§ Ms Tessa Jowell (Dulwich)I am grateful for the opportunity today to speak about the situation in London's hospitals. We have two contradictory views of reality— that of the Secretary of State for Health and everyone else's. The Secretary of State tells increasingly bewildered and angry Londoners that all is splendid in the national health service; another version is played out, day by day, in the casualty and acute wards of London's hospitals.
I received a letter yesterday from a constituent who is a consultant at Bart's—the hospital which the Secretary of State seems to have a particular mission to close. His letter was written on Wednesday of this week. He says:
You may be interested to know that the situation here today has been chaotic. There have been two patients waiting in casualty since Monday afternoon, that is for 40 hours, for beds to become available in the hospital. A further 11 patients were in casualty overnight as there were no beds available for admission to the hospital, and therefore 13 of the 16 casualty trolleys and cubicles were occupied prior to the working day commencing. In fact I visited the department and, as you can imagine, the situation is chaotic. Accident and emergency or casualty departments are not adequately staffed or in fact geared to having in-patients as there are no facilities for this. With regard to hospital admissions today, five out of 10 admissions have had to be cancelled for elective surgery. This includes two of my patients with gynaecological cancer.Is that what the Secretary of State means about making London better?1412 Last night I visited four of the major casualty departments in London, and another this morning—five in all. At none of those hospitals—the Whittington, Bart's, St. Thomas's and King's—were any beds available. At King's, 16 patients were waiting to be admitted to the hospital and being nursed or cared for on trolleys. At Bart's a man who was clearly very ill arrived. The hospital had no trolleys and had to throw a mattress on the floor in order to treat him. Every hospital repeats the same story. When I asked the staff, "Has it got worse?" the unanimous answer from every nurse and doctor was, "Yes, it has got worse —much much worse."
What is needed to make it better? The answer is simple. More beds—so that hospitals can admit patients who need to be admitted. It is an irreconcilable contradiction that we have hospitals in London that can perform transplant surgery and give the hope of life to people who, even five years ago, would have been regarded as terminally ill—treatments that are more complex, more advanced than in almost any other part of the western world—yet we cannot guarantee that our hospitals can find a bed in order to admit an elderly lady with a broken arm, who needs to go into hospital only because there is no one at home to look after her.
For patients who wait on trolleys for admission to hospital in the middle of the night, their only hope of being admitted before the following morning—when other patients are discharged—is by filling beds left empty by patients who have died during the night. London hospitals regularly start the night with no empty beds.
None of that chaos has come about by chance; it is the predictable outcome of the Government's being hoodwinked by their own rhetoric—the rhetoric that says that London has too many hospital beds and that market forces will now do what successive Governments, and 20 inquiries into the state of London's hospitals, have so far failed to do. The situation that is now unfolding is entirely the result of Government policy, although the Government are now distancing themselves from it.
Let the Secretary of State tell the people to whom I spoke last night—nurses working in the casualty departments of London hospitals, consultants and the relatives of patients—that London has too many hospital beds. The Government are alone in believing that, when waiting lists lengthen, the answer is to cut the number of beds. That remedy will make matters even worse.
Moreover, Ministers do not even seem to know how many beds, consultants and staff are available, what the waiting times are for each unit and how many beds at any one time are "blocked"—which is the rather unpleasant term used when patients are waiting to be discharged, but are unable to leave the hospital. That information is not held centrally, although it is essential for Ministers to have it if they are to deal with the turmoil that they have created.
What, then, is the actual number of hospital beds in London, and how has the position changed in recent years? In 1986, London had nearly 50,000 acute beds; by 1991 —the most recent year for which figures seem to be available—the number had fallen to 36,000, a reduction of more than 14,000. In the rest of the country—comparisons are constantly made with the rest of the country—the rate of closure was 80 beds per million people per year. In London, the rate has been three times as high: 240 beds for every million people close every year. That, too, is a direct result of Government policy, through the operation of the internal market.
