§ Mr. Simon Thomas (Ceredigion) (PC)
What an esoteric title this is for a Westminster Hall debate. I assure hon. Members that the working time directive will have an impact on the national health service in Wales. It is timely and appropriate that we explore that issue in an advance of the introduction of the directive in August this year. To date, Members of Parliament have had little time to consider in detail the impact of the directive, which has been negotiate I directly between the United Kingdom Government and the European Union, and its effect on the health service in Wales, which, on the whole, is a devolved issue.
I welcome the hon. Member for West Carmarthen and South Pembrokeshire (Mr. Ainger) to his place. It is unusual to hear the Whip's voice and as I am not a member of his party, I will be able to bear it, although I cannot speak for members of his party.
Let us be clear about the directive Employees should work only a 48-hour week averaged nit over a reference period. They should rest for 11 consecutive hours per day, have a rest break when the day is longer than six hours, have a minimum of one rest day per week and a statutory right to four weeks' holiday. Night working must not average out at more than eight hours at a stretch. That is all very commendable, although the Government chose an opt-out from the directive for many years. I hope that the hon. Gentleman will confirm that the Government are not seeking further opt-outs and that the directive will be introduced as planned.
It is clear what the directive's effect on the NHS will be. By August 2004, junior doctors will be able to work only 58 hours per week; by 2007, that will be 56 hours per week; and the full directive hours of 48 per week will be implemented by August 2009. Many NHS trusts in Wales are concerned that there are simply not enough doctors to cover the new arrangements. The NHS could do one of two things: hire hundreds of new doctors, which is hardly feasible given the time it takes to train them, or radically rethink the v ay in which some services are provided. I would like to examine some aspects of that issue today.
In England, the Department of Health has set up a strategic change fund to examine how we can change the service. It supports pilot projects on new ways of working. It is not clear whether anything similar will happen in Wales, so I hope that the hon. Gentleman will comment on how Wales can respond to the change.
Patients will be concerned about something much more fundamental—the impact on waiting times and on primary, secondary and tertiary care. A few days ago inThe Western Mail, Mike Ponton, director of the Welsh NHS Confederation, said:"These developments"—recent developments in the NHS—"and others such as the impending European Working Time directive which will affect junior doctors' hours, mean that there is no option but to think radically about the way we provide services."
420WH A scoping exercise on the European working time directive undertaken by the North West Wales NHS trust found the following. The adoption of a full shift system, which would be necessary under the directive, will significantly reduce the daytime availability of junior doctors. The areas that need to be addressed to achieve compliance are mainly those of human resources, reconfiguration of services, training and education. The reconfiguration of services may not be restricted to secondary care—that is, the district general hospital—but could involve primary care and tertiary or specialist care as well, and even NHS Direct and the ambulance service. Finally, the factors that will impinge on working towards compliance with the directive will be the GP contract, which has been newly negotiated in Wales, and the consultant contract. The report concluded that the main issue with the directive is the provision of out-of-hours cover, as that is what impacts on waiting time targets and GP contracts.
We know that waiting times in Wales are worse than in England. We know that the first Assembly Government's dream to have no one waiting more than six months for out-patient treatment and no one waiting more than 18 months for in-patient treatment has never been realized; it is a promise that has never been fulfilled. Currently, 68,000 patients are awaiting out-patient treatment. The number waiting for in-patient treatment has recently fallen to 1,401, although that is of no comfort to those who are waiting or to those who are attending hospitals in England. I think of my constituent, Mr. David Duff, who contacted me recently. His appointment at Gobowen orthopaedic hospital is not for another 18 months. It seems that the English hospitals contracting with the NHS in Wales are taking the Welsh time of 18 months not as the longest time, but as the earliest possible time, because that is how they can fulfil their contract.
