Hospital and Dental Services (Southampton) (Hansard, 7 May 1996)

§ Mr. John Denham (Southampton, Itchen)

I am grateful, at this late hour, for this debate, because in the past year a series of problems in the hospital and dental services in Southampton and South West Hampshire health authority area has caused mounting concern about the future of our local NHS. I cannot mention all the problems tonight but I hope that I can raise enough to make the Minister realise that they are not minor or isolated problems but are part of a pattern that is making people in Southampton ask where their health service is going. It is a pattern of cuts in vital services—a two-tier health service in which who pays for care is more important than how ill people are.

These examples are a case study of the problems inherent in the Government's management of the national health service. and especially in their health market. I shall deal briefly with the situation in the Southampton University Hospitals NHS trust and the Southampton and South West Hampshire health authority, and touch on the state of dental services in that health authority area.

I have three points at the outset. I am not trying to suggest that no one is treated well in the local hospital service or that no one is looked after or gets better in Southampton hospitals—of course many people receive a high standard of care every day—but I will say unambiguously that that quality of care is now under serious threat. I do not criticise the staff at any level. I have no doubt that all the people involved in the hospital services and the health authority are working as hard as they can, often against the odds and under considerable pressure. I recognise the openness with which the Southampton University Hospitals NHS trust and the health authority have responded to my inquiries and requests for information. It is perhaps true, in part, that that makes it easier to document the problems we face in Southampton, but that is no bad thing.

The background to the current problems is the trust's financial crisis. It faces an £11 million shortfall in the current financial year, but the financial pressures have been building for some time. I shall give some examples. Fred Woolley house, a much-loved national health service convalescent home, was closed for a period up to April this year to save money. It has been temporarily reopened, but the trust makes little secret of its desire to close it permanently. It fills a much-needed role in the local health service. It offers recuperative care, often for people who have undergone major traumatic surgery. It is a vital bridge between hospital care and a return to a life at home. There is a local campaign to save Fred's, and I give it my full support.

If that service goes, we all know what will happen. Some people will be discharged to their own homes too early, increasing the pressures on families and general practitioners. Some will, inevitably, return to hospital.

I visited the accident and emergency unit at the general hospital recently. Again, I was impressed by much of what I saw, but it was emphasised to me how many of the elderly people admitted as emergencies in late 143 December and January—at a time when such admissions hit the national headlines throughout the country—had been discharged from hospital prematurely.

The stress on GPs is building up. One local GP wrote to me this week: There is an overall increase in our workload, much of which is driven by the desire of the hospital trust to reduce its costs by passing work without accompanying resources to primary care. Needless to say, the financial crisis leaves resources and facilities unused. A ward in the Tom Rudd unit at Moorgreen hospital, which could be providing rehabilitative care, lies empty. Again, the result will be early readmissions to hospital, a new burden on families to care or admission to a residential care home with perhaps another home sold to pay the costs.

On 29 April, following a similar move last year, the health authority wrote to GPs further restricting their ability to make extra contractual referrals. Once again, the GP's ability to refer patients to the most appropriate provider of care has been restricted.

We hear a lot about funding for the national health service from the Government, but that letter from the health authority to GPs make it clear that The financial difficulties facing the NHS in the coming year are probably more severe than at any time since the reforms were implemented. Does the Minister agree with the health authority and that statement? If not, why does he think that it is wrong when that view is shared throughout the local health service?

The ability of the Southampton University Hospitals trust to meet the needs of children who need emergency care is also being restricted. As The Southern Daily Echo reported last December: Sick children needing emergency treatment are regularly diverted to hospitals in Poole and Portsmouth, while eight paediatric beds are lying empty and unused at the city's General Hospital. Apparently, children had been diverted to other hospitals at least twice a month from the beginning of that financial year. All too often, we have had reports of mothers and newly born babies being sent from hospital to hospital across the south in the search for intensive care cots.

Care of the terminally ill has been yet another cause for concern. Dr Roger Ryall, clinical director of cancer care for the trust, spoke of his fears when faced with demands to make a cut of £800,000 in his budget and, in particular, on the impact that that will have on the terminally ill. He is quoted as saying: If we are forced to make these cuts, what will happen is that we will be much less able to buy time for people. There are two categories of treatment—a lot of patients can be cured now and live a long time. We have to protect services for those people. Where we will not be able to give such a comprehensive service is for people for whom we buy time—patients who know from the day they arrive we cannot cure because it is too extensive. It is indeed alarming and appalling that senior clinicians are forced to talk publicly about reducing the level of care offered to the terminally ill.

