§ Mr. Steve Webb (Northavon)It seems appropriate to have a debate about cancelled operations and waiting times on a day when the Chancellor will no doubt announce—or re-announce—the investment of vast billions of pounds in the health service during the coming years. I make no apologies for raising the topic, as it is one that will not go away. In my constituency surgery and mailbag, day after day and week after week, the pressures on the local health service are among the biggest issues. I am grateful for the opportunity to bring them directly to the Minister's attention and I hope that he will offer some encouragement for the future.
I have nothing but praise for doctors, nurses and the other NHS staff—who are often not mentioned on such occasions—and for the work that they do in our local hospitals. I am not criticising them, as they need and deserve our support. They are trying, under great pressure, to deliver a first-rate service. By bringing such concerns to the Minister's attention, I hope that the Government will be encouraged to do more to support them. I shall comment on three issues: cancelled operations, waiting times, and plans in the local area to try to address those problems.
I shall set the context in relation to cancelled operations. The latest figures show that in England about 1.1 per cent. of operations and elective surgery are cancelled. In the Avon area, the figure is 1.9 per cent., which is a little less than double the rate of cancellation. I was alarmed to receive statistics from the House of Commons Library that showed a much more rapid deterioration in Avon than elsewhere in the country. The Library has given me quarterly figures to 1999–2000 from 1995–96. In that period, the number of cancelled operations throughout the country rose by about 11 per cent., while the number in Avon rose three times as fast. The problem of cancelled operations is clearly national, but it seems to be especially acute and rapidly becoming worse in Avon. I realise that Avon is not the worst authority by any stretch of the imagination according to these dodgy, or, rather, unwelcome, league tables, but clearly the problem is quickly becoming much worse.
The Library's statistics show not only how many operations were cancelled but how many breaches of the patients charter followed. It is a requirement that, once an operation is cancelled, treatment should take place within a month. Of the growing number of cancellations, the proportion of operations not performed within a month of cancellation doubled. Three times as many operations were cancelled and double the proportion of that larger number were not treated within a month.
The charter was breached in every quarter from the start of 1995–96. It was never breached more than 100 times in a quarter until the final quarter of this year, when it was breached 221 times. To humanise that figure, 221 people who looked forward to the date of their operations may have arrived at the hospital, or were telephoned first thing in the morning, to be told that their operations would be cancelled and they did not receive treatment even within a month of the time expected. That is a serious problem. A cancelled operation is one of the cruellest experiences possible and it seems to be happening much more and far too often in Avon.
38WH The trusts that serve south Gloucestershire—the subject of the debate—and North Bristol NHS trust have kindly provided me with some briefing material, as has the health authority. When I requested the debate, I was not aware of the statistics. All that I had seen were the faces coming to my surgery, from which I observed that a problem existed.
The figures bear out that first-hand, anecdotal experience. I have been given monthly figures for cancelled operations from last October. In a typical month, if such exists, North Bristol NHS trust cancels 80 operations, which is, obviously, 80 too many. In January, it cancelled 253 operations—more than three times as many. At the time, we heard a lot about winter pressures, which I had the opportunity to discuss in a separate Adjournment debate in the House. Cancellations on that scale cause misery for far too many people. Clearly, winter pressures were part of the story, but even in summer the trust has to cancel 80 operations a month. The trust's briefing suggests that long-term trends are involved, which are not going away. Long-term upward trends are evident in emergency admissions, the number of over-85s admitted and length of stay in hospital.
The word that has arisen in researching the topic and speaking to hospital staff is "pressure". I am told that in summer it used to ease off, but now all year round there is pressure and a lack of capacity. The lack of capacity in the local NHS was evident from the national beds inquiry, which showed that Avon is an outlier. It has one third fewer hospital beds per head of population than the national average and about one fifth fewer than the regional average.
