§ Motion made, and Question proposed, That this House do now adjourn.— [Mr. Wells.]9.34 am
§ Mr. Roy Beggs (East Antrim)
I appreciate the opportunity provided by this Adjournment debate to focus on hospital provision in Northern Ireland. Many of my colleagues wish to catch your eye, Madam Speaker, and you will be as relieved as the Minister to learn that I do not intend to prevent him from having reasonable time to respond.
Everyone in Northern Ireland can expect to use the hospital services available to us at some time or other. We are all concerned to maintain the excellence of our hospital provision. In 1998, the national health service in Northern Ireland will be 50 years old. It came into being under a Unionist Government, which was committed in the post-war era to the improvement of social welfare. My colleagues and I welcome the commitment given by the Government to increase expenditure on the health of the nation year on year, and would welcome a similar announcement from the Opposition to ensure appropriate future funding levels for Northern Ireland.
It should be recognised that Northern Ireland has special problems as one of the least well-off regions of the United Kingdom with specific regional problems, such as an unusually high rate of heart disease and a high number of patients suffering from cancer. Those problems should be borne in mind when funding decisions are made.
The cash crisis and the inadequacy of present funding of the health service in Northern Ireland received a positive response from the Minister exactly a week ago when Ulster's cash-hit health service received additional funding of £5.2 million to be shared among the four health boards to help them buy a range of elective services. Some of the patients, who have been waiting too long for operations, will now receive long-awaited surgery, but waiting lists are still too large and patients have to wait too long for the problem to be resolved by piecemeal funding in response to all-party representation or press and media attention directed at the Department of Health and the Minister.
We welcome the Minister's response, but I hope that he will acknowledge that Members of Parliament who represent Northern Ireland constituencies have been pressed forcefully by their constituents, who are enraged to learn that surgery was on offer and was being sold to patients in the Republic of Ireland while British citizens who have paid taxes and national insurance were left on 818 waiting lists because health authorities and fundholders could not pay for the operations to which their patients were entitled. Many are afraid to be named lest they suffer further delay. My colleagues and I want to see such future funding as is necessary to eliminate unreasonable waiting times for any patients in Northern Ireland. When the waiting lists have been cleared, nobody would object to the expert services still available being sold on to relieve the suffering of patients from outside Northern Ireland.
Further evidence of crisis in hospital provision was highlighted in the Belfast Telegraph on 6 February. The article, which was entitled "Cancer unit in crisis", highlighted the threat that existed for Northern Ireland cancer patients at the Province's regional cancer centre because of the overwork and maximum use being made of the special diagnostic simulator machine at Belvoir Park. It is the only one of its kind in the Province and had had problems earlier this year. There were genuine fears of a more serious breakdown that would have delayed urgently needed diagnosis and treatment.
Cancer patients and their families throughout Northern Ireland are deeply grateful to the anonymous donor whose generous gift of £400,000 will provide a new diagnostic simulator. We all appreciate the fact that its £250,000 installation costs have been made available by the Department of Health, which has been shamed into finding that money by the generosity of the anonymous donor. The investment could save lives, because earlier diagnosis and treatment will become available when the second simulator is in use.
The perception of a growing crisis in our health and social services provision in Northern Ireland has been expressed by patients, medical practitioners, trade unionists, and by the Royal College of Nursing, the largest professional working group in the NHS. The public at large want to see the nurses in our hospitals and those who are employed elsewhere in the health service properly rewarded for their care and devotion, without long-drawn-out pay negotiations.
My constituents in East Antrim are dismayed because no improvement was made to the A8 from Larne to Ballynure, before Moyle hospital at Larne was closed. No improvements to the road have been made since the hospital closed, either. Are any improvements even being considered, either now or in the future, to make access to the Antrim hospital faster and safer for motorists and ambulances travelling from the Larne borough area?
What assurance can the Minister give that congestion on the A2 between Carrickfergus and Belfast will be relieved in the not too distant future? Again, that would provide faster and safer access for my constituents in Islandmagee, Whitehead, Carrickfergus, Greenisland and Newtownabbey to the Whiteabbey and Belfast hospitals. Can the Minister assure me that he will continue to support the retention and upgrading of the existing services at Whiteabbey hospital in my constituency, which must not be run down in order to fund the failure to rationalise hospital provision in Belfast?
The most recent figures for admissions to Northern Ireland hospitals, published in columns 443–44 of Hansard on 18 November 1996, show how long patients had waited for admission. It should be of concern to all of us that although by March 1996 progress had been made to clear up most of the backlog of patients who had waited more than two years, 800 patients had still waited longer than 18 months at that time.
819 Can the Minister report significant progress over the past year in reducing the number of patients who have been on waiting lists for more than 18 months? Is the inability of health boards and fundholders to pay for operations creating another backlog of non-urgent operations for the future? Is the failure to fund the number of operations that our hospitals are capable of carrying out part of a deliberate strategy designed to reduce the number of acute hospitals in Northern Ireland?
Can the Minister assure us that patients who do not wish to be placed in mixed-sex wards will have their wishes respected, and will be allowed to retain their dignity and their right to privacy in single-sex wards?
Will the Minister, together with representatives of the Northern Ireland ambulance service and the hospital trusts that serve my constituents and others, set aside some time on a regular basis to discuss matters with the chief executives, and to examine for himself examples of the appalling incidents that have occurred and keep occurring, causing distress and suffering to young and elderly patients alike?
The Minister would not normally have sight of those horror stories, because in such cases my colleagues and I now write to the chief executives of the appropriate bodies, but a debate such as this affords us the opportunity to raise them in the Chamber.
Why should a pensioner who fell and broke her thighbone on Friday night have to lie in agony on a hospital bed until Monday before being transferred to Belfast city hospital for treatment? Are there no proper facilities for treating patients, whether pensioners or not, at weekends? There was a good final outcome to the case, and the patient made a good recovery.
