§ 3.1 pm
§ Mr. Michael Neubert (Romford)
Passers-by in Parliament Square on the morning of Budget day were amazed to see the arrival of a 1928 fire engine in scarlet livery, with brass gleaming and bells ringing. In the front seat, open to the March weather, was a 33-year-old cancer patient, Mrs. Brenda King, from Rainham—a very decorative lady. Together with Mrs. Valerie Grootveld, from Collier Row, in my constituency, who is also suffering from cancer, and with other friends and supporters, she had driven from Havering in style and in considerable discomfort to present a 60.000-signature petition to my hon. Friend the Member for Hornchurch (Mr. Squire) and myself. They were protesting against the proposed closure of the regional radiotherapy unit at Oldchurch hospital, Romford. Both my hon. Friend—who is in China, and therefore cannot be here today—and I fully support their campaign. We have undertaken, if it becomes necessary, to present a petition to my hon. Friend the Minister for Health, so that he will be in no doubt about the strength of public reaction to the proposal.
In the meantime, we have asked the campaigners to continue collecting signatures. To those sceptics who say that a signature costs nothing, we can point out that active fund-raising in the last few weeks has raised several thousand pounds for the purchase of valuable computer equipment for the radiotherapy unit. That is another example of people's public-spiritedness in support of their Health Service.
For those reasons, I am more than grateful that this subject was selected for the last debate before the House rises for the Easter Recess. It is no less than those courageous campaigners deserve for their efforts.
Unhappily, this is the third such debate that I have had to initiate in a little over three years in defence of local health facilities in Romford. In the last debate before the House rose for the Christmas Recess in 1976, I argued against the closure of the regional neurosurgical unit at Oldchurch hospital. I was delighted when a reprieve was announced six 751 months later. Naturally, I hope that that occasion, with its coincidence of proximity to a Christian festival, will be a happy augury for today's debate.
Disappointingly, the neurosurgical unit is again under threat—the intended victim of another planning exercise by the London health planning consortium. The latest proposal will be resisted equally strongly.
Last May I argued against the closure of our excellent cottage hospital—the Victoria—which has served the community well for nearly 100 years. The Minister must now make a decision on that. Local people cannot understand why there are constant proposals from within the National Health Service to close down local facilities, particularly when figures published not so long ago showed that numbers on hospital waiting lists in the Barking and Havering health authority area were substantially higher than the average for England and Wales as a whole. "Will nobody", they ask, "in the upper echelons of the NHS stand firm and defend existing local facilities against constant soft-option suggestions of centralisation, contraction and closure?"
Yet there can be no surprise that, as in the case of this cancer unit, a working party consisting exclusively of medical and administrative specialists within the NHS should reach conclusions that are broadly professional and bureaucratic in character.
For instance, it suggests cancer treatment centres with catchment populations of 1 million, each centre with multi-disciplinary, co-ordinating and planning committees, all of which are presided over by a Thames cancer advisory committee. It is all too familiar. Distinguished professional people are bound to see the problem in terms of achieving the highest possible standards of medical treatment and to give a lower priority to the human implications of moving patients like pawns across an administrative chess board. But if the policy is "Patients first", who represents popular opinion in those committee room exercises? Whose National Health Service is it anyway?
Having once reached its theoretical solution, the working party was then obliged to fit its plan to local circumstances. In the case of the cancer unit at Oldchurch, it is literally a very painful 752 fit. It proposes that cancer patients at present attending at Romford for consultations and treatment should instead travel to Bart's hospital, in central London. Such a suggestion is not only inhuman and unfeeling; it is also impractical. To ask patients suffering from the most terrible of illnesses, and being mostly elderly, to travel to Bart's and back rather than to Romford, as they do now, to undergo treatment, with unpleasant side effects of fatigue and nausea, and to suggest that if the resultant ambulance journeys were too long and uncomfortable some patients might find it "more convenient" to use public transport, is a disgraceful denial of everything that a decent Health Service should stand for.
Ask the public what they think of that order of priorities. From talking to patients, and from my visit to the unit last Friday morning, I know that they are very satisfied with the service that they receive from the dedicated team at Oldchurch and would wish to forgo any notional improvements offered by a central London teaching hospital in favour of the convenience of local treatment. For them, the distress and discomfort of travelling to Bart's would be real and not theoretical.
The working party itself acknowledges the impracticability of its proposal by pointing out that it implies the need for hostel-type accommodation for patients to stay overnight who cannot sustain the two-way journey in one day. The cost is not mentioned. Could the ambulance service cope, anyway? It is already under severe pressure in London. What would be the cost of the extra vehicles and drivers who would be needed? The present cost of the London ambulance service works out at 90p per patient per mile. The round trip to Bart's from Romford must add at least another 20 miles.
