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St Mark's Hospital, Finsbury

Volume 932: debated on Friday 20 May 1977

The text on this page has been created from Hansard archive content, it may contain typographical errors.

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

5.01 p.m.

St. Mark's Hospital, in Finsbury, is a small and highly specialised hospital dealing with diseases of the rectum and colon. It has a worldwide reputation in this field and has trained a large proportion of the surgeons with a particular interest in colon and rectal surgery in Britain and abroad. It has been responsible for much new work, not least in the recognition and treatment of pre-cancerous conditions. The double contrast barium enema was introduced to this country at St. Mark's, and a large number of teaching hospitals in this country refer cases to St. Mark's Hospital.

St. Mark's is in no sense a local hospital. I have, so far as I know, not one constituent as a patient in the hospital at the present time. One-third of out-patients, and half the in-patients come from parts of Britain outside the London region. For certain specialist services, like colonoscopy, 60 per cent. of patients are referred from outside the London area, and over 500 requests for second opinions on histopathological specimens are received from other hospitals each year, half of them from outside London, and 30 per cent. from overseas.

The large post-graduate teaching hospitals have their national rôle recognised by being excised from the regional structure of the hospital service. They have their direct link to the Department of Health and Social Services, and are funded separately. St. Mark's, however, is within the regional structure and falls under the control of the City and Hackney District Authority, which falls under the area health authority, which falls within the appropriate regional health authority.

Last November, because the district had exceeded its financial budget, an order went out from the district administrator that St. Mark's must close two of its wards—40 per cent. of its beds. The closure was to take place at only five weeks' notice at the end of the year, and there had been no advance consultation with the medical staff to see whether other steps could be taken to save funds and to assess the consequences of the proposed closure. On protest, the closure was reduced to one female ward of 14 beds.

The closure of wards and even of whole hospitals on purely financial grounds cannot always be avoided. However, I say that when a hospital gets an order by letter, without advance consultation, to close wards at five weeks' notice, that is clear proof of incompetent administration. It was indicated that the ward would probably be opened again when the next year's money became available on 1st April of this year.

Responsibility for detailed decisions on hospitals ought to rest with regional, area and district authorities. But the Act of Parliament gives the Minister powers to oversee, and if necessary to overrule, those bodies. We gave him that power so that he could ensure that the quality of administration comes up to some minimum standard.

I arranged with the Minister to visit St. Mark's at the beginning of the year and the staff were encouraged by the interest he showed in their work and their particular situation during that visit. He and I were then led to believe that the ward would be opened again in April. Instead, once again, the district administrator issued without consultation an edict that the ward would be open only at some unspecified time before April 1978.

No rational case has ever been set down in writing putting the pros and cons for the continued closure. In his letter to me on 19th April the Lord President of the Council promised me that the Minister would be writing to me again in the near future. He has not done so. All I have is the brief explanation in the Minister's letter of 31st March with its vague references to bed occupancy rates. I have sent on to the Minister the comments of medical staff on that point with a wealth of supporting facts. I asked him on 4th April, and again on 29th April, to set out his side of the argument. He has not done so. Instead the authorities and the Minister rely on one brutally simple point, that the City and Hackney District has overspent and that savings must be found within that district and that no arguments about the consequences, particularly for a non-local facility like St. Mark's, can be allowed to interfere with that stern accountancy. All this despite the fact that the Department had to admit to a House of Commons Select Committee the other week that the NHS lost £40 million last year because the Treasury under estimated the effect of inflation on hospital procurement prices.

The quality of the administrative machine in this case has been reflected in the various statements made about the savings produced by the ward closure. The first figure was that the three months' closure would save £18,000. In the Minister's letter to me of 31st March, that got bumped up to between £50,000 and £60,000. That turned out to be a mistake and was corrected down to £12,000 by a telephone call. Now the Minister is standing pat on a figure of £6,000 per month which he says, includes savings of £750 a month for administrative and clerical staff. That is another mistake, because the Minister knows perfectly well that the staff represented by that figure would not be re-engaged when the ward is re-opened and that figure ought to be something very significantly less.

