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Ophthalmology Services (Thanet)

Volume 928: debated on Friday 18 March 1977

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

4.1 p.m.

The ophthalmic services in Thanet are in a serious state. It is a tragic situation. The tragedy of gradual and increasing blindness due to cataract or glaucoma in old people, deprived thereby of the pleasure of watching television or of reading a book, is rendered intolerable by the present state of the National Health Service in this field. The delay of about 18 months in operative treatment in the case of old-age pensioners sometimes means that their last years can never be alleviated by a simple treatment.

The fact is that one able consultant ophthalmologist works alone in Thanet. Eye illness in the elderly constitutes about 80 per cent. of cataract cases and 20 per cent. of glaucoma cases. There are also the problems of squint with children, a number of miscellaneous cases requiring grafts and others arising from accidental injury. A new field in the treatment of retinal problems now has an interesting future. It is of imperative urgency that a further consultant surgeon is appointed for the South-East immediately, particularly for Thanet, which suffers the worst in South-East Kent.

The delay that has existed in this matter is admitted. This issue came to me from the case of a Mrs. Mary Davies, of Harold Road, Cliftonville. She was first diagnosed as in need of an operation for cataract in February 1975. Her appointment to see the consultant surgeon was for 24th May 1977. I intervened in October, and as a result of the intervention the surgeon saw her and she received the treatment, but it meant that someone else went down the list.

On 10th November 1976 the Minister of State replied that the waiting time was
"approximately two years for routine cases"
and that
"an additional consultant was included in the programme for 1977–78. Priority depends on the South-East Region."
There was no comment from the Minister himself.

On 25th November the medical area authority confirmed that
"the waiting time for in-patient treatment can be up to two years. This is very largely due to the lack of in-patient beds in the district to cope with the demand … the provision of a new Central Eye Unit at Canterbury Hospital was planned to meet the deficiency. Lack of capital resources has held this development up until the 1980s."
In so far as that is a statement of fact, it is untrue. In so far as it is a statement of intent in the future, it is equally untrue. Capital resources are not great. There is no lack of in-patient beds, as I have taken the trouble to find out.

On 23rd November 1976 Dr. Porter, the regional medical officer, took the matter up with me and said:
"The accommodation for work is at Dover, Canterbury and Thanet"
with four eye surgeons. None of the units
"are sufficiently large enough to attract trained junior staff. The aim is to provide a new centre concentrated at Canterbury, but clearly this cannot be done until the capital investment programme improves."
As I shall establish, that is not in accordance with the facts of the future, although it is true, and he gave the figures, of the work that is done by the four eye surgeons.

On 1st December he regional medical officer gave the disposition of the four consultants and their work load. The work load for the four eye surgeons in the district is first-class. They do the maximum amount within a programme of part-time work. Mr. Darvell has the maximum of six sessions in Thanet, and this week he has increased this so that he will undertake operative treatment not only on Mondays but on alternate Thursdays. The general medical hospital at Margate is in a position to provide a further session, so that we can have sessions on each Monday and each Thursday, which would enable us to catch up with our backlog.

On 24th January 1977 the Minister of State said that we had a current waiting time of 39 weeks and that he had been misinformed of the extent of delay. He stated that priorities must be decided locally in the first instance, and that the authority must act on these priorities. On 7th February he said that the regional health authorities would shortly know their capital and revenue allocation for 1977 to 1978. He stated that the priorities were primarily for local consideration, and that the relative priorities could be decided only by the health authorities.

The priorities are now set out, There has been no costing in the light of the facts, and it is now for the Minister to press the regional health authority for early permission to proceed. In fact, the routine waiting time is 35 weeks. The muddle and confusion in this matter, from the Minister downwards, has proved quite indescribable during my investigation of the problem.

Every time I write, I have to write five or six letters, one to the Minister, one to the regional health authority, one to the Kent area, one to the district, one to the consultant and one to the patient. The ball is thrown from one to the other, until finally, as a result of the granting of the debate, it is clear that some help is forthcoming.

