I hope that this debate as the latest in a series of attempts to resolve the future of the Health Service in south Glamorgan will have achieved its primary purpose by the time the Minister sits down and that we will at last have a decision on the 10-year hospital plan.
Massive disquiet has built up during nearly two years since public consideration of the health authority's 10-year plan started. It is more than 10 months since the document reached the Secretary of State for Wales. At that time, I urged him to reject the plan and to send the health authority back to the drawing board because of the manifest defects contained within it. Indeed, this is already a second attempt as, in the words used by the Secretary of State for Wales in his letter to me on 29 June, south Glamorgan's first round plan
was not approved because of significant inherent weaknesses
That means that the future of the Health Service in south Glamorgan has been under a cloud of uncertainty for far too long and desperately requires an injection of support and confidence from the Government. The Minister will be aware of many requests for a proper sense of urgency to be given to the matter. I refer to the terms of early-day motion 990 in my name and early-day motion 880 standing in the name of my hon. Friend the Member for Vale of Glamorgan (Mr. Smith).
The Minister will be aware also that concern was highlighted during the Vale of Glamorgan by-election, when the public gave their views to the Government in no uncertain terms. That concern was partly to do with local issues, including the future of Sully hospital, but it was accentuated by massive public rejection of the Health Service White Paper. After the election, a plea to the Secretary of State for Wales to back off was given in early-day motion 879.
It appears, however, that the Government are hell-bent on introducing the proposals of the Health Service White Paper into Wales, and neither the Secretary of State for Wales nor the Minister can avoid complicity in that intent which undermines and threatens confidence in the Health Service. The Secretary of State for Wales, in his letter to me on 29 June about the planning activities of health authorities in Wales, states that strategies will have to be "framed in the light of the White Paper".
He goes on to state that
the fundamental principles of the NHS remain unchanged under the White Paper,
which appears to be a ritual incantation by which Government Ministers hope to evade criticism and is simply untrue. But he then confirms that
the future roles of those involved in securing the delivery of service will change, and it is recognised that these changes will require a reorientation of the planning process to a new environment".
Put into simple English, that means that, during the 10 months that the 10-year plan has been in the Minister's in-tray, things have changed and it now needs to be assessed against the background of the White Paper proposals.
I challenge the Minister, in his reply to this debate, to give just that context. I have already quoted the Secretary of State for Wales in support of my contention that we need to know how the White Paper will operate in Wales in order to judge the Government's decision on the hospital plan, but if further evidence is needed, just look at his words in the Welsh day debate on 1 March when he promised an early debate, confirmed that special factors in Wales required the White Paper to be implemented in a different way from England, and promised us separate and specific documents setting out how this would work. We are still waiting; everyone working in the Health Service in Wales is still waiting and the public in Wales are still waiting.
In a letter bearing the same date, ironically, Mr. John Wyn Owen, director of the NHS in Wales, stated:
detailed implementation of the proposals has to reflect the different organisational arrangements and the needs and circumstances of different parts of the United Kingdom".
The hope in the Welsh Office bunker now appears to be that it may get away with just the vague generalisations about Wales in chapter 11 of the White Paper. However, that just is not anywhere near adequate and I can tell the Minister that the Government simply will not get away with it. Let him now, tonight, tell us what has been decided about the south Glamorgan 10-year plan and precisely how that will fit into his right hon. Friend's plans for the Health Service in Wales as a whole.
There are many points to be clarified, hut, just to give a flavour, it would help if he will say tonight that there will be no hospital opt-outs in Wales. That will help us assess the validity of the hospital pattern in the county. The Secretary of State for Wales has tried to convey a softer tone than his colleagues in the Department of Health, but that is only skilful packaging unless his policies and decisions are to be different. As far as south Glamorgan is concerned, I demand that the Minister come clean and tell us how our Health Service will be run in future.
Coming to the contents of the 10-year plan, I will briefly list the main concerns and objections to the draft plan, and ask the Minister to ensure that his response includes specific reference to these points which were made formally to his colleagues at the Welsh Office over the past two years, so they should have been anticipated for him.
First, has the over-ambitious plan for a new district general hospital in the docks been rejected? The Minister should note that the unanimous view of the consultants, academics and others I have spoken to is that if it is built the health authority will not have the money to run it without serious damage and ward closures at the two existing district hospitals at Llandough and Heath—what a group of consultants described as
bleeding the existing services of all development just as happened when the Heath opened".
Has he taken into full account the reported views of clinicians on the plan? Will he also note that, for two years, development land has been blighted because of this particular proposal and Cardiff has lost actual jobs—I have been into the facts—because of this delay? Has he questioned the health authority on its extremely sketchy evaluation of the medipark which it proposes, but for which there is not room, and what is the result of his evaluation? I have been promised a response from the health authority on this, but it is still awaited and I hope its work has been more dependable and goes into greater detail than appears on present evidence.
