HC Deb 15 May 2000 vol 350 cc120-8

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Clelland.]

10 pm

Mr. Paul Burstow (Sutton and Cheam)

There is nothing inevitable about illness and disability in old age. They are not synonymous. That is not to say that an ageing population does not present challenges; it certainly does. By 2031, nearly one in three of the population—some 18.6 million people—will be over 60. It is cause for celebration that, as we age, many more of us will continue to lead active and healthy lives, but it is inevitable that the number of people needing acute and long-term care will increase.

Change is needed in the national health service: a change in culture and mindset, and a change in organisation and practice. The NHS reforms of the 1980s and early 1990s created a breeding ground in which I believe ageism flourishes. More and more older people are being admitted to fewer and fewer beds for shorter and shorter stays; two in three general and acute-care beds are occupied by people over 65; more than half the recent increase in the number of emergency hospital admissions involved older people; and bed occupancy rates have more than doubled over the past 10 years in the geriatric sector.

The first step in eradicating age discrimination in the NHS is an acceptance that ageism exists at all levels of the health service. The Minister will know that the concerns I expressed this evening are echoed by Members on both sides of the House. Indeed, his hon. Friend the Member for Shrewsbury and Atcham (Mr. Marsden) introduced a ten-minute Bill, the Health Care Standards for Elderly Persons Bill, only last month to press the case for an independent national inquiry. I certainly believe that such an inquiry would have a part to play in addressing the concern felt by many outside the House.

As one of the sponsors of the hon. Gentleman's Bill, and as a co-chair of the all-party group on ageing and older people, I believe that the issue needs urgent attention. Both Age Concern and Help the Aged have collected evidence of ageism in the NHS, and the number of cases rose steadily. In its report "Turning your back on us", Age Concern discussed the findings of a Gallup poll carried out in March last year. It found that one in 20 people over 65 had been refused treatment, while two in 20 felt that they had been treated differently since they turned 50.

Even the Department of Health has found evidence of discrimination. A review of renal services revealed that as many as two thirds of kidney patients over 70 had been refused dialysis or transplants. More recently, the spotlight has fallen on the use of "not for resuscitation" orders. The British Medical Journal recently drew attention to a gap between guidelines and practice in the use of such orders. An article in the issue of 29 April refers to an independent review. Following a complaint by the family of an elderly woman who had died in hospital, the review stated: It was hard to avoid the conclusion that the treatment plan…was to do little more than allow the patient's life to ebb away. At no point had the family or the patient been consulted about the decision to mark the hospital records "not for resuscitation".

Research has found that more than two out of three patients with NFRs are not involved in making that decision. More worrying still is the finding that labelling patients "not for resuscitation" makes them 30 times more likely to die—and with no say in the decision. That cannot be right or acceptable. I hope that the Minister will be able to say something about what the Government are doing to stamp out such an immoral practice.

The need for action at all levels of the NHS to tackle ageism was brought home to me by the case of Mrs. Marge Terry. When Mrs. Terry, described as an "elderly and alert lady", was admitted to St. Helier hospital last September with breathing difficulties, she had every reason to expect to be quickly discharged and back in her home at Bawtree house, a residential home in my constituency. Mrs. Terry, who was 91-years-old, never recovered. After four weeks and five ward changes, she died.

A catalogue of neglect has prompted Mrs. Terry's daughter, Mrs. Eileen McAndrew, to speak out. During those four weeks, the NHS let Mrs. Terry down. Cleaning was inadequate. Bedside cabinets and tables were left sticky and dirty. Bins were left full to overflowing with tissues and other waste. Her records were not kept properly. Address details were wrong. Her age was recorded incorrectly three times in the same notes. She was left sitting in bed in a nightdress and bedjacket badly soiled with blood.

Mrs. Terry waited four days to see a doctor after developing a serious chest infection and a further two days for an X-ray. Soiled bandages were left lying on her bed. She was given little help with eating and drinking. As a result, food was left to go cold. Staff blamed her for that, describing her as unco-operative. She was even left to take her own medication.

On Saturday 9 October, the hospital phoned Mrs. Terry's daughter to come in as quickly as possible. Sadly, Mrs. Terry died minutes before she could get there.