I received information on 11th March from the district administrator, Mr. Forryan, that the Canterbury and Thanet Health District had included an additional eye surgeon as fourth—but this morning he has risen to third—in the list of priorities in its applications to the regional health authority. The first priority is for a psychiatrist, the second is for a haematologist, and the third is for an ophthalmologist. In my view the ophthalmologist should rank first with the psychiatrist.

To overcome the backlog of cases and ensure a reasonable service for Thanet the following action is required: at Margate General Hospital, instead of one operating session a week on Monday mornings there should be two, on Mondays and Thursdays. Beginning this week, sessions are starting on the alternate Thursdays.

In Margate, the sole operating surgeon, Mr. Darvell, has under his care three male, three female and two children's beds in the Margate wing. For the extra session he will require a further four beds, but in this there is no problem. Mr. Darvell works a full and very heavy week and he is full throughout the week with only two afternoons for other duties. He works the maximum part-time consultancy service.

There are at present four consultants in East Kent—Mr. Darvell, Mr. Snow, Mr. Simpson and Miss Starbuck. To make the operation successful, additional operative treatment must take place at Canterbury, for if Mr. Darvell takes on further sessions in Margate the additional consultant is required for the area as a whole.

These persons know the problem—and here there is a surprising fact. It happens that there are two empty theatres available for use at Canterbury at the moment. This fact has not been disclosed by anybody except the surgeons themselves. Canterbury is recognised as a suitable centre for operative eye treatment. At present the ancillary equipment that they will require is a microscope. I have inquired the price from Zeiss and the one that they want cost about £5,500, plus a further £2,000 for the additional facilities that go with it. They also require a cryoprobe which costs a further £1,000. The additional operational cost, having regard to the existence of this theatre, would appear to be small. That is a capital cost of about £10,000, which is a negligible figure. The suggestion that there may have to be investment of £500,000 is simply not supported by the facts.

Canterbury would make the best centre in which the team would work. There are, or will then be, five of them and the additional staff needed would be first, I am advised, half a houseman. That is to say, the present houseman would give up his current ENT duties and would be full-time ophthalmic. In addition, the unit would need one clinic nurse. It would not be necessary, as has been suggested, to have half a medical secretary.

Mr. Darvell practises at Margate effectively without any houseman, although he uses the part-time occasional services of one, but he has no other special staff. Four additional beds to the present 16 would be needed for the new unit to be expanded at Canterbury, but there would be no problem on that account. The whole operation could be carried out cheaply, speedily and effectively and would require no additional buildings and no additional operating theatre.

The total cost of staff with their extra-domiciliary visits would be between £12,500 and £13,000 a year. That would include £6,000 for the surgeon, £2,000 for half a houseman and £3,000 for the clinic nurse. I have been advised by the district authority that it is proposing for this new unit the additional four beds which are necessary for the fifth member of the team. There would then be a sufficiency of beds. Canterbury, with its present number, is already recognised by the Royal College for training purposes.

I turn now to the administrative system. It has taken me months to break through and get to the true position. I heard this morning by letter from the Minister of State that it is proposed to permit a further ophthalmologist for the area. If this question could have been left to the district in the first place, it could have been, and should have been, dealt with many months ago. I ask the Minister to tell the regional authority to treat the matter as one of priority so that suffering may be alleviated for the paltry sums involved.

Of course, the Minister will be the first to realise the need in due course to abolish the area authorities, with a saving of over £200 million. They are useless at present. They have been of absolutely no assistance in either this or the many other problems I deal with concerning the National Health Service.

There is one final point about which I have written to the Minister. How does it come about that the monthly allocations of finance were first notified last week—the beginning of March—when more than two months of the year had gone? How can the Government imagine that the authorities are to carry out their programme when the information relating to finance arises, it would seem, six months late?

4.13 p.m.

I am grateful to the hon. and learned Member for Thanet, West (Mr. Rees-Davies) for raising this matter. He has shown once again his continuing and proper concern about the health services available to his constituents, a concern previously expressed in correspondence, about this and other matters, with various Ministers and in discussions and correspondence at various levels of health authority.