Is not the following story a disgraceful example of the falling level of provision in our health service? An 80-year-old woman suffering from an acute kidney infection was, on her doctor's advice, conveyed by emergency ambulance to hospital at 4.24 in the afternoon. She was accompanied by her husband, and was wearing a coat and slippers but no stockings. She was discharged at 5.40 and informed that there was no ambulance to take her home.
The patient and her husband, who was also 80, waited while a nurse tried to contact a relative, but gave up and set off on their own. There was no taxi rank in the vicinity of the hospital, and they walked a considerable distance on a freezing cold night to a railway station where they waited for an hour to make part of their journey by train, and then found a taxi in which to complete the journey on that wintry night, arriving home two and a half hours after the woman had been discharged from hospital.
Last year, a man took his six-year-old grandson, who had broken his arm, to Antrim hospital. The waiting time for an X-ray was an hour, after which he was advised that the staff present could not set the child's arm and the grandfather would have to take him to the Royal Victoria hospital.
Unfortunately, six or seven weeks ago, the same man's eight-year-old grandson had to be taken from Larne to the Antrim hospital, where, after an X-ray, a fractured ankle was diagnosed. Again, there was no one present to set the child's ankle and the grandfather had to drive to the Royal Victoria hospital.
820 I hope that the Minister will take time to examine those cases and that, even though there were apologies and excuses, he will ensure that there is no repetition of such incidents.
Not everything in Northern Ireland is gloom and doom, however. I am sure that the Minister will join me in congratulating Londonderry-born Dr. Peter O'Hare and Gill Elliot from Belfast—two Ulster scientists whose recent breakthrough has been hailed as one of the most important in gene therapy, and a major step on the way to combating several diseases, including cancer.
I hope that there will be close collaboration between those involved in cancer research at Queen's university Belfast, the new state-of-the-art cancer research unit of the Ulster Cancer Foundation at Belfast city hospital, and the Marie Curie research institute in Surrey, where the characteristics of the mystery protein VP22 were discovered for the first time.
Will the Minister robustly seek from the Government financial support to take forward that valuable work, and avoid placing further and increasing burdens on charities and fund-raisers that are already competing with the national lottery?
We have the expertise in Northern Ireland to have the best hospital services in the United Kingdom, or the world for that matter. That can be achieved only by increased funding, better use of resources, savings on administration and adequate community care funding for those discharged after a short time in acute hospitals. I urge the Minister, on behalf of the people of Northern Ireland, to seek that funding from Government.
§ Mr. David Trimble (Upper Bann)
I congratulate my hon. Friend the Member for East Antrim (Mr. Beggs) on securing this debate. It is unfortunate that the debate coincides with what will probably be the last plenary session of the inter-party talks in Northern Ireland before the pre-election recess; that explains why hon. Members from other Northern Ireland parties are not present. One of the advantages of having a somewhat larger party is that we have greater depth of resources and can afford to be in two places at one time.
We must bear in mind some general points about hospital provision. I hope that the Minister agrees that the Government have an obligation to deliver to the people of Northern Ireland the same quality of health care as is available elsewhere in the United Kingdom, and agrees that, because of our differing circumstances, to achieve that may require more expenditure in Northern Ireland than elsewhere.
I regret to say that Northern Ireland has, generally speaking, a much less healthy population than the average English region—that problem is not confined to Northern Ireland: there are regional differences elsewhere as well—and the difference will have to be reflected in the services provided.
Northern Ireland has a lower density of population, so one cannot say that it needs the same provision as a region in southern England with a population of 1.6 million. Our greater geographical area and sparser population impose additional burdens on services, and an apparently higher level of provision will be needed to obtain the same level of service. One will also have to take account of the nature 821 of the road network. Our roads vary in quality, and my hon. Friend the Member for East Antrim referred to some of the difficulties that his constituents encounter as a result.
Those general points will have to be borne in mind when we consider what appears to be the Department's fundamental strategy, which is to close comparatively small hospitals in order to concentrate on half a dozen acute hospitals to provide for the health needs of the whole of Northern Ireland. Does the Minister believe that that is the right strategy and that it takes account of the particular needs of the people of Northern Ireland—or is it driven by the needs and desires of administrators and consultants? That is a fundamental question.
We must also ask whether the policy of closing the comparatively small hospitals is a good thing in itself. When the right hon. Member for Wokingham (Mr. Redwood) was Secretary of State for Wales, he discovered that there were no significant financial savings in that policy and he reversed it in Wales. Those hospitals should be able to deliver a service. There is no reason why centres serving populations of 20,000 or so should not be able to sustain a certain level of provision.
The closures involve not only significant transitional costs but a significant loss in terms of recent investment. The Minister will know that my concern relates largely to the situation in Banbridge and the recent closure of its hospital. One of the disadvantages of that decision is that the investment in surgical wards a few years ago has largely been written off.
The way in which policy has been implemented in Northern Ireland recently seems to me to involve significant waste and to ignore the geographical realities, which do not always coincide with trust boundaries. Banbridge hospital was part of the Craigavon area hospital trust and a satellite to the main hospital.
The Minister has decided that Craigavon area hospital will have to provide for the need that would otherwise have been provided for at Banbridge, but that does not always take account of the geography. It is not all that easy or convenient to travel from Banbridge to Craigavon; the roads on that route are less convenient than the major dual carriageway that runs roughly north to south from Newry to Lisburn and Belfast.
Consequently, the closure at Banbridge does not assist the hospital trust and is likely to involve a transfer of resources out of the area. The nature of the road network also creates problems in the provision of an ambulance service. When the hospital is withdrawn from Banbridge there will obviously be a greater need for a better ambulance service. One need not labour the point that speed is crucial in terms of people's prospects, especially in the case of heart attacks, for example. The necessary speed of response is simply not provided in Banbridge, and especially the rural part.