Mrs. McAndrew put it in the following terms: In the four weeks my Mum was in St Helier Hospital, I saw her deteriorate from an elderly alert lady, who used an electric wheelchair and kept me on my toes, to an old frail weak 91 year old going on 100, who kept asking me to take her out of here. I was very disturbed by Mrs. Terry's death. I have already raised the case with the Epsom and St. Helier NHS Trust chief executive, Nigel Sewell. It is clear from the correspondence that the trust has acknowledged that not everything it did for Mrs. Terry was up to scratch. Although the trust has taken a number of steps to improve its procedures, no older person in hospital should be treated like Mrs. Terry. The care and attention to detail that are essential to promoting recovery were missing. The trust management needs to ask some searching questions. Why was she not properly fed? Why was she left to wait for so long before a doctor saw her?

Mrs. Terry was robbed of her dignity. That was clearly not the intention of any of the staff at the hospital, but it was the result. I want the trust to commit itself to a wholesale review of the way in which acute care is provided for older people. I hope that the Minister will ensure that such a review is undertaken.

What needs to be understood in cases such as Mrs. Terry's is that, although the health needs of most older people are the same as everyone else's, the oldest old people often have a complex mixture of problems and symptoms. A medical profession that is increasingly specialised often poorly meets their needs. What is needed is a people-centred approach. By people-centred, I mean an interdisciplinary team-work approach. Therefore, medical and nursing education needs to take that on board.

In the early 1970s, the British Medical Students Association called for a joint core curriculum for all health professionals to achieve just that end, but the opposite has happened. Increased sub-specialisation has created a generation of doctors who are ill equipped to deal with the complex, multiple needs of older people. Reforms to undergraduate medical education are squeezing training in geriatric medicine out of the curriculum altogether.

Last Thursday, my hon. Friend the Member for Richmond Park (Dr. Tonge) highlighted the need for a concerted effort to tackle poor hygiene and cleanliness in our hospitals. With two in three acute beds occupied by people over 75, and the fact that hospital-acquired infections make death as much as seven times more likely, there is a crying need for investment in the cleaning of our hospitals. Saving through cheap cleaning contracts is a false economy as the cost to the NHS of hospital-acquired infections has risen to some £1 billion a year.

Last week, I visited the Florence Nightingale museum at St. Thomas's hospital to mark the 180th anniversary of that great reformer's birthday. When it comes to care and to hospital cleanliness, it seems that many of the hard-learned lessons that Florence Nightingale taught us have been forgotten. She introduced simple hygiene measures, scrupulous cleanliness and effective nurse training. All of that is described in her book, "Notes on Nursing" and in many letters and other writings. She said: It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Ageist assumptions in health care are doing harm. Work by Help the Aged as part of its dignity on the ward campaign shows that the most effective care for older people builds on the Nightingale legacy and creates an experience of well-being.

The key findings of Help the Aged's report were, first, that to create a "positive culture of care" that values older people, the needs of both patients and staff must be addressed. Secondly, staff motivation is central to the delivery of a high standard of care. Help the Aged found that the motivation and morale of staff and their leadership had a direct effect on the quality of the care provided.

The report identified six factors that are essential if we want to protect the dignity and to promote the recovery of older patients: a sense of security, of significance, of belonging, of purpose, of continuity and of achievement. Although, as Help the Aged has acknowledged, those six senses need further refinement, they provide a conceptual framework for understanding what matters to patients.

Help the Aged also identified some basic prerequisites for staff to deliver better services, the first of which is adequate staffing levels. Low staff numbers leads to a lower quality of care, as staff do not have the time—and, often, the inclination—to do what is necessary to provide a positive culture of care. They are simply too busy. The second prerequisite is adequate resources for staff to perform their roles. Effective medicine requires sufficient basic equipment to provide care properly and effectively. The third prerequisite—it is probably the most important of all—is effective leadership to create "zero tolerance" of bad practice.

Clearly, the national service framework for older people, which is expected in July, will be crucial in driving forward change and driving out ageism. I hope that it will incorporate the model described in dignity on the ward. Will the Minister tell the House whether the framework will explicitly challenge ageist assumptions in the NHS and force practitioners to re-evaluate what they do? Will it require older people to be involved in the commissioning and design of services? Will it place multi-disciplinary working at the heart of good patient care? Will it make it clear that there is no place in the NHS for age-based rationing?