The hon. and learned Gentleman referred to his elderly constituents and to one particular case. Let me say at once that I fully sympathise with anyone who suffers pain, hardship or personal inconvenience. I share the hon. and learned Member's concern, and so also, I know, do the health authorities, which, as the bodies primarily responsible for the administration of services at a local level, have to take decisions on how to allocate the resources at their disposal, including manpower resources.

Perhaps I should first explain the procedure used by my Department for the allocation of consultant posts. This is designed to leave as many decisions as possible in the hands of health authorities, and it is for the health authorities concerned to decide whether there is a need for a particular post.

Ophthalmology is not one of the few specialties in which there is a recommended national norm for consultant staffing; and even these are regarded as guidelines to be interpreted flexibly in the light of local conditions. Authorities themselves are in the best position to judge the demand for services, the provision of alternative facilities elsewhere, the availability of supporting staff and the facilities in related specialties and so on. Decisions on such matters are best taken in the light of local knowledge, and are not, therefore, for my Department.

Similarly, deployment of posts within a region is a matter for the regional health authority. Consultant posts can be relocated within a region without the approval of the Department being necessary. We have a rôle to play only if an authority wants to increase its total manpower in a specialty. If there are, say, five posts in a given specialty in a region, it is for the regional health authority to decide how they can best be allocated among the various hospitals. In reaching this decision, it will naturally take account of local views and of the opinions of the medical profession working in the region. I am sure that the hon. and learned Gentleman is aware that there are a number of advisory committees to enable the authority to receive expert specialist advice on matters such as this.

It is, however, necessary for regions to come to my Department when additional posts are required. For convenience, this is done on an annual basis. Each year regions are invited to submit bids for new posts in each of the 40 or so medical specialties. These bids are purely in terms of a number of posts. A region will indicate that it wishes to have, say, three new posts for surgeons or five new posts for anaesthetists. No detail is given of where the posts will be used in the region. This is a matter entirely for the health authority. It follows that my Department does not attempt to make an assessment of need for the posts. As I have already explained, such an assessment can best be made at a local level, and we work on the assumption that if an authority requests a post it considers that there is a need for it. Once again, there will be extensive local consultation on this programme of bids for new consultant posts, and the medical profession locally will be invited to comment.

Hon. Members might ask why my Department is involved at all if it does not attempt to assess whether the posts are needed. The answer is that in certain specialties the demand for new posts exceeds the supply of candidates who will be available to fill them. The reasons for this are complex and are not strictly relevant here. The main point is simply that in these specialties candidates for consultant posts are a scarce resource, and some form of rationing is necessary to ensure that all regions get their fair share.

I am dealing with the general issue. I shall be coming specifically to ophthamology.

Each year, my Department makes an estimate of the likely number of candidates for consultant posts in the following year. This is based on the figures available for the number of doctors in the National Health Service training in the various specialties, together with information from previous years about wastage, emigration and recruitment of consultants from sources outside the NHS, such as the universities. In reaching this estimate, my Department is advised by the Central Manpower Committee, a joint committee of the Department and the medical and dental professions set up to advise on matters relating to hospital medical and dental manpower.

This process of estimation provides an indication of the number of new consultant posts which are likely to be filled during the following year. To approve more posts than this would mean that some would remain vacant. Experience has shown that posts are more likely to remain vacant in those parts of the country which have traditionally been least attractive to doctors and which, therefore, have fewest doctors per head of the population at present. In other words, if we approve too many posts, those that will be filled will be the ones in parts of the country that are already better off. It is for this reason that my Department has a rôle to play.

Of course, it is necessary to make an allowance for replacement of consultants who retire or die or leave the NHS for other reasons. Once this has been done, the remaining posts can be allocated to regions. Our policy here has been to allocate posts preferentially to regions which currently have the lowest ratio of staff to population so that in the long run there will be a much more even distribution of medical manpower across the country. It is then up to the region to allocate these posts to the different areas and so on down.

