the Eastern health and social service board appear to be based solely on the financial shortfall of its budget for coming years. It lays the blame squarely on the Department of Health and Social Services, which is its funding authority.
It seems that the medical and health arguments follow financial dictums rather than the reverse being true. I remind the Minister that a delegation of councillors that visited the Department were assured that the Department had sole responsibility in this matter.
The question of hospital viability should revolve around clinical efficiency. A report produced two years ago by Professor Normand for the Eastern board found that the Downe group offered the highest order of clinical efficiency, and was the most efficient of all the hospital administered by the Eastern board—including the major teaching hospitals in the city of Belfast and its environs.
Over three decades, the board has denied proper capital investment in the Downe group, and there has been extreme penny-pinching in terms of personnel—presumably so that the group could be termed non-viable, because of the various restrictions imposed on it by the board.
Only last week, the Downe hospital made an application to the board for one junior doctor—which was refused. However, a number of appoints were made to the already fattened staff of junior doctors at the city hospitals. That illustrates an absence of pro rata provision as between Down and Belfast. Good luck to the people of Belfast, but justice and equity demands adequate, just and equitable funding and staff provision, in the Downe hospital group.
841 The Normand report was followed by an inquiry undertaken by an in-house project team. In April 1992, it categorically reported to the Eastern board that a new hospital should be built in the Downe group area, to replace the out-dated surgical and general unit there. I think that unit is about 170 years old. It is recommended that the new hospital should form an extension of the maternity hospital built and opened five or six years ago.
In June 1992, the Eastern health board published a document that has set health and social service provision on its head. The document, entitled "Framework for General (Acute) Services within the Eastern Health and Social Services Board Area", was published for so-called consultation. In July, I protested strongly, pointing out that no notice had been given to enable the House to debate that dramatic document, and that the consultation period coincided with the parliamentary recess and the summer vacation in Northern Ireland.
I should have thought that such a severe review of future hospital services would have been documented in depth. The board, however, has devoted a mere nine lines to the future of the Downe hospitals. I feel that the report pre-empted the consultative and research period by stating:
it is unlikely that the hospital would meet the future standards of clinical effectiveness required.That is entirely contrary to the board's own in-house review, and contradicts the statistics that were available. The board had undertaken no audit of the services before making its statement.When challenged, the board claimed that the Department had inserted that passage in its report. The Department denied it, saying, "It is the board's report." We now know that the passage was inserted by the Department, with the obvious intention of bringing about an early closure of the Downpatrick hospitals. I believe that there have been machinations involving the future of our health provision. None of it has anything to do with health; it is all to do with budgets, finance and short-term convenience.
I think that it was unfair and insulting to make such a statement. It was received with anger and hostility. In both medical and psychiatric care, the hospitals have often been at the forefront of advanced medical provision. They cater for 95 per cent. of presenting cases, and only 4 or 5 per cent. have to be transferred—as is proper—to the high-tech acute services that are available in some of the larger hospitals in Belfast. At this time of less intrusive surgery—microsurgery has now been provided in Downe—the argument should go the other way: such less intrusive methods should go out from the centre to the peripheral hospitals, rather than being brought to the centre. The same has been said about the London hospitals in the past week: the core has gone, so the periphery should be enhanced.
I believe that clinical effectiveness can be measured only by clinical outcomes. The board's own comparative performance indicators confirm that the acute medical and surgical wards in Downpatrick operate in an effective, efficient manner. The levels of outcome in acute medical and maternity wards in the Downe have outdone those of any of the other health board hospitals. The framework document, however, concentrates on inputs, failing to address the critical issue of outcomes, on a financial basis. The cost per patient admission is lower in the Downe than it is in any other acute hospital in the group.