The situation in Wales and in the NHS was recently examined in considerable detail by the Audit Commission, which had some rather shocking things to say. It said that the health service in Wales is currently "unsustainable" and that health spending is "inefficient and ineffective", despite the funding increases. It says that the NHS in Wales applies"the wrong resources in the wrong place for the wrong reasons."There could be no more obvious condemnation of what has been happening. It says that too many patients are treated in the wrong setting and—I hammer home the lessons of the working directive—that Wales has fallen behind England in reconfiguring services.
§ Lembit Öpik
I thank the hon. Gentleman for his congratulations. Does he support or oppose the suggestion of an opt-out from the working time directive for certain sectors?
§ Mr. Thomas
I do not support any opt-out from the working time directive, which I support completely. I am saying that the NHS in Wales needs to reconfigure 421WH its services to meet the obligations of the directive, but it is not doing that. It is rather late in the day to achieve those aims, which is a pity.
The Audit Commission report comes to the same conclusion. On the failure to implement change or reconfigure services—the hon. Gentleman might be interested in this conclusion—it states:"The consequence may also be severe damage to community, social, and political confidence in Wales' ability to use devolution effectively to meet the challenges of change."As a supporter of devolution, he will be as shocked as I am about that conclusion.
We know that north-east and north-west England have similar patterns of apparent comparative poor health, but they have consistently delivered more and better health care at a lower cost than in Wales. The differences between England and Wales in terms of admissions to hospitals are not caused wholly by the myth that Wales is somehow a sicker society, but by the fact that many more patients in Wales are treated in acute centres—for instance, in hospital rather than by the GP—when they could be treated elsewhere, which would be a more effective use of money.
The only reconfiguration that has taken place in Wales is the establishment last year of 54 unnecessary health quangos. As the Audit Commission said, that has resulted in"duplication of services and complex managerial problems."Only this week, the Secretary of State for Health announced the abolition of half the English health quangos, which has freed up £500,000. I would be delighted if the hon. Gentleman responding to the debate were to announce the same for Wales today or even say that the National Assembly will shortly be making such an announcement.
Finally, the working time directive will affect the new contract for GPs in Wales. A survey byPulse magazine reported in January this year that 92 per cent. of GPs felt that the new contract would lead to a rise in referrals to accident and emergency departments. That is precisely what the Audit Commission report and the earlier Wanless report warned against for Wales. More pressure will be applied to A and E because, under the new system of working, as many as eight out of 10 GPs will be able to opt out of out-of-hours care. That is a huge worry. It was announced today that the first independent private GP in Wales has been appointed. I hope that the name of Joanna Longstaff will not go down, like that of Aneurin Bevan, as the signal marker of a real change in how the NHS is working in Wales.
From my perspective, general practitioners in Ceredigion have already announced that they are to close 24 branch surgeries as a result of the new out-of-hours contracts. That means that many patients who usually go to their branch surgery to meet the GP will be isolated if they have no car or cannot visit. Whether or not they are elderly, they will let their condition worsen, and they will certainly end up referring themselves to accident and emergency departments rather than going to their GP. The implications are huge.
422WH The 24 branch surgeries that will close include the Llanilar health centre at Ponterwyd, Pontrhydfendigaid and Pontrhydygroes—I love these names; it is great thatHansard finds a way of coping with them, and they are all in the best part of my constituency—Aberaeron surgery at Llangeitho, Llanon and Tregaron; Newcastle Emlyn surgery at Cardigan, Cilgerran, Aberporth and Velindre; and Tregaron surgery at Llanddewi Brefi and Pontrhydfendigaid Llangrannog, which is some 11 miles away from the nearest surgery, is also losing its branch surgery. I could go on, but as I said, there are 24 of them, and I shall not mention them all. One result will be more referrals to accident and emergency departments.