I turn to the specific issue that the hon. and learned Gentleman raised. Ophthalmology is not a specialty in which there has been a shortage of candidates for consultant posts. It has been popular with young doctors, and more than sufficient are in training to meet the demand for new posts. It follows that it is normally possible to approve all requests from authorities for new posts in this speciality, and this was what my Department did this year. We received requests for 12 new posts for consultant ophthalmologists and we approved them all. The South-East Thames Regional Health Authority asked for one post in the specialty and this was approved.

I understand that when the authority was first asked in October 1976 to submit bids for new appointments in 1977, it in turn, and in accordance with its regular practice, invited all its area authorities and district management teams to submit details of the additional consultants they would like to see appointed. The requirements of each district were then considered by a regional manpower com- mittee and co-ordinated in the regional bid to the Department.

In January of this year regional authorities were notified of the outcome. As I have already mentioned, the posts approved for South East Thames Region included one in ophthalmology, and the decision as to where it should be established is for the regional health authority to take.

As in the previous decision on which posts to apply for, authorities have to take account of several factors. First, they must have regard to the financial implications of what is proposed. Consultants are expensive—not so much in terms of their salaries, but because of the cost of the supporting staff and facilities they will require if they are to carry out their duties. The district management team has quoted figures which are not the same as those quoted by the hon. and learned Gentleman. This is a matter of fact which will need to be resolved.

For that reason, no authority can establish all the posts that are needed in any one year, and inevitably each authority has to set priorities and to postpone establishment of certain posts from one year till some date in the future. Secondly, the regional authority is obliged to take account of the needs and claims of other parts of the region. Only it is in a proper position to assess the relative weight which should be given to the various claims and to decide how to allocate the resources available.

Similarly, each district management team must balance competing demands for improvements in the various services it administers and establish the degree of priority proper to each. While this will not necessarily accord with regional priorities, the regional authority will clearly need to take account of district views in making its overall decisions. In this case, although the Canterbury and Thanet District asked for an additional post in ophthalmology, it regarded the need as less urgent than that for an additional psychiatrist at St. Augustine Hospital or for a post in haematology. If the hon. and learned Gentleman's information is correct, evidently it no longer regards a geriatric post as being of a higher priority.

Thus, although the regional authority has not yet decided on the allocation of the posts at its disposal, since it must take account of competing demands from other parts of the region as well as the needs of other specialties within the district, I cannot exclude the possibility that it will be unable to allocate the ophthalmologist post to Canterbury and Thanet. For the reasons I have given, the final decision must rest with the regional health authority. The Department would not seek to restrict its freedom to make the best choice consistent with the competing demands already mentioned.

Nothing that I have said, however, is intended to imply that the district management team, area health authority or regional health authority considers there is no case for the improvement of ophthalmology services. The hon. and learned Gentleman has given some graphic examples of the need in his area. There is general agreement that these services would merit improvement, but the authorities feel that for the present they must give precedence to even more urgent demands in other specialties and in other localities.

The hon. and learned Gentleman has referred to waiting lists and waiting times for ophthalmology treatment in Canterbury and Thanet. The district management team is well aware of the problem. In particular, it appreciates that waiting times in the Thanet part of the district are slightly longer than those in Canterbury. Consideration will be given to ways in which it might be possible to improve the situation.

Difficulties over waiting lists and waiting times for both out-patient appointments and in-patient admissions are not, of course, confined to this district. This problem has long troubled the Health Service in a number of areas and specialties. The size of waiting lists and the length of waiting time reflect, in particular, the resources that are available, and there will probably always be a waiting list problem of some kind since there is a limitless demand for hospital treatment. Many improvements can, however, be undertaken to reduce waiting times to a more acceptable level even within the present financial restraints. We are at present actively engaged in an exercise to this end.

The hon. Gentleman has said, and I am happy to hear it, that an ophthalmologist has been allocated to this region by the regional manpower committee. We have applied for that from Thanet and Canterbury to the region and thence to the Ministry. Surely it is not to be suggested that we are now to be deprived of this and that it will be passed to some other part of the region when the fact is that we made the application in October. All I am asking is that, the specialty having now been supplied to the region, the region should pass it on. Who else is in the field?