1413 In his report following the inquiry into London hospitals commissioned by Ministers, Sir Bernard Tomlinson estimated that London needed to lose 2,500 beds. It is not clear where that calculation came from, what was the start date for the closure programme or, indeed, whether that figure has long since been exceeded—which the statistics suggest is very likely. Even Sir Bernard offered a cautionary note, stating:
We do not make anywhere in the report the statement that there must be an immediate reduction in beds. We believe there have to be planned reductions in beds to go along with the other changes we have supported.He offered the following warning:It will be essential that adequate transitional funding be provided to ensure that service changes take place in an orderly fashion. The level of such funding will to a large extent dictate the pace of change. Change that is not managed and funded in this way is likely to be chaotic, and will do serious damage to London's health services, and to its medical research and teaching.Given what Londoners now confront daily in their hospitals, Sir Bernard's remarks were prophetic. There is nothing planned about the random, chaotic and disruptive closures that are now taking place.Rigorous and systematic research has been carried out on the required level of hospital beds in London. In April this year, Professor Jarman, of St. Mary's hospital medical school, published an article in the British Medical Journal. He concluded:
Hospital admission rates for acute geriatric services for London residents were very similar to the national values in all age groups.In inner London, acute services showed an admission rate at 22 per cent. above the average value—or the average rate —for the rest of England.However, the admission rate of inner deprived Londoners was 9 per cent. below that of comparable areas outside London. For psychiatry, admission rates in London roughly equalled those in comparable areas. When special health authorities were excluded"—SHAs will, incidentally, join the market next April—in 1990-91 there were 4 per cent. more acute plus geriatric beds available per resident in London than in England. Bed provision has been reduced more rapidly in London than nationally. Extrapolating the trend of bed closures forward indicates that beds (all and acute) per resident in London are now at about the national average. Data from the Emergency Bed Service indicate that the pressure on available hospital beds in London has been increasing since 1985.Information from the Emergency Bed Service, which compels emergency admission to hospital by some means or another when hospitals say that they have no beds and cannot admit seriously ill people, is generally regarded as one of the best tests of the adequacy of hospital bed provision in London. Since 1985, the number of admissions of seriously ill people through the service—people who have had to be "refereed" into hospital—has risen threefold.
According to Professor Jarman,
Data regarding bed provision and utilisation for all specialties by London residents do not provide a case for reducing the total hospital bed stock in London at a rate faster than elsewhere. Bed closures should take account of London's relatively poorer social and primary health care circumstances, longer hospital waiting lists, poorer provision of residential homes, and the evidence from the Emergency Bed Service … higher average costs in London, some unavoidable, are forcing hospital beds to be closed at a faster rate in London than nationally.1414 In the light of the research evidence provided by Professor Jarman and his colleagues, and the daily experience of the Emergency Bed Service and London hospitals, I shall be interested to hear how the Minister will continue to sustain the case that London has too many hospital beds—given that waiting lists have lengthened, and the number of people waiting for more than two years for treatment has grown.
Waiting lists in London increased by a staggering 19.3 per cent. between June 1992 and August 1993. Within that average for the four Thames regions, there is a disturbing variation from 30.7 per cent. in North East Thames to 4.2 per cent. in South East Thames, with nearly 27,000 patients waiting more than a year for treatment at August 1993.
London's complex problem is made worse by the fact that six out of 10 hospital beds are occupied by elderly people over 65. The difficult relationship between acute care and community care in London must be understood, especially as two policies are heading for a collision. The loss of capacity to care for elderly people in hospital has not been matched by replacement facilities, or continuing care beds, as they are called, in the community—quite the reverse.
The health service has withdrawn, almost wholesale, from long-term care for the elderly. All that care—or virtually all—is now in the private sector, provided by private nursing and residential care homes. Many of my elderly constituents want to be looked after in the part of London in which they grew up and where they have always lived, but the nursing and residential care homes that they need do not exist in Southwark. For them, going into a residential nursing home means moving to Clacton, Bexhill or Eastbourne, many miles from their families and from what has always been their home. National comparisons shows that London has been specifically disadvantaged in that respect. In the rest of the country, about 12 beds are available for every 1,000 people, whereas in London the figure is little more than nine.