I believe that, even when the national health service's national framework is in place, there will be a need to make ageism illegal. Just as the House has legislated to protect the rights of ethnic minorities and disabled people, it is now time for us to protect older people. Outlawing age discrimination would not entail older people receiving treatment that is of no benefit to them or having treatment imposed on them against their will. Anti-discrimination would simply make doctors think more than they do now before refusing treatment for an older person.

What older people need now is tough antidiscrimination legislation, a national service framework that is people-centred and well-resourced, and a change in medical education, that equips our doctors with skills and understanding to work with older people. By ensuring that our health service is fit for older people, we make it fit for everyone. Quite simply, there can be no place for ageist assumptions in the NHS. Ageism must be met with zero tolerance.

10.12 pm
The Minister of State, Department of Health (Mr. John Hutton)

I welcome the opportunity that the hon. Member for Sutton and Cheam (Mr. Burstow) has provided to the House to discuss an issue that is of very great importance to all of us. I congratulate him on the eloquent and considerably persuasive way in which he made his speech.

The issue is important to us, first, because most of us have elderly relatives, friends and neighbours. Secondly, many of us will, at some stage in our lives, be involved in the care of older people. Last—but not least—we are all getting older, and we are living longer. Already, one in five people in the United Kingdom is over 60. By 2020, we will have the highest percentage of people aged 60 and over in the European Union. It is essential that we ensure that older people are not discriminated against in the national health service and that they do not receive an inferior service simply because of their age. Therefore, services for older people are, and have been, a priority for the Government.

We know from patient surveys, for example, that older people are generally satisfied with the services that they receive from the NHS. However, there are spheres in which standards fall short of those that we should all like. Perceptions of age discrimination affect the confidence that users and carers have in the NHS.

I must emphasise as clearly as I can that any type of discrimination—whether it is on the basis of age, race or gender—is completely unacceptable in the NHS. In fact, discrimination contradicts the ethos and some of the basic principles on which the NHS was established 50 years ago. Action is and will be taken to challenge and correct such practices.

The hon. Gentleman mentioned the recent Age Concern report, "Turning Your Back On Us". The Government welcome publication of that thoughtful report and the contribution that it has made to the debate on the standards of health care for older people in our country. Recently, I had the pleasure of meeting Lady Greengross, the chief executive of Age Concern, and I gave her a very clear undertaking that we wish to work closely with Age Concern and others in addressing the issue of discrimination in the NHS.

Age Concern and others have called for an inquiry into age discrimination in the national health service. The hon. Gentleman repeated that call tonight. I fully understand the concerns that older people sometimes get a poor deal from the NHS. We have recognised those concerns and take them very seriously. In 1997, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), who was then Secretary of State for Health, commissioned the Health Advisory Service 2000 to undertake an investigation into the care of older people in acute wards in general hospitals. He published the report, "Not Because they are Old" in November 1998—the hon. Gentleman might be familiar with it. The report made it clear that older people should receive the same quality of care from the NHS as younger people, based on clinical need, not on their age or where they happen to live. A health service circular was distributed to the chief executives of all health authorities and trusts, together with a copy of the report, requiring appropriate remedial action where the essentials of care were not being provided locally.

The Government followed up the report by putting in hand work to develop a new national service framework for older people, which we will publish later this year. That will be an important landmark for improving quality and equity in health care for older people. The hon. Gentleman asked whether the new national framework would address discrimination. I assure him that a significant section of it will address fair access to NHS services. He also asked whether older people would be involved in the planning and delivery of health care for their age group. We were very lucky to have the active participation of a group of older people and their carers in preparing the national service framework. Older people and their carers have been fundamentally involved in the preparation and development of the standards.

The national service framework will be an important landmark for improving quality and equity in health care. For the first time, it will set national standards and define new service models for the health care of older people. It will include performance measures for monitoring progress. Against that programme of action that we have already taken, a further inquiry into age discrimination in the NHS would not be helpful in solving the problems that older people face or perceive. We need action to tackle the issues. The important task is to concentrate on preparing for the implementation of the new national service framework to deliver higher quality services to all older people based on clinical need.