Secondly, has the Welsh Office provided an answer to the question of how to provide south Glamorgan with proper, modern accident and emergency facilities? The Minister may recall that the whole rationale for a new DGH was that it needed to put such facilities somewhere. I have made alternative suggestions in order to provoke proper discussion. Has a proper job now been done on this matter?
Thirdly, has the Welsh Office undertaken a proper evaluation of the costs and practicalities of running the services set out in the plan as approved or amended by the Secretary of State's decision, which we now eagerly await? Will he give me an assurance that this information will be published so that the basis of his decision can be seen and understood? Is the Minister aware of the numerous challenges to the financial basis of the draft plan and has he been into this fully?
Fourthly, has the Welsh Office clarified the role of the neighbourhood hospitals referred to in the plan and will the Minister share that clarification with us? He must be aware that the vagueness on this point has caused great concern. The relationship between the neighbourhood hospitals and community services is not clear. Nor is the expectations on family doctors. The plan for the neighbourhood hospital in Barry is now quite well advanced, so these expectations should be made clear in the Welsh Office decision tonight. Does he not agree that it is ludicrous to conclude this expensive review of hospitals without also undertaking a serious review of primary care, and has he noted the worry on this point expressed by the college of medicine, the family practitioner committee and the local medical committee among others?
Fifthly, what is the timetable for the provision of neighbourhood hospitals? Does the Secretary of State accept the health authority criterion of one per 40,000 population? Does the plan now include a detailed timetable for their provision? This is a point I have pushed repeatedly, as it would be unacceptable to approve a plan which involves the closure of hospitals like the Royal Hamadryad without knowing that they are to be replaced with something better both in terms of health care and in terms of the living environment.
Sixthly, does the decision guarantee a secure future for Llandough hospital and Sully hospital? The Minister will be aware that these are two of the most appreciated and best loved hospitals in the country, and we want them retained. He will also be aware that the proposal to close Sully is the single most unpopular recommendation in the original plan. Tied to Llandough, it can have a secure future with its present usages, plus an expanded role in recuperation and therapy—where could there be a better site?—and it can provide a site for the neighbourhood hospital for the east of the vale of Glamorgan. I warn the Minister not to trifle with the views of people in my area and in that of my hon. Friend the Member for Vale of Glamorgan by giving us a decision that fails to deal satisfactorily with Sully.
Seventhly, will the Minister assure me that the decision takes into account the present constraint on nursing budgets and puts that right? It would be ludicrous to have a decision on plant and buildings which fails to deal with this point. At present, the nursing budget for Llandough, for instance, is inadequate to pay the agreed number of staff because it is assumed that everyone is on the mid point of the scale. In fact, the hospital has stable staff, and this crazy system is a penalty for having loyal and well motivated nurses. It is a penalty for success, and that is why one ward is closed, staffing is on a knife-edge and the loyalty of people is being tested to the extreme. With the Welsh Office insisting on £2·1 million of cuts in this financial year, it looks as if the Government have a deliberate policy of uncertainty and demoralisation, so will the Minister offer us some reassurance and reverse this trend? Will he agree with me that any plan will have its problems if it is based on inadequate funding which continues to fall further and further behind the need?
Eighthly, does the decision take account of the need for the integration of the hospital plan—for the proposals from the health authority cannot be properly termed a health plan—with the services provided by family doctors and other community-based health services? There are many detailed concerns on this front of which the Welsh Office is well aware, and a decision which fails to answer this point will be empty and meaningless. Again, the White Paper is relevant. One doctor told me at the weekend that for the first time he wondered whether it was worth carrying on rather than taking early retirement because the Government will devalue the preventive and developmental work he has enjoyed, force him away from the patient care which brought him into medicine and push him into being a part-time accountant.
Will the Minister reassure us and tell us he is listening to the passionately expressed views of doctors and that Wales will be spared the policy of conflict and insult being pursued by the Secretary of State for Health and his pale shadow in Wales, the hon. Member for Delyn (Mr. Raffan)? It is impossible to underline this particular point enough. I have met doctors and received letters from doctors and listened to doctors. They resent the failure of the Government to listen to the voice of experience, they resent the threat to the relationship between doctor and patient, they reject the naive assumption that better health care will result from making a doctor undertake accountancy tasks, and they stress, from a professional point of view, that the man and woman in the street is right to fear the introduction of shopping around for the best buy when applied to medical treatment.
Will the Minister agree that we can do without this approach and that, in Wales at least, doctors will be regarded as human beings and professionals who need to be involved in the future design of our Health Service? That positive approach to doctors, I urge the Minister, is essential to make any plan work. Hundreds of my constituents have written sensible and thoughtful letters supporting the doctors' argument. Will he also reflect on the words of a surgeon who recently stressed to me that, as well as the nurses and technicians, the porters and ancillary workers are also vital members of his team, and that he was shocked and ashamed at the figures on their pay packets. Will the Minister set this plan in the context of humanity and teamwork?