The strategy proposed is to use community care and nursing homes to help people to stay in their own homes, and to rely less on keeping people in hospital. We would all sympathise with that objective. However, the downside of that strategy is that when the pressure comes, no slack and, therefore, no capacity is available. According to the health authority briefing, the bed figures
may explain why, at times of peak demand, the option to increase emergency capacity by the cancellation of surgical procedures is utilised.In other words, no slack is available: hospitals must cancel operations. That is a source of great anxiety.I could list many cases of people whose operations have been cancelled and who have come to see me. The Minister is well aware of the nature of the problem. It is the cruellest experience to have an operation cancelled on the day or in hospital, and that cruelty is compounded by the fact that some of my constituents have had operations cancelled two or three times. They phone me up and tell me of the cancellations and I feel completely helpless. I write to the trust, which tells me that there is a perfectly good reason, such as a sudden influx of emergencies or what are called medical outliers—that is the term for people being treated for whom there are no beds, who therefore take those that would have been used by the people due to have operations. There is always a good reason, but when will the situation end?
Cancelled operations are part of the story—one symptom of the pressure on the local NHS. Long waiting times are the other side of the coin. The Minister 39WH responded to a previous debate of mine about a year ago on orthopaedic out-patient waiting times. It is unfortunate that I have to raise again the fact that, despite an awful lot of imagination and effort on the subject of orthopaedic out-patient waiting times in the Avon area, the waits are still unacceptable.
The problem is not only in orthopaedics. One of my constituents—I shall refer to him only as Mr. K—needed a heart bypass. He was told in March 1999 that he was on a waiting list and is still on it 15 months later. I wrote to the United Bristol Healthcare NHS trust, which said that it was sorry and that he would be seen within the absolute upper limit of 18 months. The chief executive said that the trust had
encountered numerous problems in the past year in admitting routine patients for cardiac surgery.Of course, my constituent does not think that his is a routine case. He feels that his heart problem is getting worse with every passing month. He is unhappy to be told that his is a routine case and that 15 months is therefore acceptable. The trust does not want the situation to have dragged on so long, but it is only at 18 months that he will go to the top of the queue. One reason is the number of urgent admissions, which obviously take priority. The blackly humorous word doing the rounds in the Avon area is that the only way to receive heart treatment is to have a heart attack. That is the way to jump to the head of the queue, or the wait is 18 months. That situation is deplorable.
The chairman of the trust says that there is a shortage of theatre staff for cardiac and thoracic surgery and that that has tended to lead to a large number of cancellations. He also says that there will be seven new beds, which is welcome. He does not say where the staff will come from, which is worrying if there are not enough staff for existing operations.
All sorts of surgery are affected. Another constituent, Mr. H, needed the condition of his heart investigated through an angiogram. He was told that it would be a year before he could have that done—a year before staff could assess what treatment was needed. The trust reassures me that it monitors people and if it thinks that a situation is urgent it will carry out treatment straight away. Mr. H was told that he could wait a year, so he paid privately for an angiogram, which concluded that he needed quadruple bypass surgery. If he had not had the angiogram and the need for the surgery had not been detected, would he still have been alive to have had the surgery? How many people come off waiting lists because they die?
The key promise that I want from the Minister today is to investigate the reasons why people come off waiting lists. I want him to consider not only death, but people forced to go privately even though they have no private health insurance cover. I do not mean members of BUPA or any such organisation, but ordinary members of the public who are put on waiting lists but see their health deteriorating as month after month goes by. Many are in discomfort for months, losing earnings—not all the people involved are elderly by any means—and cannot face the wait. They are driven to raid their life savings of thousands of pounds to have private treatment.