There are other major disadvantages implicit in the working party's proposals. The proposals would destroy the present beneficial interrelationship between the radiotherapy unit and other departments within the district. The unit already has a radio-pharmaceutical department under development, and it serves as a base for physics medicine. It works closely with the neurosurgical, gynaecological and ENT departments at the hospital. The 753 training of junior medical staff would be adversely affected by this move, and there would be a waste of public investment implicit in the closure of a well-established unit and the break-up of a skilled team of medical and nursing staff. For all these reasons, I hope that the proposal will be rejected.
Of course, the provision of health facilities in this country is characterised by historic accident; of course, resources are not always evenly or appropriately distributed; but that is life. Naturally, it is important to ensure value for money in a public service, especially when money is short. But recent experience—come to that, the experience of Gaius Petronius, in AD68—has shown that sterile planning exercises can cause more problems than they solve, can cost more money than they set out to save and, so far as they represent only a substitution of error for accident, are no advance at all.
Contrary to what the London health planning consortium report says, there is room for expansion at Oldchurch hospital. Space for a second cobalt machine was deliberately left and stands empty today. If there is a risk that the present cobalt machine should, after nine years, break down, that is a risk with which we may have to live for a little longer.
But such inadequacies as there are should be met with a positive decision to hold the line until the necessary resources are available for expansion. In addition, there is ample evidence of public willingness to boost funds by voluntary effort. I have already mentioned the fund-raising that is in progress in connection with the latest campaign to raise money for a piece of equipment that is needed now for the radiotherapy unit. There is another major example of such effort in the raising of £175,000 for a hospice at Havering-atte-Bower. I believe that a solution to the problem of Victoria hospital could embrace similar local voluntary fund-raising in an attempt to bridge the gap between what can be provided from public sources and what the public themselves are prepared to commit in addition, to enable the retention of their own, well-loved local services.
Contraction and closure, on the other hand, can lead only to lower standards of local service and greater public dis- 754 satisfaction. We should resist such weak-kneed defeatism.
§ The Under-Secretary of State for Health and Social Security (Sir George Young)
As anyone who knows my hon. Friend the Member for Romford (Mr. Neubert) would expect, he has put forward a persuasive and compassionate case on behalf of those whom he represents, and I join with him in commending the courage of those disabled persons who came to the House on Budget day.
I fully understand the concern which my hon. Friend has expressed about the future of the radiotherapy unit at Old-church hospital. I have also heard about it from several people both inside and outside the House. My right hon. Friend the Minister for Health has been told of the petition which has been got up in the Romford area and which 60,000 people have signed. I shall arrange for my hon. Friend's office to be cleared to make room for it. I also commend the strength and initiative of local fund raisers. What my hon. Friend said towards the end of his speech about a partnership between the statutory health service and local voluntary organisations is very much in keeping with this Government's philosophy.
I should make clear, at the outset, that no decision has been taken to close the radiotherapy or neurosurgery units. The report which suggested the closure is the subject of consultation. It has been circulated widely and is being discussed by health authorities, community health councils and others who are interested. We will have to see what the area health authority and, in its turn, the regional health authority have to say about it.
The proposal arises from the report of a study group which was set up by the London health planning consortium. The consortium was itself set up in 1978 by the main authorities concerned with the Health Service in London. Its job is to look at major planning issues which affect London or the Thames regions as a whole. There are bound to be problems of this sort because of the size of London, which contains 19 area health authorities divided between four regional health authorities. More than anywhere else in the country, the provision of services and their planning has implications 755 across health authorty boundaries. And in the case of regional specialties, such as radiotherapy or neurosurgery, the problems often have implications for several regions at the same time.
London also contains 12 medical schools, and their needs have to be taken into account in planning. That is why the consortium was set up, to bring together in one planning body the four Thames regions, the University of London, the postgraduate boards of governors, the University Grants Committee and the Government.
As I have already indicated, one of the major problems that concerned the consortium was the planning of the main regional specialties. One of its priorities was to look at the distribution of these services across the Thames region. In many cases, units have been built up by different authorities over the years, almost in competition with one another. Many of them are small and not properly supported. To look into this problem, the consortium set up five independent study groups. They were asked to look at cardiac surgery and cardiology, at neurosurgery and neurology, at ophthalmology and at ear, nose and throat services, as well as at radiotherapy and oncology.