Ninthly, will the Minister accept that the Welsh Office decision—unless it refers the whole business back to the health authority—must involve wholesale changes to the plan and that he should therefore allow a period of public discussion and comment before the Welsh Office decisions become final? I appreciate that individual closures, for instance, are subject to a specific procedure of comment even after the overall plan is agreed, but the overall plan is fundamental to the future of our Health Service in south Glamorgan and should be seen to stand or fall on its own merits as an overall plan.
Tenth and finally, will the Minister tell us whether we will now have a plan which allows the public and everyone in the Health Service to plan ahead with confidence and enthusiasm, or is it a flexible friend for the administrators to manipulate as they will? He will be aware that the plan has been described by the health authority both in terms of certainty and uncertainty, and it is very important for us to know how dependable the decisions in it are. Will the Minister be very specific on this point?
I have concentrated on the main aspects of the plan, but the Minister must know that there are serious worries on all aspects of the future of our Health Service. Ambulance services, waiting lists, outpatient clinics, the pay of ancillary staff—described to me by one senior administrator as "scandalously and dangerously low"—community services, properly integrated paediatric services, preventative medicine, services for the elderly, specific services for women, and the threat to stability of the new general practitioners' contract are all important, too.
The key to the whole way in which the Health Service operates is the problem of chronic underfunding. Ministers may reflect the blinkered approach of the Prime Minister and claim that there is no problem of underfunding, but there is a serious problem and Ministers who ignore that basic problem and allow the Health Service to bleed to death will not easily be forgiven, certainly in Wales.
It will not be enough for Ministers to claim that decision-making and the deployment of resources have been devolved to the health authority. The Secretary of State appoints his majority to the health authority, and will do so even more under the White Paper. They are his creatures and most would not be there if elected, so he has to carry the can. The Health Service is the best-loved public service in south Glamorgan, and we want it treated with care and respect.
My constituents in Cardiff, South and Penarth want to know that they can depend on a well-planned Health Service in south Glamorgan, funded adequately to meet their particular needs as and when required, and staffed by people who are as much appreciated by the Government and the health authority as they are by the general public. They want that service set within a Welsh Health Service that is designed to meet the needs of the people of Wales. The Minister's announcements in answer to this debate will be totally inadequate unless I can carry back reassurances to them on each of those points.
The hon. Gentleman has expressed his concern about the future of the Health Service in south Glamorgan and, indeed, a wider concern. I am sure that he recognises that the decisions of my right hon. Friend the Secretary of State for Wales on South Glamorgan health authority's strategic plan and the future of cardiac services in south Wales are all-important in that context. It was my right hon. Friend's intention to announce his decisions on those matters today. However, I am sure that it would be helpful to the House if I outlined the main points now.
Some 59 representations have been received by my right hon. Friend about the strategic plan since it was submitted in October 1988. Those were made by a wide range of people and organisations, including hon. Members, members of the public, community health councils, local councillors and individual medical personnel.
My hon. Friend welcomes the broad objectives underlying the guiding principles for the 10-year strategy as set out in the plan. Those are reprovision of the accident and emergency service; early provision of a new cardiac unit; improved specialty groupings; enhancement of academic and research facilities; improved condition of the estate; and minimum revenue costs in order to finance high-level capital expenditure.
My right hon. Friend has agreed that future acute services should be rationalised and concentrated on three major acute hospital sites—the University hospital of Wales, Llandough, and a new hospital on a third site to be decided by the authority. The new hospital, which will have an important teaching function, will provide accident and emergency services with related specialties from a location with good road communications with the rest of the county.
My right hon. Friend has also agreed and welcomed the concept of neighbourhood hospitals which bring elements of health care closer to local communities and welcomes, in broad terms, the more involved role intended for general practitioners and primary health care teams. However, he feels that the authority should work closely with the South Glamorgan local medical committee and family practitioner committee working party on neighbourhood hospitals in drawing up those plans.
On regional services, the authority's proposals are broadly in line with departmental policies, and we would expect South Glamorgan district health authority to continue to play a major role in providing regional services to patients from all parts of Wales.
One aspect of the strategic plans that attracted particular attention was the suggestion that the main cardiac surgery and cardiology unit should he moved to Llandough hospital from the University hospital of Wales, in conflict with the Department's existing policy of development at the UHW. Clearly the location of the regional cardiac unit would have a significant effect on the strategic plan as a whole.