The hon. and learned Gentleman has made an important point. With respect, it is not one for me or my Department. If—and I do not know the facts here—there was only one application from a district management team to the regional health authority for an ophthalmologist post and that was the application which came forward to my Department, obviously the hon. and learned Gentleman, his constituents and the district management team will no doubt feel that they had a strong claim on that post. I do not know the position at this stage, although I can write and let the hon. and learned Gentleman know whether any other district has put forward a claim and the region, in its wisdom, has decided that it would merely put forward a request for one post.

Surely the manpower committee, when it considered this, would have to consider the demand in the light of the circumstances of the area and, therefore, it must have known that there was a demand for one ophthalmologist in the South-East Thames area or anywhere else.

With respect to the hon. and learned Gentleman, my Department would not have known that, because the application from the region was for one post for the region. I have tried to indicate that the way that post should be placed within the region is very much a matter for the regional authority itself.

I wish to come back to the question of waiting lists which the hon. and learned Gentleman mentioned in his speech. I am assured that the district management team is fully aware of what is required here and I understand that it was in advance of many in introducing the sort of flexible arrangements locally which can be very helpful.

The team has made it clear, however, that the long-term solution ought to lie in the provision of proper new facilities for ophthalmology in a 30-bed central unit for East Kent. The present thinking is that such a unit would also cover parts of the South-East Kent district and could, therefore, be suitably located at the district general hospital in Canterbury.

I should perhaps comment that my Department's long-term policy, on which appropriate professional bodies have been consulted, is that specialised services should be concentrated in district general hospitals because of the range of equipment, supporting facilities and specialised staff that are required to provide services of a desirable standard. This will take a long time to achieve, especially in the light of the Government's priorities document and its emphasis on non-acute services, but authorities are expected to move towards the goal of centralisation when decisions on the organisation and development of local services have to be made.

Consideration of this proposal is, of course, at a very early stage, and it will have to be discussed further as part of plans made by authorities within the new National Health Service planning system. As the system develops, the content of such plans will tend to become subject to wide-ranging discussion among local interests, and the arguments we have been rehearsing in this debate will no doubt contribute to that discussion.

I should like to turn now to the separate point raised by the hon. and learned Gentleman about the notification of financial allocations to health authorities. I fully accept the desirability of notifying authorities of their allocations well in advance of the financial year. In the not-too-distant past it was the practice to issue allocations by Christmas of the previous year, but the uncertainties surrounding the level of public expenditure that can be permitted even in the immediate year ahead have unavoidably delayed the notification of allocations for the last three financial years.

There are fundamentally two issues to settle before the total sums available nationally to the NHS for capital and revenue purposes can be determined. One is the change in volume of the service at a constant pay and price level compared with previous years. This depends upon the annual review of public expenditure, culminating in the annual White Paper on public expenditure. The latest was published in two volumes, one in January and the second last month, Cmnd. 6721. The second issue is the level of additional sums to meet the pay and price changes to produce the final cash limit sum. In the present state of the economy the hon. and learned Gentleman will appreciate that it has not proved possible to be certain about either of these factors well before the commencement of the year but it is to be hoped that as we reduce the rate of inflation and improve the balance of payments we can return to the more stable conditions for the planning of public exenditure. Certainly the situation is better this year, despite the economic circumstances. We issued the cash limits for both revenue and capital to regional health authorities on 21st February, which is some three months earlier than was possible last year for the revenue cash limit.

Although cash limits could not be notified to regional health authorities as early as one could have wished, we must also not lose sight of the fact that the National Health Service planning system was instituted last year. Health authorities were last May sent planning guidelines and resource assumptions for future years and advised in drawing their plans to allow for changes in the financial assumptions following the report of the Resource Allocation Working Party, as well as for other reasons. All health authorities would therefore have been giving thought to flexible plans for 1977–78 and on receiving their cash limits would be able to modify those plans.

It is in the context of plans evolved under that system that health authorities must consider the needs of Canterbury and Thanet health district and the priority, which the hon. and learned Gentleman has been stressing, to be afforded to particular services such as ophthalmology.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes past Four o'clock.