I shall give the example of a mother of two from Thornbury in my constituency, who was told by her doctor that she should see a consultant about an ear 40WH condition. She waited for the appointment, but time went by, so she paid privately for a consultation and was told that she needed an operation for a degenerative ear condition. It must be the worst possible scenario to be on a waiting list with a degenerative condition, because people in that situation know that each week and month that goes by makes them worse. Her NHS treatment was cancelled and she got to the stage where she was so desperate that she paid thousands of pounds, which she could ill afford, for a private operation. After being treated, she was told that if her condition had deteriorated for as long as the NHS was prepared to let it, and she had waited until the date she had been given for NHS treatment, there was a high probability that she would have suffered a stroke. She was also told that the delay between diagnosis and treatment had meant that her condition had degenerated so much that she would not recover the hearing in her ear. Had there not been such a delay, there would have been enough bone left to insert a hearing aid into the ear and her hearing might have been saved.
I wonder how many similar stories there are; we do not know because there is no evidence. I have tabled written parliamentary questions asking the Government to collect data on the people who come off NHS waiting lists by paying privately and have been told that such data are not collected. As a matter of priority, they should be. I hope that, if he says nothing else, the Minister will assure me that that data will be collected so that we can monitor how many people are being forced into that situation, over what time period, in what parts of the country, in what specialisms and how serious the situation is. If ever there was an indicator of pressure in the NHS, it is people desperately trying to buy their way out of long waiting lists.
A final constituency case is Mrs. E, from Chipping Sodbury, who was told in May 1999 that she faced an 18-month wait to see a consultant. She could not afford the £6,000 for private treatment and she badgered the hospital by ringing every week—at one stage, I gather, every day—and after 13 months she was seen and told that she was now on the in-patient waiting list for treatment. So she had waited 13 months to be told that she could be on the waiting list. She has had to give up full-time work and work part-time because of the discomfort. Her consultant was recently quoted as saying that the situation is extremely frustrating but medical staff have little control over it, that he did not know how they could get round it and that he felt very sorry for the patients. I therefore criticise not the people who work in the NHS but the system that puts them in the impossible situation of telling patients that they cannot be treated and of cancelling their operations.
Things are happening in the Avon health authority area. Money is going in and plans are afoot. We are told that there will be improvements in cardiology and orthopaedics. A hospital-at-home scheme, costing a quarter of a million pounds, will reduce the pressure on beds in hospitals—which should in turn mean fewer cancellations. Frenchay hospital is gaining 28 acute medical beds and there is work in the community to prevent people from coming into hospital in the first place. That is all part of the picture.
However, I am concerned about the conclusions of the briefing that I received from the local NHS trust. It says that it is making headway on cancelled operations and 41WH believes that it will break the back of the problem, maintaining good performance on in-patient waiting times. However, my heart sank when I read that it is falling behind in out-patient targets. Something tells me that, unless things change dramatically, the Minister and I—the electorate permitting—may be here again another year, and another year. I may have more tales of woe and more tales of cancelled operations and unacceptable waiting times. I asked the Minister last time if he would take responsibility for the situation, because everyone always blames everyone else. Things are being done and money is being put in, yet the problems are still with us and I see no imminent prospect of a dramatic improvement.
We need hard evidence about the consequences of long waiting times and cancelled operations and of people being driven to fork out private savings for care that they should be able to get on the NHS. I hope that the Minister will promise such research and hard evidence on the scale of the problem and will reassure me that we do not need to be back here in 12 months.
§ The Minister of State, Department of Health (Mr. John Denham)I congratulate the hon. Member for Northavon (Mr. Webb) on securing the debate. He described several problems, but I am not convinced that his proposal to divert resources from patient care into the bureaucracy of running surveys will cut waiting lists or improve the quality of care from the national health service. We need to deal with the problems of long waits and cancelled operations not only in the hon. Gentleman's part of the country but all over. That is the right way to reduce the number of cases, which I accept, from my constituency experience and his, is leading people to choose private treatment. We can reduce that number by improving service quality.
I shall describe our strategy and some of the changes occurring in Avon as a direct result of measures introduced by the Government. The hon. Gentleman will understand that he might have to wait until we publish the new national plan for the NHS next week to learn all the details. I recognise that the recent high number of cancelled operations at North Bristol NHS trust has increased the length of time that patients must wait for operations. The hon. Gentleman described clearly the effect on individuals, the disruption to their lives and families and the delay in providing their treatment, which I accept have occurred. We are investing heavily in the NHS and I shall shortly set out some of the measures that that investment has facilitated.