Before commenting on my right hon. Friend's decision on cardiac services in south Wales, I shall correct a false impression created by some hon. Members. Since the then Secretary of State for Wales accepted in 1984 the Welsh Medical Committee's report on cardiac services, it has been Welsh Office policy to expand the unit at the UHW. There has been considerable success in increasing the number of open-heart operations performed there. During the 1980s, it has doubled. However, it has not expanded rapidly enough, and there have been difficulties in overcoming the obstacles to increased throughput. It is not true to say that no progress has been made or that there has been no investment. Real development has been achieved and we funded it—but we want to do better because the toll of death and disability from heart disease in Wales demands it.
My right hon. Friend accepts the Royal College of Physicians' estimates of required throughput, and he has slightly improved on it so that we can aim at achieving 1,200 open-heart operations per year. My right hon. Friend noted the royal college's recommendation that the centre of excellence that Wales needs should be located at the University hospital of Wales, where the necessary clinical, diagnostic and other support services would be available, and which is the preferred academic base. Most respondents to the consultation supported that view, and so does my right hon. Friend. He believes that the UHW, not Llandough hospital, is the right location for the main cardiac unit.
The royal college report argued that such a unit should perform all the open-heart operations required. At 1,200 adult and paediatric open-heart operations per year, it would be a very sizeable unit. Not uniquely so, but large—particularly in the context of the UHW. The health authority argued in its strategic plan that that was not practicable, and my right hon. Friend shares that view. He considers that it would distort the critical balance of the UHW and that the construction phase would cause unacceptable disruption to services and to the comfort of patients and staff. As a consequence, he decided that the adult unit at UHW should be expanded to perform 800 open-heart operations a year and that a second unit should be built after a thorough appraisal of the options.
The health authority has today been asked to set the development of the main unit in train. In addition, it has been invited to submit proposals for increasing the number of cardiac operations commissioned through the authority from 600 to 800 a year.
South Glamorgan health authority's plan contains broad proposals for the closure of hospitals and other substantial variations in the service provided by the district health authority. My right hon. Friend's decision on the overall strategy, including his approval in principle to the rationalisation proposals, in no way removes the need for the health authority to secure individual approval for such changes at the appropriate time. If the authority decides to pursue a particular change, each proposed closure or substantial variation in the service provided must be subject to separate and detailed formal consultation nearer the time of implementation before they could be effected. In the event of local opposition, my right hon. Friend would consider appeals and decide the matter.
Copies of my right hon. Friend's decisions on the strategic plan and cardiac services in south Wales will be available from the Vote Office later today. Following my right hon. Friend's decisions, the future planning work to be undertaken by the health authority will take account of the elements of the submitted plan on which he has called for further work. These will he included in a full and revised strategy as part of the second round of strategic planning in common with the other district health authorities of Wales. The preparation of the new strategy will enable the authority to take full account of the likely changes brought about by the Government's White Paper "Working for Patients" and the guidance given by my right hon. Friend will provide a firm basis for the authority to review its plan. We look forward to receiving the authority's new plan in due course. Meanwhile, later this year, the Welsh Office proposes to issue guidance for all authorities for undertaking the second strategic planning round. It will, of course, be essential that a close dialogue is maintained between the district health authority and the Welsh Office.
I sincerely hope that all who are concerned with, or have an interest in, the future pattern of health services in south Glamorgan will see my right hon. Friend's decision as a clear and sound basis on which to build and develop an up-to-date service for the future.
Why has the two general district hospitals option, favoured by most professionals, been rejected? Will the Minister confirm that the site of the third GDH will not now be at the Cardiff docks? What is his decision on Sully hospital? Many people await that announcement. Has the hon. Gentleman fully evaluated the costs? Has a decision been taken on the programme for neighbouring hospitals to meet the requirements throughout the county?
I have covered the point about the neighbourhood hospitals.
The plan says that some 2,400 acute beds will be required in the south Glamorgan area. We believe that that figure is somewhat excessive and that it should be about 2,100. Even so, as I am sure the hon. Gentleman will recognise, if those beds were to be divided between two hospitals, it would mean about 1,000 acute beds each. That would be a very large hospital, bearing in mind that the University hospital of Wales has some 880 acute beds. That is the basis of the decision in favour of three hospitals, rather than two. I cannot tell the hon. Gentleman where the third hospital will be located. Indeed, we have not told the authority as much. It is for the authority to decide. We have, however, stated that the hospital must be sited in a place where access is good.
I am sure that the hon. Gentleman has noted what I said about the closure proposals, and that certainly applies to Sully hospital and any other hospital.
As for financing of the strategic plan, it is difficult to anticipate all the financing details in a 10-year plan, but my right hon. Friend the Secretary of State has asked me for a revised and more robust financial plan. That is amply described in the decision letter.
We hope thereby and with these decisions to build up a worthy service which can realistically be achieved for the benefit of the people for whom it is provided.