We get assurances from the trust that ambulances are available and response times adequate, but we hear far too many stories from constituents who have had to wait a long time for ambulances. I am not satisfied that the reports from Ministers and administrators give us a correct and accurate picture of the situation. There is a general lack of confidence in the ambulance provision in the Banbridge area, and that needs to be addressed seriously.
822 The Minister will know of the alternatives proposed by Banbridge council, which has tried to be realistic. It would much prefer the hospital to be kept open, but it has been prepared seriously to consider other ways of delivering a good service, through developing what is referred to as a polyclinic or community hospital. That would build on the present out-patient services and try to provide as much of the service that people need as close to them as possible.
I am glad to see the Minister nodding in agreement, but unfortunately the only promise that I am aware of his having made so far is simply to continue the existing out-patient services. I hope that he will go much further than that.
Banbridge presented proposals for a polyclinic to the Department some time ago, but what response has been made and what action taken? No clear decision has emerged, and instead we shall have further delay as a result of the decision to explore the possibilities of the private finance initiative. I appreciate the fact that the Minister is working with financial problems, and that PFI is sometimes regarded as a way round those, but it means a further delay.
Bringing in PFI could delay provision by a further two years and that is not satisfactory. Many people regard its introduction with distaste because they see it as a roundabout way of transferring the advantages of the site, its development potential, and the profit that will come from it, to the private sector.
As for the strategy that is supposed to underlie the Department's approach in the maintaining of six acute hospitals, I fear that what is happening to health provision in my area will undermine the service. As I said earlier, it is unlikely that, following the closure of Banbridge hospital, all the patients will travel to Craigavon. Given the geography of the area, there is a strong possibility that many will go to Daisy Hill, Lagan Valley or even Belfast—for the prospects of Daisy Hill and Lagan Valley are not completely unclouded. Some resources will be transferred from Banbridge to other hospital trusts. Craigavon needs the finance that comes from Banbridge; it cannot cope with the present situation. I am worried that the future of Craigavon area hospital may be undermined.
As was said earlier, the primary concern now seems to be the convenience of consultants and administrators rather than the needs of patients. Moreover, there is an overall lack of finance. The present Minister may not be able to remedy that, but it is a serious problem. Despite what was said by the Chancellor of the Exchequer, there has not been an overall increase in resources for the health service in Northern Ireland, although substantial additional resources have been made available in England and Wales. Indeed, the Government's current expenditure plans show significant real increases for England and Wales as a whole, while Northern Ireland's total block grant for the current financial year shows a decrease of 0.5 per cent. in real terms. That is not a large figure, but it is a decrease in real terms. There are also problems relating to allocation within the block, and other problems arising from that.
Were it not for the pressure exerted by my hon. Friends, especially my hon. Friend the Member for Belfast, South (Rev. Martin Smyth), we would not have had the desperately needed extra injections of finance that we have had in recent weeks, but we need more. There should 823 be a fresh look at financial provision for health in Northern Ireland, so that we obtain the service that we require. It must be acknowledged that, because of the geographical and health factors that I have mentioned, Northern Ireland needs more expenditure than England and Wales.
§ 10.2 am
§ Rev. Martin Smyth (Belfast, South)
I appreciate the opportunity to contribute to the debate on health issues. My hon. Friends have dealt, to a large extent, with individual examples—specific constituency issues—but they have also touched on principles. My hon. Friend the Member for Upper Bann (Mr. Trimble) referred to the PFI. I believe that some large firms in Northern Ireland would find the task that they have been asked to undertake too small for their own capacity, in terms of the time taken up by consultation and planning and the lack of any attempt to press ahead with major issues. I am thinking of firms such as Mivan in south Antrim. I wonder whether we have sufficiently thought out the issues involved in some of the schemes that are considered in Northern Ireland.
I echo the tribute paid by my hon. Friend the Member for East Antrim (Mr. Beggs) to the dedicated skill of those who provide our health service. We must bear it in mind that some of the problems that we are experiencing arise from the tremendous success of that service. For instance, people who had cardiac surgery 10 or 14 years ago are now returning for more, and the same applies to those who have had orthopaedic operations in the past. After years of useful, healthy life, those people now find that they need further surgery. I do not want to minimise the work that has been done, and I feel that the entrepreneurial and inventive skills involved should be recognised.
Having said that, I must add that, as the Minister will know from his own figures, informed observers are criticising the lack of spending on Northern Ireland's health care. The quality of the service was at its peak in 1992. The Minister can heave a sigh of relief: he was not responsible for such matters then, and cannot be held responsible for the whole downturn which has followed. Let me ask him, however, about the split in the spend in the top slicing. How much do the Department and the health management executive keep to cover overall demand? How much, for example, has been spent on independent consultants? How much time has been taken up? Who, in that sense, manages? There seem to be many different fingers in the pot.
Are we looking for a real remedy for the problems of hospital provision, or just a repair job to tide us over? There is a tendency to employ more consultancy and management staff, rather than introduce better technology. I have been interested in the issue of medical records for some years, and I believe that one of the difficulties in the past has been the fact that consultants have been blamed for not bringing patients in when, in fact, the medical records were at fault. Given that £1 million may have to be spent to provide a hospital building, or part of a building, to house medical records, would not a good computer be cheaper, take up less space and provide the answers much faster? I raise that point because it has been brought to my attention.
824 I understand that schedule 3 to the Health and Personal Social Services (Northern Ireland) Order 1991 reserves powers for the Department, which may determine whether it might be impractical to negotiate or contract for certain services. How often has it done that? Is it true, for example, that the Eastern health and social services board pays 23 per cent., compared with the average of 50 per cent. paid by health authorities in Great Britain? Is there a proper spread of finances?
The other night, I was thinking about a cause celebre—a missionary strategy in an African country years ago. Excellent nurses were sent out to that country, but within a year each returned broken. Finally, the council of the sending body decided to look at what was happening on the ground, and realised that there was a senior nurse there who should have been dispatched long since.