There are two further arguments to bear in mind on the issue. First, an inquiry along the lines proposed by the hon. Gentleman would almost inevitably take time, posing a real risk of delay in taking the necessary remedial action that he and others are rightly calling for. Secondly, his call for an inquiry rests in part on an assumption that the Government will not act unless such an inquiry finds evidence of unsatisfactory practices. He is looking for a means of forcing us into taking action to address his concerns. Nothing could be further from the truth or more divorced from reality. The Government are already committed to taking action to improve services for older people, as evidenced by the forthcoming national service framework and the development of a range of new intermediate care services designed specifically to meet the needs of frail older people. We have a range of other initiatives under way to improve health care services for older people.

I fully understand the hon. Gentleman's argument, but things have moved on. Now is the time to get to grips with solving some of the problems that he and others have identified, rather than rehearsing the case for an inquiry. We accept many of the criticisms that have been made and think that it is time to take action to address them.

Mr. Burstow

The Minister may have noted from the balance of my remarks that I was looking for action. Since the issue of "not for resuscitation" orders marked on records was highlighted in April, Age Concern has received information on 100 further cases. What action are the Government taking to stamp that practice out so that people are consulted before their records are so marked?

Mr. Hutton

We are very aware of some of the concerns that have been expressed about the policies and guidelines on resuscitation and we are carefully considering those issues to see if there is a need for further action. That is a fair point and we are alert to those concerns. It may be that we will need to return to that general issue. I accept the hon. Gentleman's case that we need to do more to involve older people in the debate about improving services and we are trying to do that in a number of ways. The work on the national service framework has been informed by older people and carers through two groups which we set up to ensure that the development of the NSF was informed by those who matter most—older people and those who care for them. I recently received a joint letter from Help the Aged and the Carers National Association on that point. It states: We wanted to write and express our appreciation for the way that older people and carers were involved in the development of the National Service Framework for Older People. We know that it is difficult to get these things right, but felt that their involvement in this case has been real. It also states that the groups were treated as equal partners, their views were respected and carried weight, and they were involved from a very early stage which meant their advice helped to shape the final report to Ministers.

We will involve older people in other ways as well. The expert patients taskforce, which is chaired by the Chief Medical Officer and which was established in November 1999, is a partnership of people who are living with chronic conditions, voluntary sector organisations working in this area, health and social care professionals and carers' representatives. Organisations on the task force include Age Concern, Arthritis Care, the British Diabetic Association, and the Long Term Medical Conditions Alliance, many of which deal with chronic conditions that impact greatly on older people. In developing its recommendations about an expert patients programme, the taskforce has made access issues for older people a key consideration

As I said earlier, the Government intend to publish the national service framework for older people later this year. The NSF will enable us to work towards reducing variations in standards of care, but the volume of services is also important, and the significant investment we are making in the NHS enables us to ensure that we get services which are modern and which will reflect the way society is changing.

Earlier this year, we published for consultation "The National Beds Inquiry". It shows that, by comparison with a number of other European countries, the NHS is a relatively efficient user of beds, with comparatively low bed numbers. However, there is a wide variation in hospital bed usage between health authorities in the NHS. Interestingly, it has not shown any simple link between the number of acute beds, the management of emergencies, and elective waiting times.

All this evidence points to the need to take a whole-systems view of services, a point to which the hon. Gentleman rightly drew attention. Nowhere is that need clearer than in the case of older people. As he reminded us, two thirds of hospital beds are occupied by people aged 65 or over. Since the mid-1990s, half of the growth in all emergency admissions has come from people aged 75 or over, especially for conditions relating to the frailty and infirmity of very old people.

The hon. Gentleman is right to say that those findings require a different approach to the management of care in the NHS. NHS care has traditionally been about dealing with life's incidents, such as heart attacks and broken bones. Now an ageing population and increasing chronic disease means that NHS care has also to be about dealing with life's experiences, such as getting older and becoming frailer.

NHS care must therefore be modernised to reflect changes in society itself. The services that the NHS provides for older people are a vital part of that modernisation. At the moment, for too many elderly people, there is a lack of real choice. Many older people stay in acute hospital beds longer than they need to because they have not recovered enough to go home, but have nowhere else to go. What they need is intermediate care services to provide a new bridge between home and hospital.

Intermediate care will take many forms. Some services will be in specially designated hospital wards run by nurse consultants. Some will be in new facilities in the community, perhaps giving new purpose and life to cottage hospitals. Some will be about improved care services in the home.