More important, the Minister has admitted that the effect of closing one ward in a small hospital is to increase the overheads on the remaining beds. He puts the increase at £95 per bed per month—that is over £7,000 a month extra expenditure on the remaining 70 to 75 beds. So the extra expenditure on the remaining beds actually exceeds the net saving of the operation. On the best interpretation, therefore, more than half the gross saving is being totally neutralised in unproductive extra expenditure on the remaining beds.

But that is not all. The Minister has been forced to admit that he has left out of account the extra costs created in other hospitals in other districts where patients who would have been treated in St. Mark's are admitted. It is the Minister's replies on this point which have brought out the total imbecility of the way the case has been dealt with. Asked why he claimed that one should take no account of increased expenditure created in other districts by the St. Mark's closure, the Minister replied:
"Beds have been temporarily closed at St. Marks in order to reduce the rate of spending and assist the City and Hackney Health District to maintain its allotted cash limit. The reduction in the rate of spending in the District…cannot be affected by the cost of treating a patient outside it."
What that reply means is that so far as the Minister is concerned what matters is not whether there is a saving to the Health Service as a whole but whether there is a saving in that particular page of the accounts that relates to the City and Hackney District. He is saying that if we save £6,000 a month on this page and increase the spending by £6,000 on another page relating to another district, so long as the other district is under-spent, the closure of the ward is justified.

The Minister has not said that he cannot in practice calculate the additional costs elsewhere, though I accept that it is impossible to be remotely accurate about them. He is saying that, even if he could calculate them, he would not do so and that it is irrelevant to do so. As he said in his reply on 9th May,
"The number of patients admitted to other hospitals because of bed closures at St. Mark's is not known and no account should be taken of them in calculations."
When asked to calculate the savings to the National Health Service as a whole, he replied with these deathless—or perhaps it should be lifeless—words:
"No. The purpose of the closure was to reduce the rate of spending in one district of the Health Service."
I have great personal regard for the Minister of State and, as I have said, I know that his visit had a good effect on the morale of the St. Mark's staff. But I must say to him that a Minister of Health who is capable of that kind of approach should not be in charge of the hospital service.

In any large spending organisation it is necessary to adopt working figures for the control of expenditure in sub-units, and they must not lightly be allowed to be exceeded. But to regard them as unbreakable in all circumstances and without regard to the consequences is absurd. On that basis facilities would be shut down in one area and opened up in another just to switch figures from one account to another. If these are the management and accounting procedures which govern the service below and at ministerial level, it is time for Parliament to take more interest than it has in the past in the quality and answerability of the hospital administration.

It is because of those considerations that the St. Mark's incident ought not to be seen as just one hon. Member's efforts on behalf of one of his local hospitals. It raises the issue of the management quality of regional, area and district authorities. It raises the question of the Ministry's rôle as the highest tier in the hierarchy.

We have in this country some of the most expert and devoted medical expertise in the world. But the medical staff feel increasingly that they are the victims of bad administrators who are just not up to their jobs. If one goes into a hospital and asks the staff when they last saw district, area or regional administrators coming round to keep in touch with people at the sharp end, the normal response is a bitter laugh, as it was at St. Mark's. In the view of the medical staff, the administrators are somewhere up there, above them, taking decisions without sufficient understanding of what their decisions mean in the wards and the operating theatres. They are the staff officers who rarely go to the front line.

It is the Minister's job to put that right, and without waiting for the Royal Commission. I am not asking the Minister to take local decisions as a normal practice. But it is his responsibility to see that the quality of administration reaches the minimum standards that I have spoken about, which were certainly not reached in the St. Mark's case. That case has been firmly on the Minister's plate for six months now. Instead of correcting the errors, he has defended them and given me replies which show that he and, I presume, the Secretary of State are just as capable of them as those at lower levels.