In common with some other trusts, since before Christmas, North Bristol NHS trust has been forced to cancel many elective in-patient operations, primarily because of the high level of emergency medical admissions, as the hon. Gentleman said. That phenomenon has continued well past the usual winter pressures period. The current level of admissions is far higher than that in previous years and has lasted longer. The significant decline in admissions that usually takes place at the end of the winter has not occurred—that is in addition to a steady underlying increase in the number of admissions to the trust hospitals in the past few years. The number of patients requiring emergency admission has made it necessary occasionally to admit those 42WH patients to surgical beds. That has forced the cancellation of operations for the patients who would otherwise have used those beds.
It is a significant achievement that the trust has continued to meet its in-patient waiting list targets during this difficult period. Those figures represent patients successfully treated. Out-patient figures remain unacceptable, although since we last spoke, the figures have fluctuated. The numbers considerably improved but, regrettably, they slipped back again, particularly in orthopaedics. However, I understand that the trust plans to appoint an additional orthopaedic consultant from September. I hope that that will put back on track the progress that the trust had begun to make.
In response to our national initiatives, the trust has prepared a detailed management plan to reduce the number of over-13-week waiters in out-patients and to manage GP referral rates more effectively. The trust has introduced a partial-booking system for out-patients. Such systems were piloted in Basildon and Chesterfield and were shown to reduce out-patient waits significantly. We will publish a report about that project, which will roll out nationally, in the next few days. I understand that the trust's plans contain proposals for considerable work in the four specialities in which the out-patient waits are longest.
The trust and the health authority are working together to resolve the problems facing the trust. We should discuss briefly the Government's wider assistance for the NHS. A key part of our help is in providing the necessary funding to support front-line staff and services in meeting the increasing pressures on them. Like the hon. Gentleman, I pay tribute to the staff in the trust for their hard work. They work under great pressure.
As the hon. Gentleman knows, my right hon. Friend the Chancellor announced the largest ever sustained increase in NHS funding in the Budget. In the next four years, expenditure on the NHS will increase by an annual average of more than 6 per cent. in real terms. That is twice the historic rate of growth in funding. This year, the NHS will receive a total increase of £4.17 billion. Of the new money for England, £600 million has already been allocated to health authorities to meet local pressures and a further £60 million from the performance fund will be made available when they meet specified levels of performance. Additional sums of money have also been released, including investment in critical care beds, which will help to tackle some of the problems that the hon. Gentleman outlined.
The total allocation in Avon this year was nearly £642 million. That is an increase of £37.5 million or 6.3 per cent. That money will enable Avon health authority, working together with local NHS trusts, to reduce waiting lists and times for both in-patients and out-patients and to expand services. The hon. Gentleman made an important point: the provision of money on its own will not treat patients unless we have trained staff to provide the clinical services. We have seen big increases in the number of doctors and nurses employed in the NHS in the past three years. By September last year, the number of doctors employed in the trusts in the Avon health authority had increased by 14.5 per cent. Since April last year, the North Bristol NHS trust has appointed 12 new consultants and five registrar posts have been approved. In the past year, it has also employed more than 50 new qualified nursing staff.
43WH Significant though those rises are, we still need more staff. That is why we have expanded nurse training, why we recently announced the expansion of medical school provision and why we are increasing the number of nurses and doctors that we want to employ. For the past two years we have run a national recruitment campaign aimed particularly at nurses. In the south-west region, about 183 nurses who had left the profession returned to the NHS last year, and since February this year, a further 136 nurses have returned to the NHS.
The number of nurses entering training each year in the Avon, Gloucestershire and Wiltshire training consortium area has increased by 26 per cent. since 1996–97. This year, the number of training places will be expanded further so that 41 per cent. more nurses will enter training than did so in the last year of the previous Government. The hon. Gentleman recognises that it takes time for that investment in training and training places to feed through into the supply of nurses available to the NHS.