842 As for medical and surgical expertise, the consultant surgeons currently employed in the Downe have a vast experience in a range of specialties: as I have said, they can deal with 95 per cent. of patient requirements, and they have reduced waiting lists to a level below the provincial average. It is interesting to note that all the major operations performed in the Downe hospitals are performed by consultant surgeons or consultant gynaecologists, and are attended by consultant anaesthetists. From a patient's first interview to the post-operative recovery stage, the patient is in the hands of a consultant; he is not dealt with by junior staff, as would happen in the larger hospitals in the cities. Such procedure is in accordance with the recommendations of the confidential inquiry into perioperative deaths—known as CEPOD—which provides the guidelines for conditions of operation.
Clinical effective indicators also show that, at all levels of staff, there is greater efficiency—whether those treated are in-patients, out-patients or day patients. The Downe group has performed very creditably.
The maternity hospital is threatened with closure. Since the opening of the Downpatrick maternity unit, there has been a substantial decrease in the perinatal mortality rate, which is lower than the Northern Ireland average. The Minister will know that the Northern Ireland average is itself much higher than that in any other part of the United Kingdom. I fear that the closure of the maternity hospital, which managed to bridge the gap, would lead to an upsurge in perinatal deaths.
Four years ago, we were told that, to be viable, a maternity unit must have a throughput of 1,000 babies a year. One would almost think that the subject of discussion was a cattle market. This year, we are told that the throughput must be 2,000 a year, and that that is required by the Royal College of Obstetricians and Gynaecologists. I am extremely suspicious of such dutch auctions. I wrote to the royal college asking, "Is big beautiful? What about the smaller units?"
In a letter dated 14 September, the college replied:
It is appreciated that it is difficult to provide such cover for Units delivering less than 1,000 babies a year and this the case in over 30 per cent. of Northern Ireland Maternity Units. Indeed, about 90 per cent. of these deliver less than 2,000 babies per year. For … very small … Units, special local arrangements are usually made within the principles of HSS A5885/91. This may often include the development of Team Midwifery … Teams consisting of midwives, GPs and Consultants. Such Teams, when carefully developed, may make possible the safe continuing use of small Units provided there is good co-operation across the Team and adequate emergency services.I believe that that letter belies the department's selective interpretation of the position of maternity services. What the letter says is required is exactly what is happening in Downpatrick.One of the arguments for the retention and rebuilding of the Downe hospital concerns accessibility and population. We are very much aware in our area that the population of 70,000 increases during the summer months to between 120,000 and 150,000, with the addition of day trippers. It is a highly successful tourist area, because of the proximity of the Mourne mountains. The mountains themselves lead to medical services being needed at certain times of the year.
Accessibility, travelling distances and the geography of the area make it important for us to have rapid and easy access to acute hospital services. The area has no railway services and a very inadequate and inferior road transport 843 system. If one looks at the social indicators, one sees that there is a very low level of private car ownership. Against that background, I suggest that accessibility is one of the major factors that demands that the Department should make provision for a new building programme in the area.
The patients charter tells us that patients have the right to choose where and how they should be treated. The people of this area have made a clear choice. On 12 September 1992, 20,000 people marched through the streets of Downpatrick and demonstrated their choice under the patients charter. I doubt whether the Department has taken any notice whatsoever of their views. The march was the culmination of about 15 rallies in various villages and hamlets throughout July and August. It was a massive demonstration of what people wanted. They made their choice with their feet and their petitions to the Department. Unless the Department is only paying lip service to those petitions and is ignoring all these people, it must do something about it.
The report of the board's project team stated clearly that, for a relatively modest sum of money—modest in terms of hospital building—proper new acute and modern facilities could be provided at the Downshire site in Downpatrick, and that they could be attached to and have a dual-purpose use with the maternity hospital. It is now within the competence of the Department to say to the people of South Down, "We have noted what you say. We note your cost-effectiveness, your efficiency and the need for accessibility. We note also that you have been given undertakings three times which have not been fulfilled."