Dr. Rya11's comments are those of one clinician faced with the impact of cuts on the services that he is trying to provide, but we can have little doubt that all his colleagues feel much the same about their areas of duty and responsibility.

144 At present, the trust is in the process of shedding the equivalent of more than 370 full-time jobs. The bulk of those will fall directly in areas of front-line patient care. More than 350 care staff will go from the clinical directorate, about 18 from hospital services such as pathology and one from management. Is that not depressingly familiar in a national health service that, since 1989, has had 50,000 fewer front-line staff and 18,000 more managers? Those running the trust and the health authority make it quite clear to me that the growth in administrative and management jobs is a direct result of the internal health market. The billing for care, the need to resolve disputes about bills that have been sent out and many other activities all eat into the resources available for front-line care.

At this point, the Minister may say that I have simply given a list of cuts, and that he hears this story all day, long. However, I want to emphasise not only the damaging nature of the cuts but what they mean for the way in which the health service in Southampton is being twisted and distorted to meet the needs and demands of the health market forced on to the health service locally.

On top of the impact of the cuts—alarming as they are—is the reinforcement of a symptom that has become all too common in the hospital service in Southampton. I refer to the development of a clear, unambiguous two-tier system—a service in which what care one receives and, in particular when one receives it, is governed not by how ill one is but by where one lives and who is paying for care. We witnessed that locally last year.

I am disappointed that he is not answering this debate, but the hon. Member for Winchester (Mr. Malone)—our local Health Minister, if I may call him that—was made well aware of one particular problem last October: the cancellation of non-urgent orthopaedic operations. He will remember being challenged by a Mr. Bridle when he visited Southampton last year. Mr. Bridle was just one of many patients whose expensive operations were put on hold. In that case, as in others, operations were prioritised, not according to clinical need but according to cost. That is just one example of cost pressures overruling clinical need.

From last October, routine gastroscopy services were withdrawn from the patients of non-fundholding GPs, although the services available to fundholding GPs were not similarly affected. Under recent contracts, heart patients living in Southampton face waits of up to twice as long for treatment at the city's general hospital as patients with the same condition in Portsmouth and Bournemouth. Bournemouth patients coming to Southampton face a maximum delay of four months; Portsmouth patients coming to Southampton face a maximum delay of six months; but Southampton patients in their own local hospital face a wait of up to nine months.

It is simply unfair and unjust that people with the same conditions and the same needs, whose wait for surgery imposes the same limits on their lives and activities, and who suffer the same fears and anxieties, wait for different lengths of time for the same treatment by the same doctors in the same wards of the same hospital. Why does this happen? It happens as a direct result of the workings of the internal market. These effects are not endemic across the country, but they are felt with particular force in 145 Southampton because of the very size of the Southampton University Hospitals trust in relation to the main purchasers.

The local health authority purchases only about half of the care provided by the Southampton hospitals. That means that when the major local hospital trust runs into financial problems, it turns to the health authority for assistance. That in turn means that all the burden of bailing out the hospital falls on one purchaser, and in particular on the patients whose care is being bought by the health authority. In effect, the trust looks to half its patients to carry the costs of all its financial problems. That is precisely what the Southampton University Hospitals trust has tried to do.

The trust has a shortfall of £11 million. It said that it would make £5 million worth of savings itself, and I have listed some of the consequences of the cuts involved. It then turned to the Southampton and South West Hampshire health authority with a request for the other £6 million.

The internal market means that smaller purchasers, fundholders, other health authorities and those with the greatest freedom to go elsewhere can continue to demand the higher level of service. The health authority is trapped. If it demands the same level of service for its patients as other purchasers, it can bankrupt the trust and close the hospital, but that "nuclear option" is clearly impossible. In practice, it could not find the £6 million that the trust was seeking. Instead, it had to settle for a second-rate service for its patients.

The health authority could not afford to bail out the hospital, so it had to agree to a reduction in the level of patient care. The health authority has agreed that waiting times should be allowed to double from the current maximum of nine months to a maximum of 18 months allowed by the patients charter. This applies only to health authority patients. As I have said, the health authority's waiting times are already longer than those of many other purchasers.