Each of the groups comprised eminent clinicians and specialists, who were asked, as far as possible, to take a detached view and to present proposals for achieving the best distribution of services across the Thames regions as a whole. They were concerned to secure the best treatment of patients. I ask my hon. Friend to accept that that was their motive. But that does not mean that they were insensitive to the convenience of patients. All their reports have now been completed and are the subject of consultation. All but one—the report on cardiac surgery and cardiology—are of importance, in different ways, to the Oldchurch hospital.
The study group on radiotherapy and oncology, whose report most concerns my hon. Friend, took evidence from a wide range of organisations, including both the health authorities and professional bodies. It visited the units that currently provide services and then reached its conclusions about the changes that were needed. It set as its aim to get a better organised service which 756 would enable more effective treatment to be given to patients. It took the view that this could best be achieved by concentrating services in cancer treatment centres, each serving a population of at least 1 million. Many of the existing radiotherapy centres in the country are of this size, and some are much bigger.
Because of the enormous cost of radiotherapy equipment, it obviously cannot be provided in every hospital that might wish to provide it. Larger units allow a fuller range of equipment to be provided. Breakdowns can then be covered and facilities for treating the rarer cases can be fully used.
The study group also felt that there were clinical and professional arguments for such centres. They ensure that each centre can retain expertise over the whole range of cancer treatment and contribute to training and research. We are talking here not about contraction of services but about concentrating them into large units that may allow better treatment for patients.
The provision of radiotherapy services is only part of the story. Drug treatment for cancer is also becoming increasingly important. The centres that the group proposed would be centres for medical oncology as well, but the group felt that it was essential for oncological services to be available in every district general hospital. This can be done, because there is less need for expensive equipment for oncology.
Many clinicians in every acute hospital will be dealing with cancer. The group therefore recommended that each district should have available to it the services of a radiotherapist and medical oncologist, even though the expensive equipment might be some distance away. The radiotherapist in those cases would hold joint clinics with other specialists, and would also have out-patient surgeries.
Of course, I recognise that there is a difficulty here. There may well be economic and medical benefits to patients in using the larger centres. But if, as my hon. Friend said, there are larger and fewer centres, people are likely to live further from them. The inconvenience for them and for their relatives is consequently greater. This is likely to be a particular problem in radiotherapy. Many patients are treated as out-patients, and courses 757 of treatment may require regular attendance over a period of time. In this case, therefore—perhaps more than in others —it is important to get it right.
The debate that is going on about the report may give us a clearer idea of what the right answer is. I shall ensure that my hon. Friend's remarks today are drawn to the attention of those who are now analysing the report. I believe that it is essential that the debate about the report should be allowed to run its course. Certainly, I and my ministerial colleagues have not prejudged the issue.
The radiotherapy unit at the Oldchurch hospital is an example of a small centre—a very small centre. The study group visited it and noted that it had a small local work load of under one thousand new patients per year. It has only one cobalt machine and limited support facilities. If its main machine were to break down, the service it provided would be in serious difficulties. The group did not regard the department as being "viable" in the terms that it had decided on, and it noted that it would be very difficult to expand it. A large investment would be needed before the unit could be brought up to the necessary size. It may be that the health authority will take a different view and that the general local support—which my hon. Friend mentioned—would make extra investment possible. We must wait and see.
Another factor that influenced the group was that one of the large units further towards the centre of London—at St. Bartholomew's hospital—had some spare capacity. A new linear accelerator was due to be commissioned at St. Bartholomew's and it felt that this would allow the work of the Oldchurch unit to be absorbed there. My hon. Friend is, rightly, concerned mostly with those who live close to the unit at Oldchurch. But this was a case where the group came to a different conclusion when looking at the wider picture. But the proposals in the report are not definitive or unalterable. Other proposals may be made and the health authorities and the consortium will need to examine them.
I shall return in a moment to the way in which decisions on the report will be handled. But I would like also to refer to the reports of the other consortium 758 study groups which have implications for Oldchurch hospital. Of these, the most important is the one concerned with neurosurgical services, to which my hon. Friend referred.
Oldchurch hospital has a purpose-built neurosurgical unit. It was established by the North-East metropolitan regional hospital board, because all the neurosurgical services for its area were to be found in the teaching hospitals—outside its control. The regional health authority has maintained the unit, partly because it felt it important to spread the provision of regional services more evenly throughout the region and away from the centre of London. The study group on neurology and neurosurgery found, however, that the unit at Oldchurch hospital faced considerable difficulties.
There were seemingly insurmountable problems in obtaining staff in some of the more specialised support services. Because of this, the units could not be used for advanced training and medical staffing, even at junior levels, has posed difficulties. This problem had been in evidence for some years and the North-East Thames RHA was due to review it in the near future.