I finish with three quotations from leters written by medical staff at the hospital. The first says:
"…as a direct result of the closure of Fournier Ward our surgical staff have been forced to see fewer new patients per clinic because they do not have the same back-up of beds for admission. This means that the waiting list for new surgical appointments in the clinic is now four weeks instead of two."
Another writes:
"The closure of half our female beds is unbalancing our clinical work. It is putting the staff in the invidious position of having to discriminate against the admission of female patients. There are now no less than 22 women awaiting urgent admission."
My final quotation is from a letter written by the Chairman of the Colostomy Welfare Group and General Secretary of the International Ostomy Association. He writes:
"I am appalled to hear that one of the few specialist facilities within the National Health Service should be in danger of being closed or reduced in size to become ineffective, due to lack of funds."
We know that it is not lack of funds in the National Health Service. It is lack of funds on the relevant page in the Minister's mind that is at issue. He goes on:
"As General Secretary of the International Ostomy Association, it has become clear to me from my discussions around the world, that many of the predictable problems of ostomates are in fact caused by operations being carried out by general surgeons in non-specialist hospitals."
This is a very wide issue yet it has been subjected to the narrowest of accounting techniques. It is to that problem that I hope my hon. Friend will give his attention, and give the word that the ward is to be reopened immediately.

5.16 p.m.

I have pleasure in lending my voice in support of the hon. Member for Islington, South and Finsbury (Mr. Cunningham). I appreciate that he should think my support worth having by the gift of a tithe of his time. I have a constituency interest in the matter because of the link- age of St. Mark's Hospital to St. Bartholomew's Hospital in my constituency, the hospitals being linked by coming under the same area health authority.

It is a fair charge against my party that from time to time we have argued for cutbacks in public expenditure in general and then have argued for increases in particular. However, within the total framework of public expenditure there must be an argument for cases of national priority and national exceptions that should be taken outside the general perspective. The hon. Gentleman has argued his case admirably and I am delighted to support it.

5.17 p.m.

My hon. Friend the Member for Islington, South and Finsbury (Mr. Cunningham) has raised the question of the continued closure of one women's ward at St. Mark's Hospital, although he has extended it as an example of a national problem. I take into account straight away one aspect of the national problem—namely, the fine reputation of the hospital both nationally and internationally and the record of service that it has given to the community.

In an attempt to argue things on a wider plain than has sometimes been represented, I take up the claim that the closure is a result of a movement of funds away from London, inadequacies in management and a misjudgment of priorities. My right hon. Friend is committed to ensuring a fairer distribution of resources between the regions to allow equality of access to patient care irrespective of where the patient lives. This policy is generally regarded as fair and right.

There is to be no precipitate removal of resources from the Thames regions. My right hon. Friend explained on 21st December 1976 why he had decided that even the Thames regions should get some growth in resources in 1977–78, The lowest increase in funds in real terms for any region this year is about one-quarter of 1 per cent. Thas is for the North-East Thames Region. The region in which St. Mark's Hospital lies is within the Thames regions. In addition to the problem of inequality of provision in the North-East Thames region, there is a growing need for extra beds in Essex to match its increasing population. That must be balanced against the speed at which the movement of resources can take place.

I have no hesitation in saying that the roots of the problem to which my hon. Friend has drawn attention do not lie in the reallocation of resources between areas but in decisions as to the pace at which it is desirable to move towards balanced health services in the area and region and the need to keep spending within cash limits in the battle against inflation.

The problem was that in 1976–77 in the City and Hackney district the revenue allocations increased by about 8½per cent. During the year the City and Hackney district was found to be overspending its budget and in spite of some economy measures the amount of overspending had risen to over £500,000 at the end of September 1976.

There must always be a delay in presenting accounts, and when the accounts were presented it was realised that the position was not known until November last year. It could then be seen that if the rate of overspending were to continue unchecked there would be a deficit of about £1 million by the end of the financial year.