It is clear that the working time directive will improve the lot of many NHS staff. It is about time that that happened, and we support it. However, it is not clear whether it will improve NHS treatment. That lies in the hands of the National Assembly for Wales and the Treasury. I must say that the Treasury has done its bit. In the past three or four years, its spending on the NHS in Wales has increased by 30 per cent., and we should welcome that. However, will the hon. Gentleman who is answering on behalf of the Government say how the Government propose to grasp the nettle of reconfiguration and address the waste and inefficiency that the complex and many-layered system of the NHS in Wales has introduced? Will he also say how we can be assured of proper primary and secondary care when the working time directive is introduced in Wales in August?
§ Hywel Williams (Caernarfon) (PC)
I thank you, Mr. Deputy Speaker, for the opportunity to speak very briefly on this important subject. I also congratulate my hon. Friend the Member for Ceredigion (Mr. Thomas) on securing this brief debate.
Plaid Cymru Members fully support the implementation of the working time directive, and have done so for a considerable period. Other parties that I could mention were not quite as committed to it as we were. My hon. Friend outlined several NHS-related issues that concern us. The arguments relating to junior doctors' hours, for example, have been well rehearsed, and he also referred to them to some extent.
The out-of-hours duty for GPs is a particular concern in my area and in other rural parts of Wales, as my hon. Friend said. The current pattern worries patients who have found services to be scarce and have had to travel considerable distances, as well as medical staff. The medical staff with whom I spoke in preparation for the debate were, rightly or wrongly, unclear about future arrangements and the effect of the working time directive on GPs' out-of-hours systems. My former GP, Dr. John Webb of Criccieth, put it succinctly when he asked how GPs would be affected by the working time directive if they were contracted in to provide out-of-hours services and were otherwise self-employed. They are both self-employed and employed, so do they count as employees only for the period during which they are contracted in for out of-hours service? What about the times when they are self-employed? Do not these hours also count?
423WH The aim of the working time directive is to improve the quality of services, as well as the conditions for people at work. What if a GP works as a self-employed GP one day, is due to work the following day and is then up all night? Will the working time directive do anything to improve the standard of service that is provided then? I should also say that Dr. Webb's practice ensures that partners who have been up and out all night have a day off. That is the best practice that can be followed.
Will the working time directive be practicable? My hon. Friend referred to the possible shortage of doctors when the hours are limited. Will it be practicable for small medical centres in rural areas that cannot recruit sufficient numbers of new doctors to give people time off when they have been up and out all Light? Furthermore, the employment status of some GPs will change when the new contracts are introduced. Presumably, there will be an effect on the number of hours hat they may work. Again, will there be sufficient staff?
I want to note the effects on GPs themselves. I am a former approved social worker who is well used to being up overnight performing one or two sections, having gone to work the previous day or being about to work on the following day. I know something of the pressure on people who do that sort of work, such as medical staff. I think that medical staff should be protected from that sort of pressure, but we need reassurance that the quality of service to the public will not decline.
§ Mr. Nick Ainger (West Carmarthen and South Pembrokeshire) (Lab)
I congratulate to the hon. Member for Ceredigion (Mr. Thomas) on securing this important debate on the impact of the working time directive on the NHS in Wales, although at times his contribution appeared to stray away from the directive itself.
The Government are committed to delivering a world-class health service for patients while maintaining a safe working environment for all health professionals across the NHS. We share that commitment with our colleagues in the Welsh Assembly Government.
We have been investing heavily in the men and women of the NHS in Wales. As the hon. Gentleman recognised, in recent years there has been a huge increase in the number of NHS staff, although that on its own is not the answer to the working time directive issue. There are now almost 19 per cent. more NHS staff in Wales, 30 per cent. more whole-time equivalent hospital consultants and almost 16 per cent. more qualified nurses than in 1997, and there are 6 per cent. more GPs than a decade ago. In the past, there used to be cuts in the numbers of doctors and nurses being trained, but the number of medical students in Wales increased from 950 in 1998 to 1,320 in 2003. This coming academic year, that figure is projected to rise to 1,385.