The study group felt that only two major neurosurgical units were needed to serve East London and Essex and concluded that those at St. Bartholomew's and the London hospital were likely to provide a better basis for the service in the future. The problems which concentration poses are less serious in these specialties than in radiotherapy. Neurologists have, traditionally, provided outpatient services away from the main centres, and each district general hospital will continue to be visited by a neurologist. Furthermore, neurosurgery tends to be—I am happy to say—a once-in-alifetime experience. Travelling difficulties are therefore a less severe problem.
§ Mr. Neubert
Would my hon. Friend concede that in some cases, when people are acutely ill and have been involved in accidents, distance is of the essence if they are to survive?
§ Sir G. Young
In those cases my hon. Friend is absolutely right. However, I was referring to the more usual neurosurgical operations that are, happily, not the result of motor accidents.
I accept that the report on neurosurgery would also have an important effect 759 on Oldchurch hospital. I have no doubt that the local health authority and community health council are considering it closely.
The remaining two study groups looked at ophthalmology and ear, nose and throat services and their conclusions are generally favourable to Oldchurch hospital. The study group on ophthalmology, which was concerned only with the two North Thames regions, found that, in many places, in-patient services were very fragmented. Again, there are advantages in keeping in-patient services and operating facilities to a limited number of sites. Of course, there are a great many ophthalmology patients who are seen only as outpatients. It will always need to be possible for them to be seen at their local hospital. But the study group found that, in East London, the pattern of provision which it thought desirable already existed. Oldchurch hospital has a large unit of some 50 ophthalmology beds—well above the minimum size which the group recommended. The group was clear that the hospital should continue to provide a service to the whole of Barking and Havering and to some surrounding areas.
For ENT, the local service is split between Oldchurch hospital and Rush Green hospital. Each has 10 to 15 beds and the study group suggested that the service might, with advantage, be concentrated in one hospital. But it was its view that this was a matter which could be left to local planning. My hon. Friend also mentioned the Victoria hospital, Romford. After local discussions, the AHA has decided that it wishes to continue with the closure of the hospital. The matter now rests with RHA. If it agrees, it will be for my right hon. Friend to decide whether or not the AHA may proceed.
I also found it encouraging to see that the future for Oldchurch hospital is not entirely grim. A six-phase redevelopment of the hospital commenced in 1965, and the out-patient, accident and emergency, X-ray and neurosurgical departments were replaced. A new theatre complex is to be commissioned in 1980. Phases 5 and 6, yet to be programmed, will include new ward blocks and pathology and administration departments, and 760 will result in a completely rebuilt hospital of some 800 beds.
As I have said before, all these reports are now out for consultation. The London health planning consortium has not yet taken a view on them. Area health authorities, districts and CHCs are now bringing their views together, and regional health authorities, the university and the other parent bodies will then report back to the consortium. The consortium will have the problem of deciding whether the recommendations of the study groups should be amended in the light of views expressed on them, including those this afternoon.
However, it will also need to look at the interactions between them. In the case of Oldchurch, there is the suggestion that work in two specialties should be stopped, but, on the other hand, there is the possible expansion of a third. In other parts of London the problems of overlap are far more difficult, and the Flowers report on the medical schools in London is also likely to have an impact.
Once the consortium has reached its conclusions, it will be for the responsible health authorities or, if necessary, Ministers to take decisions about their implementation. In some cases, it will be a matter that does not affect more than one authority. Particularly at the peripheral parts of regions, it will be possible for the authorities to decide what they wish to do and to get on with it. However, any changes that they wish to make, if they involve closure or change of use of a hospital, will still have to go through the formal consultation procedure.
In other cases, however, the issue may need to come to Ministers for decision. These issues will not be easy to resolve or to carry through for the very reasons that my hon. Friend outlined. It is for this reason that we have set up the London Advisory Group to help us to ensure that the decisions taken are the right ones and to take account of the interests of all concerned in the Health Service.
This is a period of great change in London. Many issues have been left unresolved for too long, so that the changes needed now are more difficult to absorb. With the restructuring of the Health Service on the horizon, it is important that we should resolve as many of these issues as possible so that the new authorities 761 can be established on a firm footing, but it is more important that we should get the right decisions. That is why the reports that have been issued are being so thoroughly considered and discussed. My hon. Friend and his constituents have put their view, and I can give an under- 762 taking that they will be taken fully into account.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-eight minutes past Three o'clock till Monday 14 April pursuant to the resolution of the House of 2 April.