That overspending has to be seen against the background that we as a Government place an important priority on reducing inflation. To that end we have imposed cash limits on all the major Government spending Departments and sub-formations under them. To achieve those limits is fundamental to achieving our particular aims in the battle against inflation. That is the background against which the management team had to act. It felt that urgent action was necessary. Therefore, it decided that a number of temporary bed closures should be made in its district and put into effect by the end of the year. In all, about 10 per cent. of the district's beds were affected, in about five hospitals, and the effect at St. Mark's was ultimately the closure of one female ward of 14 beds at five weeks' notice.

I accept that there has been criticism of the way the decision was promulgated, and there was a failure to observe normal consultative processes. That is quite clear. Following these events, as my hon. Friend said, I visited the City and Hackney District twice, once at the behest of my hon. Friend the Member for Hackney, South, and Shoreditch (Mr. Brown) and once at the behest of my hon. Friend himself, in order to see its problems at first hand, especially the problems of an inner city district, and to discuss plans for their solution. On the second occasion, as I recall it, my hon. Friend and I visited St. Mark's Hospital together.

That is the background. The action taken was drastic, and the consultation was imperfect. But the maintenance of cash limits was of paramount importance, and in the end the district management team has to manage with that end in view. However, some lessons have been learned, and I am anxious that they should be applied. Incidentally, I also visited St. Bartholomew's Hospital in the constituency of the hon. Member for City of London and Westminster, South (Mr. Brooke).

I should say that the original plan at St. Mark's was to close more than 14 beds, and that caused an outbreak of feeling. The result of the outbreak of feeling was a reduction in the number of beds proposed for closure from 43 to 14. However haphazard the lines of communication were at that time, and however emotional the situation, it must be put on record that the district management team, with colleagues at St. Mark's and both St. Barthomolmew's and Hackney Hospitals, listened and reacted in a favourable way. On the other hand, I would not want the exercise to be repeated in the way in which it was carried out.

In the course of correspondence with me, my hon. Friend has made play of the unreasonableness of closing the ward at five weeks' notice and has asked for an assurance that such indecent haste will not be used again. I am afraid that I cannot go to that extent. I cannot give that assurance, because wards are always being closed on a temporary basis in the Health Service, for all sorts of reasons, and often at much less notice than five weeks. This, of course, is where the closure is temporary. Sometimes, five days' notice may be all that is given, although naturally, I favour as long a period of notice as is conveniently possible for all change in human and health affairs generally.

I am anxious to secure smoother consultation, however, and as a result of my visit to St. Mark's I have met the fairly recently appointed unit administrator in the hospital, and I am impressed with her desire to get on with her new job.

First, there is the problem of consultation within management, which was at fault as well. Here, I am advised that within St. Mark's it is now accepted practice for the unit administrator regularly to meet the heads of departments within the hospital to convey to them the thinking of the district management team and to receive their observations. This is a welcome strengthening of the machinery within the hospital, and it ought to be encouraged.

There remains the problem, which I regard as equally important, of consultation with the staff. Here again, there was a gap in the arrangements last autumn. At present, I believe that the staff channel for consultation is one seat only on the consultative committee which covers both St. Mark's and the much larger St. Bartholomew's Hospital, so that they tend to get lost in the bigger unit.

I do not believe that that is a strong enough link between the administration and the staff. As my hon. Friend knows, it was proposed in principle when he and I visited St. Mark's that St. Mark's should have its own staff joint consultative arrangements within the overall structure of the existing joint consultative machinery.

I am advised, however, that in spite of the general feeling in principle that that should happen, not much progress has yet been made because the strong feeling among the staff with regard to the closed ward tends to distract attention from further progress in this direction. We must hope that, in an atmosphere of greater trust which may prevail when the ward is opened, a joint consultative arrangement will be set up. If that is so, the circumstances which prevailed in St. Mark's towards the end of last year ought never to recur. It is important to realise that.