I end by quoting from the Royal Commission on the national health service, which I quoted on another occasion. It is a somewhat ancient report, dated 1979, but it is still relevant today. It stated:
A fundamental principle of the national health service must be an equality of provision, so far as this can be achieved without an acceptable sacrifice of standards.I believe that that dictum can be fulfilled on this occasion. The report also said:If inflexibility is to be avoided, health authorities should implement national policy in the context of their particular geographical and demographic constraints.Those two extracts from the Royal Commission's report are a good summary of what I have tried to say to the Minister and the Department tonight.I hope that the Minister will provide hope of some succour for the people who are so distressed and worried not just for themselves but for future generations in the area of Downe and Mourne. I hope that he will also bear in mind that it would be economically disastrous and socially devastating if the Downpatrick complex of hospitals were to be closed.
The Parliamentary Under-Secretary of State for Northern Ireland (Mr. Jeremy Hanky)I thank the hon. Member for South Down (Mr. McGrady) for setting out in his usual clear, cogent and reasonable manner the concerns which he shares with many of his constituents over the future of hospital services in the Downpatrick area. It is another example of the time and effort which he devotes to safeguarding the interest of the people whom he represents.
844 The hon. Gentleman—I find it difficult at times, Mr. Deputy Speaker, not to call him my hon. Friend—is of course aware that ministerial responsibility, as he stated at the beginning of his speech, for health and social services, in Northern Ireland rests with my noble Friend Lord Arran, who, I know, is taking a keen interest in the debate. I must, however, declare at the outset more than a personal interest in the matter, having had the honour for 16 months of being charged with responsibility for health in the Province.
During that time, I became aware of the strengths of the services in the Province, and of the ways in which it might be possible to strengthen them still further within available resources. The hon. Member will therefore, I am sure, forgive me if I respond initially to his points by setting out some of the issues which I feel must be addressed if the quality of hospital services in Northern Ireland is to be maintained and, indeed, improved.
A great deal of work has gone into looking at ways in which this might be achieved. Last November, when I was the Minister at the Department of Health and Social Services, we published a regional strategy for the years 1992 to 1997, one of the central themes of which was to improve the use and quality of acute hospital services. The strategy expressed a number of aims, but I think the two most relevant to our discussion this evening—both of which, may I say, my noble Friend Lord Arran and I wholly support—are, first, that specialised hospital services should be concentrated on a smaller number of strategically placed sites, accompanied where appropriate by supporting services locally; and secondly, that there should be a substantial shift from in-patient to day and out-patient investigation and treatment.
Those are sensible aspirations which reflect the public's demand for the increasingly sophisticated and technically advanced services which lead to more effective treatment, shorter stays in hospital and better outcomes for patients. Less invasive surgery is in the interests of patients. I have often talked about the fact that many patients have to spend a considerable time in hospital recovering from the wound of the operation, let alone from what is going on inside them. Less invasive techniques mean that people have to spend less time in hospital. That must be desirable for us all.
However, I am under no illusions as to the difficulty of pursuing these aims, and, more important, the sensitivity and care that must go into achieving them. Hospitals are institutions which are particularly cherished by local communities. There is an understandable tendency for people to take the view that, while health boards or Ministers may say that, overall, people will receive a better standard of care if certain hospital services are provided at certain sites, nevertheless local hospitals must remain and, if anything, be developed further. We must balance those views against the need to achieve the best possible service for the greatest number of people within the resources placed at our disposal.
Perhaps I could put that last remark in perspective. In Northern Ireland, there are over 20 health service hospitals providing general acute services for a population of about 1.5 million. They range from large teaching hospitals such as the Royal Victoria hospital, with over 900 beds and more than 5,000 staff, to smaller hospitals such as the Route in Ballymoney, which has around 60 beds and 300 staff. The Downe hospital lies towards the latter end of this wide spectrum, having just over 100 beds providing 845 services in general and geriatric medicine and general surgery, with a further 24 obstetric beds provided in the grounds of the Downshire psychiatric hospital.
The cost of those services is considerable. This year, more than £1,240 million will be spent on health and social services in Northern Ireland—an increase of more than £70 million compared with last year—and of that total, the Eastern health and social services board will spend about £470 million.