Are we dispatching the right people? The Ulster hospital has lost two chairmen and one chief executive. Is it a fact that in 1995 its trust board asked for permission to do consultancy work so that it could get to the heart of what was happening in the hospital and that that permission was given only in 1996, a year later? Why did it take so long if there was obviously a problem?
On contracting, was the Ulster hospital unique or was the problem reflected throughout the Province? Contracts for 1995–96 were not worked out until November-December 1995. Even for this year, 1996–97, it was June before they were finalised. Is that not one of the reasons why there has been a backlog, which has caused problems? Did not the Royal Victoria hospital have vacancies and provide services outwith Northern Ireland?
I do not criticise any hospital in Northern Ireland for providing services for people outwith Northern Ireland, in Great Britain or, for that matter, in the Republic, provided that the money follows the patient. However, with better contracting, would it not have been possible to deal with the GP fundholders who claim that they sought to get patients treated in the Royal but were told that there was no provision? Marginal costs—or was it done at full cost?—were provided for patients from the Republic. As far as I can remember, 900 cardiac operations in the Royal should be done at full cost, leaving about 300 at marginal cost. Would it not have been better, when it was realised that there was demand, to have averaged that out better? Does the Minister want to intervene?
§ Rev. Martin Smyth
It would have been better to average things out so that both fundholders and boards pay the same price, rather than playing with purchasers. We must remember that the Royal is the only provider of cardiac surgery in Northern Ireland. Would it not have been a better use of resources to use the full potential complement? Is it not also a fact that the University hospital of Wales produced a report on the Ulster hospital? That was certainly requested by the trust, but it was commissioned by the Department. Should there not have been consultations involving the trust concerned, the Department and the Minister before final decisions were taken?
I have had a letter from the Minister—as I am sure other hon. Members have—advising me of the changes that are taking place and of the amalgamation of the 825 Ulster, North Down and Ards Hospitals health and social services trust. Are there any grounds for hope that the confidence expressed in the letter will be borne out? Given that the management executive was not previously prepared to put in a better team of management and support the trust board, is there any likelihood that changes will occur now?
I come to a question in which the Minister will appreciate I have a deep interest, as one who has supported the long-delayed rationalisation of the Royal and Belfast City trusts. Plans were on the drawing board at least 30 years, if not 50 years, ago. The City has sketches of what was planned. There was an imaginative idea for a tunnel to connect the City and the Royal to ensure the best use of resources. For various reasons, that has been dropped, but the Department rightly decided to go ahead again, and there have been three studies. Each hospital would automatically lose some of its provision, but, as they are 10 minutes away from each other, I do not believe that that is an insuperable problem.
A charter of excellence was granted to the City casualty and emergency unit, but it is to close. I understand why the Royal should be retained; it has the neurosurgical unit and it should be the regional trauma centre for Northern Ireland. I have no difficulty with that, but why the delay in going ahead with something that I believe rationally minded people will understand? I equally understand that sectional interests will be involved, but surely the McKenna report was clear about the provision of maternity services at the City. Does the Minister accept that there will be a drag on the health trust if the facilities and plant that are available in the wards in the tower block are not used purposefully? One has only to bear in mind the concept of return on capital to understand what I mean.
I cannot accept the arguments that are presented for the Royal site. It is true that the money needed immediately to improve the Royal's maternity buildings would be marginally less than would be required for adaptation of the tower site. However, a few years down the road, the cry will go up that we need new maternity provision on the Royal site when we already have facilities on the City site.
Cardiac specialists and others tell us that they must be situated conveniently close to the maternity hospital. What happens in Southampton, which has a fine medical school and fine cardiac provision? Women there are often sent to the community hospital at Basingstoke to have their babies. That is not 10 minutes down the road. Some of the arguments for having everything on the Royal site are false.
I must now speak specifically as the Member for Belfast, South. In considering the arguments about employment prospects in west Belfast, I remind the Minister that the Mater Infirmorum hospital is in north Belfast and that a fair number of people travel from west Belfast to have their children there. North-west Belfast will have two sets of maternity provision. We will lose the centre of excellence that has been at the City hospital for years. This year, some 2,700 to 2,800 children were born in the City, which has excellent facilities. I urge the Minister to remove the indecision that has so often been a hindrance. I sympathise with Ministers who have to make such decisions, because the clamouring voices come 826 from all angles. However, I ask the Minister to remember that south Belfast has higher female unemployment than any other part of Northern Ireland.
I understand that the Belfast City Hospital health and social services trust has asked for clear guidance on whether there has been unfair discrimination. One can have fair discrimination: sometimes we have to decide what we are going to do, and discrimination means making a judgment. However, there can be unfair discrimination. For example, the public dividend capital required in the first year was reclaimed by the Department from the City trust in the second year of operation, but not from the Royal Group of Hospitals and Dental Hospitals health and social services trust. The City trust paid £1.4 million more in dividend for the year 1994–95 than did the Royal group. As I understand it, the Royal was a trust first. There are issues that have to be faced. Hon. Members have local interests, but we still want the excellent regional services, to which reference has been made, to be retained in the Royal hospitals and the Belfast City to serve all of Northern Ireland. There are specific times when we must decide where some of those services are to be sited.
§ Mr. William Ross (East Londonderry)
This is an important debate. We are asking the Minister where we are trying to go with hospital provision in Northern Ireland. It has a long history related to advances in medical science and to the geographical location of hospitals. In the old days, single-handed consultants were willing to do everything whereas now a massive team is needed to do anything. Sometimes one wonders whether all the changes that have been made were as wise as they might have been.