This decision has created a new type of patient in Southampton hospitals: the red star patient. There are 191,000 red star patients in the Southampton area who have their care paid for by the health authority. Admission staff and consultants have literally been told to stick a red star on their files. In relation to the red stars, a letter from the trust states: it would then be necessary to inform these patients in the clinic that they are effectively on the end of the waiting list. I ask the Minister a simple question: is this what the Government's health reforms were intended to create—191,000 red star patients at the end of the waiting list, regardless of their needs or their condition? I declare an interest in this regard: I do not have a fundholding general practitioner, nor do my children—we are at risk of becoming red star patients, at the end of the queue.

In my constituency, 14 practices became fundholders as a multi-fund this year. That is not surprising, given what is happening. I know that, for many, this was a least-worst option and an agonising decision. This does not solve the problem. The more doctors who choose this option, the greater the pressure on the health authority when the trust is in financial crisis and the greater the pressure to produce a two-tier service as the number of purchasers fragments further.

146 I ask the Minister: how can he justify to 191,000 people, including me and my children, that they should be sent to the back of the queue? I do not put the blame on the health authority—it has a wide range of responsibilities. As it has made clear, if it had not agreed to these changes, emergency and urgent treatment would have suffered. There are other pressures: on services for elderly people, for people with mental health problems and for people with learning disabilities. The problem lies with the Government and their approach to managing health care.

Similar problems are apparent in the dental service in the Southampton and South West Hampshire health authority area. I have already sent the Secretary of State a copy of the report recently published by the local community health council. However, I should like to take a few moments to highlight its main conclusions. More children suffer from serious dental decay in my constituency than in almost any other part of the country. Dental illness is a serious problem for them.

In fairness, I welcome the recent appointment of a salaried dentist to serve the city centre parts of my constituency. However, NHS dentistry is becoming more and more difficult to obtain in my constituency and in the wider health authority area. In some villages around Southampton, no NHS dental service is available. In Southampton, there is no dental practice able to accept NHS patients in Townhill Park. This is a direct consequence of the so-called knock-on effect. That practice has accepted NHS patients from Hedge End, outside the city, where there is no NHS service. However, this means that the practice has had to refuse new registrations from local people. As the number of NHS dentists reduces, so the scrabble to remain with the remaining practices intensifies. No emergency service is available in Bitterne, Bassett, Bitterne Manor, Bitterne Park and St. Denys.

Those who responded to the community health council expressed grave concern about dentists who require them to register as private patients to secure NHS care for their children. Many people who are receiving private dental treatment are doing so not from choice but because they are unable to find a local NHS dentist or to travel to their nearest NHS dentist. I have carried out two surveys of local dentists since I was elected. They confirm that more and more dentists are moving out of NHS care either entirely or with restrictions on their lists. Every time this happens, the pressures on the remaining NHS dentists grow.

I conclude by asking the Minister whether he recognises the growing pressures on NHS dentistry in my area. Does he accept that, in practice, a significant number of Southampton residents are unable to obtain NHS dental care? If he does, what does he intend to do about it?

The story of my local health service is now one of a service that is not available equally to everyone. That service does not offer care according to a person's need. It operates a hospital service according to which people wait longer if they have the wrong doctor or live in the wrong area. The local dental service is such that people may not be able to obtain NHS dentistry or will have to pay privately if their children are to get NHS care. I do not believe that the NHS in Southampton is safe in the Government's hands.

§ The Parliamentary Under-Secretary of State for Health (Mr. John Horam)

I am glad to have the opportunity to respond to the Adjournment debate of the hon. Member for Southampton, lichen (Mr. Denham).

First, I note that the hon. Gentleman acknowledged the excellent work done particularly by the Southampton University Hospitals NHS trust, working in partnership with local purchasers. The Government have honoured their manifesto pledge to increase health spending in real terms every year, and new spending plans announced in the Budget mean that total spending by the NHS in England has increased from £6.5 billion in 1978–79, to £34.7 billion this year. That is equivalent to a real-terms increase of 72 per cent. since 1978–79.

The hon. Gentleman will be aware of some of the implications of that funding for Southampton. For example, a new £10 million hospital development for elderly people was opened on the former Southampton Western hospital site in January. It will provide 104 beds. Secondly, three neurosurgical theatres are being built at Southampton General hospital, at cost of £6 million, and are due to open in the summer. Thirdly, that funding will allow for cardiac expansion, including extra ward and intensive care unit capacity at Southampton University Hospitals NHS trust, which will be ready in the autumn. Those three items of capital expenditure are being funded by the huge increase in the budget for the NHS.