My right hon. Friend the Prime Minister, in his speech in the House the day after the Budget, announced a new national plan for the NHS. One of the five key challenges he laid down was about partnership. I shall lead the team that will develop that section of the national plan, and we shall focus on partnership in the health, housing, and social care systems to make all parts of the system work better together and ensure the right emphasis at each level of care. That is of particular importance for older people to ensure that they receive well co-ordinated care.

All those initiatives focus on older people and will help us to build on the achievements and improvements that we have already made. We are making the biggest-ever investment in the history of the national health service, and the recent Budget announcement of real-terms increases of 6.3 per cent annually over the next four years will ensure that that investment takes place.

It is worth bearing in mind that that investment will allow the NHS to grow in real terms by a third by 2004. By any stretch of the imagination, that is a very significant investment in the NHS and its sustainability in the future. I believe that older people will be among the principal beneficiaries of that new investment.

The extra resources present us with a once-in-a-lifetime opportunity to transform the NHS radically. We have made a good start: a record number of hospitals are being built and every accident and emergency department that needs it will be modernised. Waiting lists are coming down. By the end of this year, patients with suspected cancer who are urgently referred by their GP to hospital will be seen within two weeks.

In addition, new chest pain clinics will do the same for patients with suspected heart problems. We are taking action to improve access to cataract surgery. Waiting times for hip and knee surgery—common conditions among older people—are falling. All of those developments are positive and welcome.

As the hon. Gentleman said, older people are the biggest users of health services. We want them to benefit from the new investment in the national health service. We have extended the annual immunisation programme for influenza to ensure that everyone aged 75 and over can have the flu vaccine free of charge. All people aged 60 and over are now entitled to free eye tests, regardless of income or health status. An estimated 5 million older people will have had free sight tests by April 2001.

Those are all very positive developments. They show the Government's commitment to improving services for older people, and disprove the contention that the Government are ignoring issues of age discrimination in the NHS. We are certainly not ignoring those issues.

Mr. Burstow

I am grateful to the Minister for giving way a second time. I mentioned in my speech the case of a constituent of mine, Mrs. Marge Terry. Will the Minister be able to deal with that this evening, or will he respond in writing later?

Mr. Hutton

I was going to say something about the hon. Gentleman's constituent. I fully understand the hon. Gentleman's concerns and comments about that very tragic case. Mrs. Terry died in St. Helier's hospital in October last year. He will know that a formal complaint has been made about Mrs. Terry's treatment and that a thorough investigation into the circumstances of her death is under way.

It is not that I do not want to say anything about the case but, given the circumstances surrounding it and the fact that a formal inquiry is under way, it would not be appropriate or helpful for me to comment on it tonight. However, I am sure that all hon. Members would express their condolences to Mrs. Terry's family at what I am sure is a very difficult time. I hope that the matter can be satisfactorily resolved.

The hon. Gentleman also asked me specifically to review the care provided for elderly people in his local NHS trust. We are looking carefully at care for the elderly in all NHS trusts, as part of the preparation for the introduction of the new arrangements for intermediate care to which I have referred.

Increased life expectancy is among the greatest achievements of modern times. As the hon. Gentleman said, it is something to celebrate. The Government recognise the valuable contributions that older people can make—and do make—to their families and communities. Wisdom, experience, tolerance and good citizenship are some of the precious gifts that older people share with the younger generations.

We in the Government are determined that older people should have high standards of care in the NHS, based on clinical need and on no other factor. As I and other Ministers have made clear repeatedly, discrimination has no place at all, in any shape or form, in the NHS. We sense that there is a real appetite for, and commitment to, changing the NHS into a modern, 21st-century, consumer-focused service.

We are determined to listen to what people—the users of the NHS—think about the services that we provide, and last week we launched the biggest public consultation ever on the future of the NHS and how to modernise its services. I hope that older people in particular will take the opportunity to let us know what they think. For the first time, every member of staff and every citizen will have the chance to speak up for the modern health service that they want.

Alongside the national service framework for older people and some of the other initiatives that I have described, the consultation is a unique opportunity for everyone to shape the health service to meet the needs of older people.

Question put and agreed to.

Adjourned accordingly at half-past Ten o'clock.