Enormous advances have been made in medical science. There have also been tremendous changes in transportation, with the improved road network and all the rest of it. There has been a quantum leap in doctors' expectations of the conditions in which they have to operate. Above all, there has been a tremendous centralising influence on hospital provision in Northern Ireland, driven mainly by the medical profession and advances in medical skills. The concept of providing a certain number of acute hospitals on specified sites has been with us for many years. I do not disagree with it. We need a range of hospital provision. However, we appreciate that, for rare and difficult conditions requiring heart surgery or neurosurgery, we shall only ever have a regional service based in Belfast.
The truth is that someone living within 10 or 15 miles of Belfast will receive a much better service than someone living in Enniskillen or Londonderry, because of the travel times and distances involved. It is financially and practically impossible to provide specialist skills in every corner of the Province. That is a problem not only for Northern Ireland but for the rest of the United Kingdom.
In Belfast city, there is a high concentration of hospital beds and expertise. There are many hospitals within a few minutes, travel of each other. That is not the situation elsewhere. Coming from the Six, I have to say that many decisions have to be made, some of which have never been properly made. One of those hard decisions revolves around north Belfast, which, as we all know, is protected by Act of Parliament. It is pretty well impossible to do 827 anything with it, so I suspect that it will be a rock in the torrent of change for ever. It is a decision with which the Minister will have an enormous number of difficulties, whoever sits in his hot seat down the coming years after the general election. Hospital provision in Belfast has a domino effect on the location of acute hospitals in Northern Ireland. We cannot continue dodging the difficulties for ever.
Huge sums have been spent on acute hospitals in Northern Ireland over the years. I have here the somewhat dated Northern Ireland expenditure plans, published a year ago; it is rather a pity that we do not have the up-to-date version for the debate. The plans show that expenditure has been set aside of £10 million on the Royal Belfast hospital for sick children, £9 million on remedial works on the Craigavon area hospital and £43 million on the Causeway hospital, for which I am particularly grateful to the Minister, especially as I understand that the tenders were received yesterday. We hope that the plan can go ahead.
The plans also show £64 million to £65 million of expenditure on the Royal Victoria and £39 million on redevelopment of Altnagelvin area hospital, following £7 million on recladding that hospital. By any standards, those are huge sums of necessary capital expenditure. We are grateful to the Minister and the Government for finding such sums, but there is the problem of travel times to those hospitals and the provision that will be made in them. Those sums are not found out of thin air. The expenditure has downstream consequences. Antrim hospital is up and running. Causeway hospital has been started after 35 or 40 years. There are geographical considerations and the problem of the smaller satellite hospitals which revolve around those acute centres. The Government are sometimes not quite honest and forthright enough to say to people that, once provision A is made, provision B will be diminished or hospitals may close.
Let us consider the consequences of Altnagelvin down the years. A series of small hospitals scattered over the city of Londonderry and surrounding areas out as far as the Roe valley and Limavady are closing. I wonder what will be the consequence of the huge expenditure on the acute hospital in the long term. At the end of the day, hospitals are not provided for the convenience of the medical staff; they are provided for the benefit of the patients. Sometimes, that fundamental fact of basic need vanishes into the bog of hospital provision and the arguments on how well we can provide high-quality care on a particular site. Travel times are of great importance, especially in cardiac cases and for those injured in severe accidents involving brain or spinal injury.
To return to my local interests, I should like to highlight a problem in the provision of cancer services and follow-on treatment at the Causeway hospital. The Minister will be aware of the horror stories that we always hear of individuals getting into an ambulance or other form of transport early in the morning, travelling 50, 60 or 70 miles to receive treatment and then travelling all the way back. To put it mildly, that is very difficult to put up with.
We need to provide follow-on treatment as close as possible to the cancer patient's home. For that reason, I and the medical staff in and around the Causeway site are worried by the reports that much of the cancer provision 828 for the whole Northern board area will be in Antrim. People in Antrim say, "Oh, well, it will be mainly in Antrim, but there will be something at the Causeway site." We want to know now what services will be provided at the Causeway hospital. There seems to be a drift all the time towards centralisation. Fifty miles is a long way for someone who is ill and finds it difficult to travel even a short distance. I hope that the Minister will take a personal interest in the matter and see what can be done about it.
It is not all doom and gloom with regard to hospital provision. We have witnessed an astonishing drop in acute hospital beds in the period covered by the document from 5,634 to under 5,000. That was achieved in the years 1991, 1992, 1994 and 1995. In the same period, hospital admissions rose from 265,000 to 315,000, which is a huge increase. The increase in day care cases, from 48,000 to nearly 90,000, has been even more remarkable. Those bright spots show the benefits that accrue from advances in medical science. We all welcome that, but where does that lead us regarding hospital provision in 10 or 15 years' time? I know that the Minister is neither a prophet nor a dishonourable prophet, but perhaps he can make an educated guess about such future hospital provision in Northern Ireland.
One problem, which is associated with the general lower standard of health in Northern Ireland, means that Northern Ireland and Wales are battling it out as to which will be the worst region for waiting lists in the United Kingdom. I wonder when we will reduce our waiting lists to the Scottish level, which is remarkably good compared with those of the other three jurisdictions in the United Kingdom. Scotland has done very well, and perhaps we should consider the methods employed by the Scottish Office to see what can be done to improve the health care of our people.
I am also concerned to note that, in the period covered by the expenditure plans and priorities, the number engaged in administration has increased by about 2,000, while the number of home helps has fallen from 3,200 to under 2,000. The care of our aged people presents a serious problem, not least because there are more and more of them with each passing year. Those carers are not necessarily in better health than their charges. I support the concept of care in the community and care in one's own home. It is extremely bad for old people to be taken out of their familiar surroundings and bunged somewhere far away from their family and friends. That option should be the port of last resort. It should be made available only to those who are so incapable of looking after themselves that they need nursing care. There are a lot of people who reach that stage.
Care at home is not cheap, especially when there is no family available to provide it, or even when they can. I have looked after aged relations with dementia, so I am aware that the burden placed on the family of the carer is unbelievable. I hope that the Minister will take steps to provide increased respite care for the folk who need it—there are a lot of them.