The way in' which the Government chose to distribute the community care money last year—the special transitional grant—further disadvantaged London. My constituents lost close to £1 million because the Government chose to place the money where the homes rather than the elderly people and the needs were. That combined formula advantaged the parts of the country with large numbers of residential homes, but disadvantaged areas such as inner London where, for obvious reasons, the number of residential homes is very small. The crisis facing London's hospitals cannot, therefore, be separated from the crisis in community care
A consultant at one of the teaching hospitals told me recently that one needs to be very fit if one is leaving hospital at 85 and living in Southwark, Lewisham, Lambeth or any other part of our deprived inner city. The pressure on beds means that many elderly people are not fit when they leave hospital which is why the readmission rates are so disturbingly high. Elderly people may return to poor accommodation. They may live in poverty on a low and inadequate income, having to make daily choices between keeping warm and having enough to eat, and not have the support of relatives.
At King's yesterday, about 68 beds were occupied by people who were regarded as medically fit, but who were unable to leave the hospital because the community care that they needed was not available. Elderly people are often without the support and care at home which would enable 1415 them to cope for very long if they left hospital. They therefore stay in hospital in beds which would otherwise be available for other people and so exacerbate the crisis.
Before the Minister leaps to blame local authorities, let me remind him that the Government cannot follow their ideology and have good, working community care. One of the problems has been the straitjacket placed on local authorities in arranging their community care. They are required to spend about 85 per cent. of the money transferred by central Government in the independent sector, so their freedom to arrange what they regard as the best and most appropriate form of care is fettered by a purely ideological stricture placed on them by central Government.
All the headlines that we see almost daily in central London could have been foreseen. We have a lethal combination of the Tomlinson proposals laced with the rather contradictory recommendations of the specialty reviews and topped up with the internal market. The result is chaos, a chaos that keeps the Secretary of State away from the Dispatch Box and out of Marks and Spencer at times when shoppers would be there to confront her.
Sir Bernard Tomlinson said:
It would be quite disastrous to let hospitals simply be destroyed piecemeal by market forces. If you are going to have to remove a hospital it has to be done in a planned way over a considerable period of time.That was his commentary on the aftermath of the impact of his proposals, the Government's reaction and the specialty reviews, his reaction to the chaos that he predicted when his report was published. It is time to ask whether Ministers listen to the advice that they receive or only to take account of what they want to hear.The King's Fund also established a commission to examine the future of London hospitals. It was similarly concerned about the chaos that is now ensuing. At the end of October, its chief executive, Robert Maxwell, wrote in a letter to The Times:
It is now increasingly urgent that ministers announce their main decisions on the London hospitals, in the light of the specialty reviews published in June.We were promised statements before the end of the year. The written answer that passed for a statement earlier this week scarcely fits the bill.Robert Maxwell goes on to say that if we are to sort out the problems that have ensued, money must be made available to fund agreed capital and other expenditure, to enable all the changes to happen. He finishes by saying:
any business that was undertaking changes on a scale remotely resembling that of the changes that are proposed for the London hospital service would recognise that it simply has to spend more money to bring about the changes and it has to convince its customers and its staff that it knows what it is doing.This week, the Secretary of State acted by putting her finger in the dyke and stopped University College hospital from going to the wall. In the same breath, however, she announced that Bart's accident and emergency department is to close. The Secretary of State claimed that the statement would bring an end to uncertainty in the health service in that part of London—the statement relating only to north and east London. When will the Secretary of State make a statement in the House of Commons that will end the uncertainty for Londoners throughout London and provide the stability that health services in London so desperately need?
1416 It is interesting that when the Camden and Islington health authority put its purchasing plans in relation to UCH out to public consultation, not a single person replied in support of its proposals.
Let us compare two conflicting situations. When it appeared that the internal market would close UCH down after the threatened withdrawal of contracts by the Camden and Islington health authority, because it said that it could find cheaper treatment elsewhere, Ministers intervened. Contrast that with the situation in Dulwich that faces my constituents and hundreds of constituents of other hon. Members, where the renal unit at King's is threatened by the recommendations of the specialty review, not because it is not to use the Government's terms, "commercially successful", but because it is in the wrong place, according to the cursory appraisal of the renal specialty review.