In Avon itself the health authority received record additional levels of funding this year, with an increase of £37.5 million. The health authority is spending £11 million of that on meeting the priority of reducing waiting times for both in-patients and out-patients. The North Bristol NHS trust has agreed a £5.5 million package of investments to tackle its problems of capacity, reduce the number of cancelled operations and achieve reductions in the number of patients who are waiting too long for both in-patient treatment and out-patient appointments.
The measures in the package will mean that the trust will open an additional 90 beds this year. As the hon. Gentleman said, if one applies the conclusions of the national beds inquiry, he represents an area where there are fewer beds than in general. The opening of those additional 90 beds will be welcome. It is also important to understand how it is intended to use the beds. Those extra beds and wider changes in the way that beds are organised at the trust will allow the surgical beds at the Avon orthopaedic centre to be ring-fenced for surgical work. That means that they will not, hopefully, be occupied by medical emergencies, with the knock-on effect on cancellations that has been described. The orthopaedic centre has been most affected by the need to accommodate medical patients.
§ Mr. WebbThe Minister has only a few minutes left. I am interested in the key point about the evidence of people coming off lists into the private sector. He had the nerve to talk about spending money on the bureaucracy of surveys. How many millions of pounds were spent on the survey that he sent to millions of NHS users and staff, and how much would it cost to gather the information that I want, which would expose what is going on in the NHS today?
§ Mr. DenhamWe all want shorter waiting times for out-patient and in-patient treatments. That should reduce the number of people wanting to go private rather 44WH than go on NHS waiting lists. I see little value in spending money on studying that matter when we could use it to cut waiting times.
The involvement of patients in shaping the new national plan was essential. We want a more patient-centred NHS than we have had, and it is doubtful whether we can achieve it without some form of patient consultation. As I recall, the consultation exercise cost about £200,000 to £250,000. The exact answer is likely to be on the official record, perhaps in response to parliamentary questions tabled by the hon. Gentleman.
§ Mr. WebbI am still sceptical about the exercise. Can the Minister specify three points that were learned through the consultation exercise about patients' views that were not known before it?
§ Mr. DenhamThe hon. Gentleman may want to wait for the national plan. However, basic cleanliness and a clear management structure in the wards were given a high priority by the public, which is not always clear from talking to managers and others within the health service. Understanding how the health service appeared to patients was valuable and helped to shape the national plan. The hon. Gentleman will have to wait a few more days to establish whether we have adequately reflected the consultation in our proposals.
The trust will also use nearly £750,000 on several schemes to deal with the problems of rising medical admissions and the cancellation of operations. The aim is to prevent inappropriate admissions and to facilitate the discharge of patients back into the community. The schemes include the appointment of a specialist registrar and staff positions in cardiology at a cost of £170,000. That will improve the availability of cardiac services, which the hon. Gentleman identified as a priority area, help to manage emergency demand more effectively and reduce admissions.
More than £250, 000 will be invested in expanding the trust's existing hospital-at-home scheme, which helps to prevent unnecessary admissions and allows a speedier discharge of patients. About £170,000 will be invested in the community-based multidisciplinary stroke team and in additional outreach and rapid access occupational therapy and physiotherapy. The idea is to provide an intensive outreach rehabilitation service to enable patients to return to the community more quickly, and to support them in their homes.
I am aware of the hon. Gentleman's long-standing concern about the length of out-patient waiting times at the North Bristol NHS trust. We have had the opportunity to debate those issues in the past and I can assure him of my continuing desire to see substantial improvements. The Government have helped by making investment available in the previous and the current year, which should have an impact on the problem. I accept that some patients are waiting far too long at present. The trust has targets for improvement in the coming year, and we shall provide it and its staff with all the support that we can to achieve those targets.
§ Question put and agreed to.
§ Adjourned accordingly at two minutes to One o'clock.