By 2010, the Assembly Government plan to have 700 more consultants and GPs, 6,000 more nurses and 2,000 more other health professionals. However, we are well aware of the challenge facing the NHS as a result of the extension of the working time directive to include training grade doctors from 1 August this year.
The working time directive became law in the UK in 1998, and it fixed working hours to 48 hours in every 424WH seven days, but that was not applied to doctors in training. From 1 August 2004, doctors in training will be included under the working time directive and will be expected to work no more than 58 hours in every seven days, averaged over 26 weeks. From August 2007, that will change to 56 hours in every seven days, and from August 2009, it will become 48 hours in every seven days. In both cases, that will be averaged over 26 weeks.
The issue has been compounded by the SIMAP and Jaeger rulings at the European Court, which mean that all time spent on duty in the hospital will count as work. That will include time spent resting, or even asleep, while on call. In addition, any doctors who continue their residential duty period beyond 13 hours, breaking into a rest period, will be owed compensatory rest. The Jaeger ruling suggests that that compensatory rest must be taken immediately after the end of that duty period. In effect, that would prevent doctors from continuing to learn or from delivering a service the day after a night on duty.
Those judgments were not initially part of the directive, and they are making full compliance more rigorous than had originally been envisaged. Due to the potential impact on the continuity of care and junior doctor education, the Government are urgently discussing the impact of the SIMAP and Jaeger cases with their European partners.
§ Mr. Thomas
The hon. Gentleman has introduced an important point. It is not just about the increasing numbers, which he rightly outlined, or the response of the National Assembly Government, but about the legal framework and what will have to come into the NHS in Wales. Does he think that the answer to the working time directive is to increase the training and the numbers—an approach that I think will fail—or that some of the structural problems of the NHS in Wales should be addressed?
§ Mr. Ainger
I do not think that this is a matter of structural problems; it is a matter of how the health professionals work and the mix of skills that are used. The hon. Gentleman referred to the experiments and pilots that have been carried out in England. Such things are being considered, including multidisciplinary teams in which some nurses taking on duties that have traditionally been carried out by doctors. I shall deal with that point later.
The potential modification to the original directive is most keenly felt in small sub-specialties or smaller district general hospitals, such as Bronglais, in the hon. Gentleman's constituency. Bronglais highlights the issues faced by the Welsh NHS in meeting the directive while continuing to offer a high standard of care to patients and maintaining training opportunities for junior doctors.
Meeting the directive is not optional. It is a legal requirement and a failure to comply carries the possibility of significant penalties. However, there are no knee-jerk changes that will jeopardise the standard of care that is offered to Welsh patients, and neither will the education of our future general practitioners and consultants be put at risk.
§ Lembit Öpik
The hon. Gentleman speaks about a blanket opt-out. Is he aware that the Chairman of the European and External Affairs Committee of the National Assembly for Wales said in response to a consultation:"We have some concerns about the blanket use of opt-outs in the UK and suggest that sector-specific opt-out arrangements might be more appropriate"?Is he aware of that proposal, and that there was cross-party support for it? That means that Plaid Cymru agreed with it and that it supports the blanket use of opt-outs in Westminster, but opposes them in Cardiff.
§ Mr. Ainger
The hon. Gentleman makes an interesting point, but the Government are not seeking an opt-out. They are discussing the impact of the SIMAP and Jaeger cases with their European partners.
The Welsh Assembly Government are encouraging the local health boards and trusts in Wales to prioritise junior doctor rotas that are outside the directive, because they mean too long a working week. Assembly officials have visited trusts and health boards and are offering assistance to them on meeting the directive. About two weeks ago, from 11 to 14 May, Assembly officials visited the trust responsible for Bronglais and met the local health board. They are working with the mid and west Wales regional office to explore sustainable long-term solutions, which may involve some additional staff and the possibility of employing consultants and of GPs working differently in future. I was making that point earlier.