Staff working in the renal unit were informed of the likely outcome for south London's renal services before the review team had made any visit or taken any evidence. The provisional decision to move the unit to St. George's hospital has been taken, therefore, without what, locally, is felt to be any recognition of the excellent service offered at King's, Dulwich. It is not a line with which the patients of the kidney unit at Dulwich agree. The patients have raised about £1 million for the refurbishment of the kidney unit; they know what an excellent service they receive. They have a sense of security, knowing that the unit provides dialysis as well as transplant where necessary. They are people who are chronically ill, many of whom have moved to be near the hospital. It is their lifeline. The proposal to move the unit tampers with the rawest feelings and anxieties in those patients' lives. Tampered with is what those patients feel. On Monday, I shall go with a deputation of patients and staff to Downing street with their petition, asking the Prime Minister to listen; asking the Prime Minister to be persuaded by the 25,000 signatures asking that the successful renal unit be allowed to remain at King's.
There is a [...]road consensus about the need to improve health care for Londonders. However, the need to reduce the number of beds further is completely unproven and indeed, as I have already indicated, is refuted by the available systematic evidence. Hon. Members on both sides of the House will accept that there is a crying need for the standard of primary care in London to be improved. Virtually nothing has been achieved in the 11 years since the Aitchison report, which was specifically about standards of primary care in London, was published.
It is not a simple equation, however, that improvements in primary care lead eventually and inexorably to a reduced demand for hospital places. Improved primary and community services would mean that patients who are in King's and other London hospitals waiting for discharge, would be able to leave, but the evidence rather contradicts the declining need for hospital beds; it suggests that better primary care means that people go to their doctors earlier and are treated earlier, and that the demand on hospital services actually increases.
Secondly, we do not know to what extent the particularly deprived conditions in inner London will act as a brake on demands on hospital services. The extent to which the work done in hospitals can be done as safely and effectively in the community remains to be seen.
The impact of new medical technologies is also uncertain, but I hope that the Government will maintain an open mind. I hope that they will look at the evidence, first, 1417 that better primary care increases demand instead of reducing it and, secondly, that there is no certainty that the number of beds in London can be reduced further, and especially not reduced in anticipation of those long-heralded improvements in primary care.
There is also evidence, from the purchasing authority in my part of south-east London, that about 30 per cent. of the Tomlinson money that is being made available is being used simply to keep existing services going.
In conclusion, I shall leave some important questions with the Minister. The Government are devoted to the market as their means for distributing health care. The market will always choose the cheapest treatment, but there is no equivalence between the cheapest care and the best care.
What guarantees and monitors will there be of the quality of the contracts that are now being taken up by hospitals outside London which were previously placed with the specialist hospitals? What guarantee will the Minister offer patients, whose care is transferred to those hospitals, that their chances of recovery, their life expectancy and the quality of treatment that they receive will not in any way be compromised as a result of the change?
Is it true that the rate of success of heart bypass operations at Bart's is better than anywhere else? If so, is that successful unit to close? If so, what similar guarantees of excellence will the Minister offer patients whose treatment is transferred elsewhere? What guarantees will the Minister offer to parents whose babies are delivered very prematurely and do not go to a highly specilised neonatal unit, but to a special-care baby unit in their own areas?
Quality of care means people get better. What auditing of quality will Ministers undertake? Are the Government really set on making London better or are they simply set on making London's health service cheaper? Are they really concerned to provide a health service which everyone in London will use or is London's health service to become a service only for the poor and those who have no choice?
I will finish the words of a member of staff in an accident and emergency unit that I visited last night. When she looked at the line of people waiting on trolleys that were touching each other, she said, "I just don't know what I'd do if one of those people was my mother." Are those the kind of standards that the Government believe are fair and proper to apply to the health care of everyone who lives in London and uses London's health service?
§ The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville)I congratulate the hon. Member for Dulwich (Ms Jowell) on raising the subject. In particular, I commend her for her visits to various hospitals yesterday. I should like to comment generally on her points. If she will excuse me, I will consider the possibility of responding to her in writing on same of the specifics. However, I have a few minutes in which to comment on the points that she has raised.
As the hon. Lady is aware, the Tomlinson report is one of many reports that have identified the number of hospitals in London and the number of sites on which 1418 acute services are delivered. The Tomlinson report stated that there is, and will continue to be, over capacity in London in many specialties. That is a difficult situation and one which Health Ministers have faced for a long time. However, when the hon. Lady said that my right hon. Friend the Secretary of State for Health had a particular mission to close Bart's, she does my right hon. Friend an injustice.