I am also concerned about care in the community for those who are mentally ill or mentally handicapped in one way or another. It is a dangerous process to move some of those people out on to the streets because they are incapable of caring for themselves.
I shall conclude shortly, because I know that the Minister and the Opposition spokesman are itching to get to their feet—one to assault and the other to defend. I am 829 concerned about the incidence of smoking and alcohol consumption among young people. I believe that changes in diet and way of life are generational and that they pay rich dividends. The mother is the most likely person to influence the diet of youngsters. I suggest to the Minister, therefore, that young women should be targeted more at schools so that they are better educated and better trained about the provision of a healthy diet for families. Some people may think that is sexist, but the reality is that it is women who determine the diet in the home. They need more and more proper training. That is true of young women not only in Northern Ireland but throughout the United Kingdom.
There should be more education on the dangers of smoking, never mind drugs and the rest of it, as well as on the dangers of alcohol. That is why I object to the changes that are constantly made to make alcohol more readily available every day of the week. We are getting to the situation where society is floating on an ocean of alcohol. Although I understand that those alcohol sales may benefit the Chancellor in the immediate term, I believe that the right hon. and learned Gentleman and all the community will suffer in the long run. If anything could be done to educate people against the dangers of excess consumption of alcohol, it would be all to the good, because there is far too much drinking in Northern Ireland, never mind elsewhere.
§ Mr. Jim Dowd (Lewisham, West)
The Minister seems surprised that I have anything to say. I appreciate that his engagements in Northern Ireland may mean that he is not au fait with how the extended Adjournment debates on a Wednesday morning work. I guarantee to leave him the bulk of the remaining time in which to reply.
First, I congratulate the hon. Member for East Antrim (Mr. Beggs) on arranging the debate, which is timely and important given the severe difficulties that many hospitals throughout Northern Ireland have faced recently, and continue to face. It is worth recalling that the hon. Member for Upper Bann (Mr. Trimble) has reminded us that other engagements mean that other hon. Members who represent Northern Ireland are unable to attend the debate. Hospital provision concerns every hon. Member from Northern Ireland, from every part of the political spectrum, largely because it is of such deep concern to their constituents.
The problems were presaged by the cuts in the health budget last year. The Royal Victoria, Ulster and Mater hospitals, and those in the Causeway and Green Park trusts, have been the most seriously affected—6,000 operations and 55,000 out-patient appointments have been cancelled since the summer.
The problems became so serious that the Royal Group in particular made arrangements to cut a further 1,700 operations and to offer that capacity to fundholding general practitioners. Because of that, the Department of Health and Social Services managed by some mysterious process, which I suspect may involve the 1997–98 budget, to find an additional £3.3 million for the Royal Victoria and Ulster hospitals. As the hon. Member for East Antrim said, the final figure is likely to be £5.2 million. The final irony is that it may not be possible to spend that money in the remaining few weeks of the current financial year.
The difficulties have their origins in a combination of the NHS reforms that have been pursued by the Government and this year's cut of about 3 per cent. in the 830 health budget. Even if the House takes the most generous view of the Minister's assertion that that contains a 1.5 per cent. efficiency saving, we are still left with the reality of a 1.5 per cent. service reduction in Northern Ireland. Northern Ireland has experienced cuts of at least that scale.
In fairness, the Minister has never attempted to hide the facts. As the June edition of the Nursing Standard quoted him:'As a Minister I have to come clean and tell you that efficiency savings are just not possible … Therefore I acknowledge that there will be cuts in services and I don't like it any more than you do.' Mr. Moss, addressing the first conference of the RCN management association in Northern Ireland, added:`As a Minister I can't stand over cuts like that for too long.' However, he insisted he would not resign over the matter.That is precisely what happened—cuts were made but no resignation was forthcoming.
The cuts are obvious to all involved in the delivery of health care in Northern Ireland. A recent report from the British Medical Association spelt out the difficulties, and noted that the Northern Ireland Consultants and Specialists Committee had stated:Efficiency savings are cuts by another name and this constant haemorrhaging of funds has seriously weakened health care in the Province. We were disturbed to learn that some hospitals are having to restrict operations for non-urgent cases and that in others there is little money available to buy new equipment in order to meet efficiency targets.We intend to take our findings to the Minister and the Chief Medical Officer in the hope that the current round will not be so harsh that it impedes good clinical practice. Clearly, the hospitals in the Province cannot sustain another round of imposed efficiency cuts.The story is there to be read in the waiting list figures, which the hon. Member for East Londonderry (Mr. Ross) highlighted. Waiting lists overall grew 2 per cent. in England in the 12 months up to September 1996; the comparable figure in Northern Ireland was 13. During the same period, the number of people waiting more than 12 months fell by 40 per cent. in England but increased by 75 per cent. in Northern Ireland. Those are not figures, but people waiting for treatment and care, and they are still waiting today.
The most corrosive of the Tory reforms has been the wholly artificial internal market, which has set hospital against hospital and doctor against doctor, replaced co-operation with competition and fragmented decision making, making strategic planning much more difficult. It has distorted the relationship with patients, as the primacy of contracting clashes with the best interests of the patient, and produced a system where price too often takes precedence over quality. It has generated an explosion of unnecessary bureaucracy, with individual contracts and the pricing of individual items of surgical procedure producing an avalanche of paper throughout the system. Most damaging of all, it has led to the substantial inequity that is undermining the cardinal NHS principle of equality of access.