At the end of last year, the vast majority of patients in Southampton—more than 98 per cent.—were seen within nine months, and only five people had been waiting for more than 12 months. The hon. Gentleman may be aware that the Southampton University Hospitals trust was the first university teaching trust in the United Kingdom to achieve the excellent nine month standard. I believe that the hon. Gentleman will agree that that achievement compares rather well with the patients charter standard of 18 months. Southampton is therefore succeeding in setting and achieving a much tighter and more challenging standard for its own population. Overall, general and acute sector episodes of care completed by the trust have increased by more than 20 per cent in the past three years—a quite remarkable achievement.

I acknowledge that that level of activity has caused some financial problems in the trust recently, but I am sure that the trust, the health authority and the NHS executive south and west regional office are currently discussing an agreed strategic approach to address that problem. It would therefore be inappropriate for me to comment in any detail on the issue now, but I understand that emergency and urgent work will be unaffected, although there may some slippage in waiting times as the financial problems are resolved.

The health authority will retain its standard of nine months' waiting time, but it recognises that it may have increasing difficulty in maintaining that standard. The health authority and the trust have a long and strong strategic relationship, and I am confident that they will be able to agree on a way forward.

Secondly, may I deal with the hon. Gentleman's points about two-tierism? As the internal market develops, fundholders are improving services for their patients and 148 others are following their example. Having a range of purchasers—health authorities and GP fundholders—stimulates innovation and critical consideration of service delivery to the benefit of all patients. Joint guidance issued by the Department of Health and the profession in June 1991 clearly states that hospitals should not offer contracts to one purchaser to the disadvantage of patients of another. All emergencies are seen immediately, and all urgent cases that cannot be seen immediately are placed on a common waiting list.

The amount of hospital activity purchased will always depend to some extent on the skill of the purchaser. All purchasers need to learn from that and ensure that they place equally good elective contracts on behalf of the patients of non-fundholding GPs. Inevitably, when driving up standards, some improve before others. Our aim is to bring the quality of all services up to the standard of the best.

Thirdly, the hon. Gentleman spoke about dentistry in Southampton. We have a good record, which is demonstrated by the figures, which speak for themselves. For example, expenditure on the general dental service between 1978–79 and 1994–95 has grown by nearly 60 per cent. in real terms. In 1994–95, courses of adult treatment had increased by 7.6 million from a similar figure for 1979, and there had been a 33.7 million increase in adult examinations in the same period.

I am aware that, in parts of the Southampton area, there are currently no NHS adult services for new patients. I have seen the recent Southampton and South West Hampshire community health council report on dental health services in the area, which the hon. Gentleman mentioned, and I do take it seriously. I understand that the health authority has already responded to that report, and I know that the hon. Gentleman has sent a copy to my right hon. Friend the Secretary of State for Health, who will reply to him in due course.

The hon. Gentleman may wish to know that 59 per cent. of the adult population of Hampshire are registered with an NHS dentist. That compares favourably with the national average, which is less than that—57 per cent. The health authority runs a very efficient dental helpline service to assist patients with access to NHS dentists and to help unregistered patients in an emergency.

As the hon. Gentleman acknowledged, the health authority has already appointed one salaried dentist, in November 1995, in Southampton. I would not pretend that that addresses the whole problem, but I understand that the health authority intends to apply to my Department for a further five salaried posts to cover the areas where there is at present no NHS cover. In addition, there is an emergency dental service based at Southampton general hospital. The service has been increased from two half-day sessions per weekend to full-time sessions at weekends and on bank holidays. I understand that those may be extended to some weekday evening sessions, so the problem is being tackled locally.

It would be incomplete of me to cover the changes that we are introducing in the general dental service without mentioning the reforms that my hon. Friend the Minister for Health announced last year. The hon. Gentleman mentioned him, so I may bring him into the debate as well. That was a comprehensive package of across-the-board reforms, the product of extensive study and wide consultation following on from the 1994 Green 149 Paper, "Improving NHS Dentistry". We are working on the reforms with representatives of the dental profession, and I believe that they will deliver concrete improvements in general dental services and help the NHS to tackle the oral health challenges ahead as well as providing stability and security for dentists.

150 All that will provide a strong framework in which the general dental service can continue to develop throughout the country—in Southampton and elsewhere.