If the hon. Member for Dulwich believes that my right hon. Friend the Secretary of State enjoys having to recommend the reduction of acute services in some hospitals and the concentration on to fewer sites, with all the worry and disruption which that would cause potentially—and certainly worry in the short term in many people's minds—the hon. Lady seriously misjudges her.
The problem is very difficult and it must be handled with great care. That is precisely what my right hon. Friend the Secretary of State is doing. The hon. Lady will be aware that a great deal of time has already elapsed since the publication of the Tomlinson report. We have been extremely careful to assess all the possibilities. Many learned people from London and elsewhere have put together the reviews of different specialties and all the options so that we do not rush into decisions which we will regret later.
The hon. Member for Dulwich referred to accident and emergency units because she has visited them. I am aware that there are problems with some A and E units. I am aware of the current problems with regard to emergency admissions not just in London, but all over the country. For many reasons, including this winter's flu epidemic, emergency admissions have risen sharply and that is placing extreme pressure on A and E units and other hospital departments.
I remind the hon. Member for Dulwich that there are a number of major schemes in London to upgrade A and E departments. The hon. Lady will be aware of the scheme at King's in her constituency. She will also be aware of the £25 million development at the Homerton which involves considerable upgrading of A and E facilities. She will also be aware of proposals—not yet confirmed—to make improvements at the Whittington which she also visited last night. We are aware of the increasing demand and of why, for a whole series of reasons not all of which can be addressed quickly or in the short term, we need better and upgraded A and E facilities in London and elsewhere.
The hon. Member for Dulwich referred to the argument about numbers of beds. That is a long-term view of what will be needed in the years to come in respect of acute beds. While we may argue about different hospitals and numbers at different places, I remind the hon. Lady that there are certain fundamentals that mean that we will need fewer acute beds. Those fundamentals include the fact that developments are being made——
§ Mr. Nick Raynsford (Greenwich)Will the Minister give way?
§ Mr. SackvilleI do not have time to give way if I am to make a sensible response.
Provision is being made outside London for many specialties where previously it was necessary for people to travel to London. An example of that is the very impressive oncology centre in Maidstone. Many local people in the area who would otherwise have been treated in London, will now be treated near their homes. The hon. Lady might 1419 like to visit that facility to put the problem in perspective. She might like to talk to the staff there and discover what they are achieving. That facility will have an effect on provision in south-east London.
The increase in day surgery is another enormous factor. The hon. Lady will be aware that day surgery accounts for about 25 per cent. of operations in this country. That figure is heading towards 50 per cent. in America. I have opened many day surgery units around the country over the past year and a half. Day surgery will have an enormous effect on demand for in-patient acute beds.
It is absolutely right that, where possible, people should be treated within a day and then return to their own homes. There is nothing to be gained by unnecessary stays in hospital. There have been enormous advances in the efficient use of theatres and in-patient surgical beds. That is also having an effect on future demand. We must consider a 10 or 20-year period when deciding the real need in future. Therefore, we must take all those trends into account in our current plans.
As the hon. Lady is aware, there has also been a decline in the population of parts of inner London as there has been in most of our inner cities. That must have an effect on hospital provision. As people move out to the suburbs or other areas, they will quite rightly want to be treated close to where they live.
The hon. Lady said that the Government are alone in the view that we must make these changes. We are not. The King's Fund report is very clear and, in many ways, is even more radical than the Tomlinson report in its view of future provision. The main burden of the letter that the hon. Lady read out was that we had to get on and take decisions. The recent announcement by my right hon. Friend the Secretary of State was the first of such announcements which must be made about our response to the Tomlinson inquiry.
Many professionals in London and elsewhere are acutely aware of the enormous subsidy to London health care from the rest of the country. They are aware of how much of the funding of the national health service is spent in London. We have to try to restore the balance to some degree.
Yesterday, an article in a national newspaper said:
No one likes shutting hospitals, but 20 reports going back 100 years have documented the surplus supply of hospital beds in London … inner London has 70 per cent. more beds than the national average and twice as many consultants. Closures have not kept pace with the falling population … yesterday's decision"—it was made earlier this week—makes sense.That was not The Daily Telegraph or The Times—it was certainly not the Evening Standard—it was The Guardian.