Experience throughout the United Kingdom, and Northern Ireland specifically, has brought to light innumerable cases where the likelihood of receiving acute or secondary treatment has become dependent on the management arrangements of the patient's general practitioner rather than medical priority. The chief executive of the Royal Group of Hospitals and Dental 831 Hospitals health and social services trust, Mr. William McKee, when announcing the reductions in the Royal in the summer, said as much. He was quoted in the Belfast Telegraph as saying:We can only provide services where the Health Board or fundholding GP is providing finance. This means that where a person lives and whether or not the GP is a fundholderwilldetermine who we … treat.The chief executive of the Eastern health and social services board, Dr. Kilbane, had to write to all the acute trusts in the area last autumn, following a conference of GP Forum, which represents fundholders and non-fundholders. He wrote:A very strong view was expressed at the meeting that General Practitioners were increasingly concerned at the use of criteria other than clinical need for choosing the order in which patients in the Board's area are treated. The Forum asked that the Board should draw to Trust Chief Executives attention and that they in turn should convey this view to clinical staff, that clinical needaloneshould be the criterion which governs the order in which patients are treated and the treatments they receive.I would be obliged if you would draw this strongly held view to the attention of appropriate … staff'.There we have it; a patently two-tier system—evidence of which is now incontrovertible—and the latest revelations from the Royal Victoria hospital, mentioned by the hon. Member for East Antrim, merely provide further proof.
The development of the internal market has not only distorted priorities, but wasted a great deal of money that should go to front-line patient care. We are well aware that the last thing that is needed is the destructive, dogmatic process that has been the Government's hallmark. We are keen to engineer change—health service professionals want changes—but we are fully conscious that the only way to construct enduring and beneficial advance is step by step, taking people with us as partners in the process to achieve our objectives.
Nowhere will that be better demonstrated than in our plans for locality commissioning. We intend the strategic planning of the health boards and the provider responsibilities of acute units to remain, but the decisions about what treatment to organise on behalf of patients should be drawn together in local GP commissioning groups. In the light of such changes, the role of health boards will be changed and they will be able to reassert their traditional strategic role.
I was very interested in what the hon. Member for East Londonderry said because he alluded to some of the key strategic issues concerning the changing nature of the delivery of health care and the need to take some fairly hard decisions. When I first served on the health authority just the other side of the River Thames—in Lambeth, Southwark and Lewisham—in 1976, we had 14 hospitals; today we have four. It has not been easy to achieve, but it has involved—more than anything—taking people with us rather than simply telling them what is good for them. To some extent, that element has been missing from the management of the health service in Northern Ireland.
The hon. Member for Belfast, South (Rev. Martin Smyth) mentioned the problems relating to the Royal Group of Hospitals and Dental Hospitals health and social 832 services trust, the Belfast City Hospital health and social services trust and other trusts. At present, formation of trusts throughout the health service is entirely spontaneous, and without strategy. At no time have services been considered, not institutions; what patients receive, not bricks and mortar. Even the recent merger of the Ulster Hospital trust and the North Down and Ards Community health and social services trust was driven solidly by the financial position of the Ulster hospital, not by any view about what care packages patients need.
This is the atomisation and break-up of the health service that the reforms have engendered: providers, commissioners, community care and acute services are considered almost as separate businesses. That must end, as must the evasion of hard decisions, which will have to be taken—in many cases, the sooner the better.
A Labour Government created the NHS and, if the British people give us the opportunity in a few weeks' time, it will fall to a Labour Government to rescue and renew it, by re-establishing our vision of a comprehensive health service, publicly funded and publicly operated, free at the point of use and universally available on the basis of clinical need alone. A Labour Government will make a substantial difference and change the disastrous course on which the NHS throughout the United Kingdom is set.
§ The Parliamentary Under-Secretary of State for Northern Ireland (Mr. Malcolm Moss)
I congratulate the hon. Member for East Antrim (Mr. Beggs) on his success in getting this important subject debated today. He, like many other Northern Ireland Members, has long been involved in efforts to improve and maintain hospital services, especially in his constituency. I know of his tremendous efforts a few years ago to retain acute services at the Moyle hospital in Larne. Although his fight for retention of acute services was unsuccessful, the efforts of the hon. Gentleman and those associated with him, in Larne borough council and elsewhere, did much to convince the Northern health and social services board of the need to keep the Moyle open and retain a range of services there.
Today's debate has given hon. Members from Northern Ireland an opportunity to raise issues concerning hospital services, albeit most of the hon. Members present are from one political party. They have raised some important issues and I have listened extremely carefully to their comments, which ranged widely. I shall try to respond to some of the more important comments now, but I suspect that, in view of the limited time that has been left to me, I shall be unable to cover all of them so, in the time-honoured tradition, I shall write to hon. Members about any substantive issues that remain outstanding.
During my two and a half years or so as the Northern Ireland Health Minister, I have come to realise that local communities and the Members of Parliament who represent them take great pride in their local hospitals and staunchly oppose anyone—certainly any Minister—who for any reason seeks to alter the status of a local hospital. Nevertheless, I believe that it is my duty, as the Minister with responsibility for health and social services, to consider the overall strategic picture and to assess the future of local hospitals in that context.
That issue has been raised by several hon. Members this morning. The question was asked, "Have we got regional strategy right?" At some stage, when we have 833 gone out to consultation on this, I shall want to hear what hon. Members regard as a more appropriate regional strategy for the future.
When I spoke in the debate on the Department's new regional strategy for the period 1997 to 2002 in the Northern Ireland Grand Committee in March 1996, I emphasised the necessity for all of us involved in the governance of Northern Ireland to consider the wider picture and to address the matters holistically. Today, I re-emphasise that need. We must decide together how best to spend the limited money available for health and social care, so that we can attain the highest possible levels of care, levels equivalent to or better than—I prefer to consider the "better than"—those in the rest of the United Kingdom.
The money and resources available for health care cannot match the ever increasing demand—a fact of life that we must all, like it or not, accept. It follows therefore that we must be ready to adapt and change health care provision, to ensure that the highest quality of care best suited to need is accessible to everyone.
This is where the balancing act comes in: between the pressures to concentrate resources and provision at a limited number of regional sites, and the needs of local communities, particularly in the more rural areas of Northern Ireland where people live some distance from the main regional centres. I do not claim for a moment that these decisions are easy to make.