Assembly officials are also working with local health boards throughout Wales to advise them, as commissioning bodies, about how best to invest the 1 per cent. uplift for inflation that is included in their discretionary allocation. The £30 million a year is directed at additional support to junior medical staff to meet the dual requirements of the new deal for doctors and the working time directive.
The hon. Member for Ceredigion mentioned the problems with branch surgeries. I should like to make a couple of points about that. He may be aware that the working time directive was discussed with the general practitioners committee in Wales at its monthly negotiating meeting with the Assembly Government. It is aware of the direct and, more importantly, the indirect impact on it and its staff, and it has been planning accordingly.
The hon. Gentleman believes that the working time directive has affected branch surgeries. In fact, it is far more likely that it is the general medical services contract, which is due to come in at the end of this year, that has had the impact. The contract introduces a new set of quality standards for premises to ensure that surgery premises are fit for their purpose, and that guidance is produced on issues including information technology, patient note availability, patient privacy, infection control and clinical waste disposal, which are all important.
§ Mr. Thomas
I agree with what the hon. Gentleman has just said, but my point was not that the working time directive directly affected the branch closures. In fact, it was the other way around: branch closures will put more pressure on hospital accident and emergency 426WH departments, and particularly that of Bronglais general hospital. That will have an effect on junior doctors and others working in those hospitals.
§ Mr. Ainger
I understand the hon. Gentleman's point. The Welsh Assembly Government recognise the importance of branch surgery closures, particularly in rural areas. They understand that those branch surgeries form an important part of the fabric of primary care delivery in rural areas. There is a proper laid-out procedure to be followed before any branch surgery can close. There should be full consultation, and there is an appeals procedure. However, we are dealing with general practitioners; at the end of the day, they are independent contractors and cannot be directed to carry on providing particular services in particular areas.
Complying with the directive is crucial, but the directive is not the only development in the health service in Wales. It is being addressed alongside other changes in Wales, such as "Agenda for Change", the new consultant and GP contracts, NHS modernisation and the local Wales action plans. Together with the directive, those initiatives offer us an opportunity to deliver a different but better health service in Wales. The Assembly Government are dealing with those changes through NHS trusts and, on a wider basis, through their regional offices. Trusts are being encouraged to explore the possibility of sharing resources, and they are seeking sustainable long-term solutions to certain specialties on an all-Wales basis.
As I said, at the level of the Welsh trusts, we are exploring a phased implementation of more innovative systems of care, including systems that utilise available staff more effectively and efficiently. That includes many of the ideas that are being piloted in England under the hospital at night principle. In addition, the introduction of cross-cover between specialties is being looked into. The question of who needs to be on duty and whether they can be on duty from home is being examined critically as a possible means of solving the problems posed by the SIMAP and Jaeger judgments. We aim to comply with the directive through doing that, and through the addition of limited numbers of key professionals.
Concern about the issue is understandable, as it clearly needs to be addressed. There needs to be a greater integration of primary and secondary care in the out-of-hours period. That is planned by the health boards in various reports. They are trying to bring in GPs because of new developments in contracts. Obviously, radically different systems will be in place in hospitals in order to cut out the repetitive aspects of the care pathway. All tasks will be scrutinised and appropriately delegated to competently trained staff, who will operate in a multidisciplinary team. That means that many tasks originally performed by doctors will now be performed by other trained staff. The directive will require most junior doctors to adapt to shift systems. That will require some additional staff, and it will represent a cultural change for staff and patients alike, but it is necessary to meet a legal requirement.
427WH The working time directive and recent case law represent difficult but not insurmountable challenges to the health service in Wales. We must apply simple, logical principles. We will add innovative systems of care and expand staffing where necessary. Whenever possible, we will maintain the current shape of the service. The Welsh Assembly Government are 428WH addressing that important issue, and are working with local health boards, trusts, GPs and others to ensure excellence in health care while striving for compliance with the directive.
Question put and agreed to.
Adjourned accordingly at sixteen minutes to Five o'clock.