Given the scale of that expenditure, I am sure that no hon. Member would disagree that it is the clear responsibility of all those involved in planning and securing services to ensure that maximum value for money is achieved at all times. Every penny saved that was wasteful expenditure will go back into patient care. The health and social services boards, holding their new responsibilities as purchasers of services, have a major role to play.
In that context, I was pleased to learn of the publication on 11 June of the eastern health and social services board's consultative document on the framework for acute hospital services in its area, to which the hon. Gentleman referred. The document was not influenced by the Department; it was a matter for the board itself.
I know that the document has failed to find favour with the hon. Gentleman, but nevertheless, as the major purchaser in Northern Ireland of acute hospital services, the Eastern board must of necessity formulate a strategy for the future. I believe that its consultative document represents a constructive step towards achieving that goal.
The document explains why the existing pattern of hospital services needs to change to keep pace with modern developments and shows that, if performance in the main acute specialties in Northern Ireland were to improve to the same levels as in some English regions and some Ulster hospitals, overall bed numbers in the board could fall by more than 700, while the number of patients being treated could increase. That is very much in line with the thrust of the regional strategy of the DHSS, and it is an aim that I fully endorse.
It would be irresponsible to register such an aim without making it clear what needs to be done to achieve it. The Eastern board has done so in its document by outlining the standards that need to be met in hospitals that wish to provide acute services for the board in future. The board has been very helpful by assessing in its document the extent to which hospitals in its area meet the criteria that it has set down.
Some might not agree with that statement—I believe that the hon. Member for South Down might number among them—but only a few weeks ago, on 20 August, the hon. Gentleman met my noble Friend Lord Arran and expressed his dissatisfaction with the board's consultative document in general and with the section dealing with Downe hospital in particular. Such was his right. Last March, I well remember him expressing concern about Downe hospital in a meeting with me.
846 When he met my noble Friend Lord Arran, the hon. Gentleman made it clear that he found the section in the Eastern board's document relating to Downe hospital exceptionable, particularly in its references to the clinical effectiveness of the hospital. I have read the section, and it is quite clear that Downe hospital was assessed in the same way and by the same criteria as other hospitals in the eastern board.
I remind the hon. Member that the document published by the Eastern board in June was issued for consultation and does not represent the final views of the board on the future pattern of acute hospital services in its area. The consultation period ended on 30 September, and I have no doubt that a great many of the hon. Member's constituents have made their views known to the board. I know that they have argued the very point that he has aired so ably on their behalf this evening.
It is now up to the board, on the basis of the outline that it provided in the document and of the comments that it received from people and organisations interested in this matter—I can assure the House that it received many—to put together its statement of purchasing intent, which will give a clear sign of the sources from which it expects to purchase services from 1994–95 onwards.
The hon. Member will, I am sure, be particularly interested in seeing that document. I know that my noble Friend Lord Arran has pressed, and will continue to press, for its early completion and has received assurances from the chairman of the board, Mr. Norman Ferguson, that it will be made available as soon as possible—hopefully, early in January.
Finally, I confirm that any proposals for closure or change of use of facilities by the Eastern board stemming from its consultative framework document and the consultation process, whether they relate to Downe or any other hospital in the eastern area, if they are of a major controversial nature—I assure the hon. Gentleman that this would be so—be agreed by my noble Friend Lord Arran before they can proceed.
My noble Friend has confirmed that he will maintain the closest possible interest in the outcome of the Eastern board's consultation and will, in considering any issue that requires his agreement, take full account of the views of those affected by the proposals. He will endeavour, if possible, to meet them and their representatives to listen to what they have to say before taking a final decision.
I thank the hon. Member for South Down for his speech, which I am sure will be used for definitive reference in the months ahead. He has served his constituents not only honourably but effectively, as I know he does on so many matters. I know that we shall hear from him again on this issue, and I assure him that we shall listen to what he and his constituents have to say.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-four minutes to Nine o'clock.