All this means providing treatment in the most appropriate settings where the necessary skills and expertise are available. In terms of hospital care, many factors besides purely financial ones have been at work for some time now and are driving change in the way hospital services are provided. I want to mention a few of them this morning.
First, more patients than ever are being treated as out-patients or day patients. Secondly, day surgery—a point mentioned by the hon. Member for Upper Bann (Mr. Trimble)—is growing at a tremendous rate. Thirdly, as a result of these and other factors, lengths of stay are generally declining. Fourthly, new treatments allow care that was once provided in hospitals to be provided in more local settings. Finally, the report known as Calman 1 has resulted in a move towards a consultant-provided service—as opposed to what used to be a consultant-led service.
One immediate outcome of changes of this kind is a reduced requirement for in-patient beds. Moreover, increasing specialisation by doctors leads to a concentration of work on fewer sites in order to provide the case loads necessary to retain and develop skills. There is evidence to suggest that that concentration leads to better outcomes for patients—for instance, in the treatment of some cancers. Changes in the hours of junior doctors, which we all welcome, mean that they now work in larger teams that require sufficient volumes of work to develop their skills.
It is clear to me, and I hope to all present today, that in these circumstances Northern Ireland cannot sustain its current pattern of 18 acute hospitals all providing in-patient acute care. That does not make clinical sense; nor does it make economic sense. The Department's regional strategy for 1997 to 2002 was published last year and envisaged specialised acute hospital services being 834 concentrated on far fewer sites, so that patients can receive their care from highly skilled specialists, and can benefit from the latest advances in medical technology.
Acute in-patient care will in future be built around the cornerstone of Northern Ireland's six major hospitals—the Royal Victoria hospital, the Belfast City hospital, Craigavon, Antrim, Altnagelvin and the Ulster. There will of course be other hospitals, as we said in the regional strategy document; but the misconception persists in Northern Ireland that we will be left with just six hospitals. That is not true.
As I have said, we want to provide care at the appropriate level and in the appropriate setting. That involves balancing the idea of providing the latest high-technology care in the bigger centres against the other services that must be provided near people locally. That will mean retaining other hospitals besides the six that I have listed, but they will not be doing the same things.
There is no doubt that the role of local hospitals will change. Some of them, along with the six, will continue to provide a range of acute services, although that may be a smaller range than at present. They will do that possibly by linking up with each other or with the larger hospitals to secure clinical expertise and maintain the quality of care.
§ Rev. Martin Smyth
With modern technology, is it not possible to tap into the expertise of world-class specialists, even in small local hospitals? That is why I referred earlier not so much to more people but to using technology better.
§ Mr. Moss
That is an extremely important point. The use of modern information technology will certainly enable more advice to be given and work to be done at smaller hospitals, since it will allow for more contact between consultants. Initially, however, consultants may offer more peripatetic services in a given area instead of just being based in one large hospital.
Other smaller local hospitals will evolve to deliver a range of complementary services such as out-patient clinics, specialist nursing services, convalescent and rehabilitation services, and diagnostic and therapeutic services. The hon. Member for Upper Bann raised some concerns about the Banbridge hospital. We are mindful of the possibility of some delays in relocating the services that will remain there. After all, the decision that I took was only to remove the in-patient services. We intend to retain out-patient and diagnostic services at the hospital site, and we intend to spend money on revamping the nursing block which is still on the site. Treasury rules demand that we look at private finance initiative solutions, but I can assure the hon. Gentleman that I am pressing for those rules to be waived in this instance so that we can get on with the necessary work on the building and move the services from the current site.
§ Mr. Trimble
I thank the Minister for stating that he is pressing to have Treasury rules removed—I trust that he will be successful—but I also noticed that he was talking only about continuing the existing out-patient services. Can he also give us some hope of the technological developments that he has just been describing being applied to the site?
§ Mr. Moss
We intend that there will be more than just out-patient services on the site. I mentioned diagnostic 835 and therapeutic services. We invited local GPs to discuss with us which services would best be provided in Banbridge rather than elsewhere. We fully intend to provide as many services as possible—as make sense—in Banbridge, to save the local population travelling some distance along those roads, with the associated problems of the ambulance service to which the hon. Gentleman referred.
§ Dr. Norman A. Godman (Greenock and Port Glasgow)
What role does the ambulance service have to play in this scheme of things? How many ambulance crews have been trained as paramedics; what encouragement are they given to train as paramedics?
§ Mr. Moss
That is an extremely important point. In view of what hon. Members have said about the ambulance service, I am slightly concerned about it and shall be examining it over the next few weeks. I shall then answer the points that they have made. We encourage paramedic training, but in future some emergency treatment will be offered in the primary care-led service, not the secondary care-led service. The ambulance service can still have an important role, but resuscitation after heart attacks might in future be done in the primary care service instead of in hospitals, in the first instance.
836 The pattern of hospital provision in Northern Ireland will be affected by the major strategic change which involves the health service moving from being secondary care led to being primary care led. Cardiac services at the Royal have been mentioned. It is certainly disappointing that the problems arose, but the understanding is that the Royal will treat 1,100 cardiac cases a year. They will come from boards and from fundholders. An additional 100 are allowed through the private system. If seven cardiac cases from the Republic of Ireland are treated, they are an extension of that private provision and are not displacing people from Northern Ireland who need cardiac surgery.
The Royal hospital took the view, back in the autumn, that it might not hit the target that it sought to achieve, but it decided just after Christmas that it would. Fundholders who turned up with money to purchase surgery were told that the complement had been filled—the hospital cannot do more than 1,200 cases. The target agreed at the start of the year has been met.
With reference to the acute hospitals reorganisation project—AHRP—and the McKenna report, I shall be making a decision on that in the near future. It is a difficult decision, as the hon. Member for Belfast, South (Rev. Martin Smyth) pointed out.