St. Mark's Hospital has enhanced the world-wide reputation of British medicine for research, discovery, innovation, development of sophisticated procedures and superlative standards of skill and care. I cannot accept that any hospital, no matter whether it be a centre of excellence, can be sheltered from the necessity of adhering to financial allocations. In my view, no matter what machinery there is for bringing a hospital like St. Mark's within the Health Service, at this juncture it is a machinery for arguing about where restriction should be applied.

At St. Mark's I am pleased to hear that there has been a temporary reallocation to female patients of a seven-bedded male unit in the hospital, and that has allowed pressure on female surgery caused by temporary closure of beds to be reduced.

In the ultimate, other action can be taken which might reduce the pressure. Some weight has been given by my hon. Friend to the national nature of this hospital and its service, certainly to its supra-regional function. Clinically, however, 60 per cent. of the patients come from London postal districts while over 90 per cent. come from the South-East of England. Nevertheless, on the day I visited St. Mark's there seemed to be a predominance of people from Wales occupying beds in the female surgical wards.

Within the management of many districts, particularly in London, there are centres of excellence providing services to a wider catchment area than that of the district alone. Under the management of the same district as St. Mark's is St. Bartholomew's Hospital, which is also internationally famous, and it is with this hospital that St. Mark's is linked.

St. Bartholomew's has had to contribute to urgent economy measures as well and there some 60 beds have been temporarily closed. I cannot accept, therefore, that St. Mark's should be singled out for some special treatment and that its finances should be protected at the expense of other hospitals or of some other services to the community. I think that my hon. Friend accepts that that is what protection would mean.

It would mean that extra funds would have to be found from somewhere in order to preserve St. Mark's, and there is just no coffer from which some selective services can be essentially funded, regardless of the priorities and demands of the wider service given in the regions.

No doubt my hon. Friend has had pointed out to him the position of some other specialist hospitals which, having academic institutes and independent boards of governors, were not assimilated into the regional and area structure as St. Mark's was on the reorganisation of the health service.

But my hon. Friend will know that while no easy solution could be seen at that time to assimilating the management structure of such hospitals, they are not regarded as having an overriding priority call on the resources of the health service. We shall be meeting them, considering their future with them and bringing them into the structure of the Health Service, albeit perhaps on a different basis. But they, too, have had to tighten their belts in the last two years and live within severely restricted cash limits.

I turn now to the future. The North-East Thames Regional Health Authority has not abandoned its policy of seeing that Essex gets a fairer share of the region's resources, but, in common with people living in underprovided areas elsewhere, the people of Essex may have to wait another 10 years or more for what they see as their full and fair share of the resources available.

My hon. Friend probably knows that on 22nd March the district management team of the City and Hackney district issued a statement on their financial position in which they listed an order of priority for reopening three wards now temporarily closed. Their priorities were—and I am not going to question them—to open first the observation ward as St. Bartholomew's Hospital, secondly to open an acute ward at Hackney Hospital and thirdly to reopen the closed ward of 14 beds at St. Mark's. I am very pleased to be able to tell the House, that because of the easing financial position in the City and Hackney district, a timetable has been agreed for reopening those wards provided that is what the district continues to wish to do.

I know that arguments about priorities continue. Recruitment of the necessary staff is now under way and the dates for reopening could be as follows: St. Bartholomew's Hospital observation ward by the end of June, Hackney Hospital acute ward, also by the end of June, and St. Mark's Hospital, by about the middle of July—I have been given the date of 15th July.

There is also the question of moving funds about between areas and regions, and my hon. Friend said that we could get to a situation in which we were closing units in one part of the health service and opening them in another. We have always been in that position. While these three wards remain closed in East London, I shall be in Wakefield next Thursday opening a new unit. That is because there are sufficient funds available in Wakefield for that purpose. There are not the allocated funds readily available in the Hackney area at the moment for opening these three wards.

There have to be some sort of economies in order to get to grips with the particular problem of how funds may be moved. There is a time element as well, because people are given certain allocations. Their colleagues depend on them keeping within those allocations—

The Question having been proposed after Four o'clock and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at twenty-nine minutes to Six o'clock.