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  • Eric Deakins – 1978 Speech on Redditch Casualty Service

    Eric Deakins – 1978 Speech on Redditch Casualty Service

    Below is the text of the speech made by Eric Deakins, the then Under-Secretary of State for Health and Social Security, in the House of Commons on 3 November 1978.

    I begin by congratulating the hon. Member for Bromsgrove and Redditch (Mr. Miller) on getting an Adjournment debate so quickly in the new Session and for giving me the opportunity to speak about the problem generally—it is a difficult one— and to assure the people of Redditch that the difficulties over their casualty service have not gone unnoticed here in London.

    As the hon. Gentleman well knows, through our correspondence, and in his meetings with my right hon. Friend the Minister of State, we have been involved in this issue for some time now. As he ​ said, it is a most difficult one, and I hope in the course of my remarks to clarify some of the problems.

    Our concern has been to ensure that the residents of Redditch are provided with an accident and emergency service appropriate to their needs and—of almost equal importance—that they are fully informed about the different services available. I hope, if there is time, to return to this latter point.

    Hospital treatment for the great majority of casualties from Redditch is provided in one of three ways. The most serious cases are usually treated at Selly Oak hospital in Birmingham—a journey of about 15 to 18 minutes by ambulance.

    Other, less serious, cases are dealt with either at one of the hospitals in Bromsgrove, about seven miles away, or, if the casualty arises between 9 a.m. and 5 p.m. on a Monday to Friday, at the Smallwood hospital in Redditch.
    Smallwood hospital is a general practitioner hospital of some 42 beds, with a casualty department staffed by 24 local general practitioners. They provide medical cover according to a rota which they themselves have drawn up. The general practitioners are not necessarily in attendance at the hospital throughout their period of duty, but they obviously have to be immediately available if required. During the last period of 12 months for which figures are available there were, on average, 170 new patients treated at Smallwood hospital each week. It does appear, however, that the numbers have recently been increasing. Until the end of March 1977 the general practitioners in Redditch provided 24-hour seven days a week cover and were, at that time, treating about 260 new patients a week.

    I think it might be helpful if at this point I briefly describe the general picture with regard to the remuneration of general practitioners who work in general practitioner hospitals. At present, the only approved methods of remuneration are the staff fund—also known as the bed fund—system as provided for by the terms and conditions of service of hospital medical and dental staff, or, where appropriate, sessional payments at the part-time hospital medical officer rate. These practitioners are commonly referred to as clinical assistants. Where the number of patients attending the ​ general practitioner hospital as casualties or the nature of the services being provided—that is, services other than those the general practitioner might have provided in his own surgery—are such that the staff fund alone is not considered to provide adequate remuneration for the work, health authorities may make sessional appointments at the clinical assistant rate to remunerate the work falling outside the scope of the staff fund.

    The clinical assistant rate is, at present, £720 per year for one session per week. Each session is equivalent to three and a half hours’ work at the hospital. There are no nationally agreed rates for “on-call” work for this group and health authorities are expected to agree locally on appropriate assessment of sessions for any on-call work, taking into account the amount of clinical work arising from the on-call commitment, not merely the length of time on-call. The rate of payment into the staff fund and the sessional fees payable to clinical assistants are those recommended by the Doctors’ and Dentists’ Review Body, the independent body set up to advise the Prime Minister of the day on matters of medical and dental remuneration within the NHS.

    Discussions between the general practioners and the Hereford and Worcester area health authority about its future level of remuneration for services at Smallwood hospital began in 1976 when the general practitioners were still providing full casualty cover. I understand that at one stage it was thought that the general practitioners might be eligible for the new hospital practitioner grade. As they were not working as part of a specialist consultant team, however, such a regrading was not possible. At another stage in the negotiations the general practitioners were made an offer that was subsequently withdrawn. I can well understand the general practitioners’ frustration at these events which must clearly have adversely affected their relationship with the area health authority.

    In the end the only agreement that could be reached was for the restricted casualty service now in operation for which the general practitioners as a group are paid 17 clinical assistant sessions a week. This total number is made up of three sessions per day plus an additional ​ two per week to cover bank holidays, sick absences and so on.

    The concern over the introduction of a restricted service and the need for the AHA to establish what kind of service was being provided and what kind was necessary, led the authority to set up a survey of general practitioner casualty provision. As the chairman of the AHA explained in his letter of 27th February 1978 to the hon. Gentleman, the aim of the survey was to establish three things. First, the degree to which the nature and quantity of work carried out by general practitioners at the Smallwood hospital compared with a consultant manned accident and emergency department. One case for paying additional remuneration would be if the general practitioners were dealing with more serious cases than was normal in such a casualty department.

    Secondly, the survey was to find out the degree to which the work undertaken in the department might be considered part of the general practitioners’ normal workload. There is little doubt that a proportion of the patients treated in the casualty department would, elsewhere, be treated in their general practitioners’ surgeries.

    Thirdly, the survey was to provide information to help the AHA to decide whether or not the restricted service provided an acceptable level of casualty cover for the town.

    Unfortunately, both because of the illness of the officer conducting the survey, and because of the complexity and number of patient records being analysed, this review took longer than expected and, indeed, is still incomplete. Apparently the analysis of patients’ records retrospectively has not provided as much information as was expected. It has therefore become necessary to consider embarking on a prospective survey in which, it is hoped specific information will be obtained from patients during the course of their treatment. An interim report from the survey was put before the authority’s meeting on 16th June 1978. On the first of the three questions the report concluded that although the contention that the work was more akin to that of a consultant department could not be conclusively refuted, the evidence thus far available was strongly suggestive to the contrary. The report also dealt at some length with the pattern of treatment ​ for Redditch patients with particular reference to the location of the treatment whilst the Smallwood hospital casualty department was closed.

    I understand that the AHA discussed the report and the whole situation in considerable detail but felt unable to depart from the general principle adopted for its area; namely, that one session per week should be paid for each 600 new attendances annually. The Redditch general practitioners’ current level of remuneration, which had been separately negotiated at 17 sessions a week, exceeds that which would be payable under the general formula; and their request for an ultimate payment of 42 sessions a week for 24-hour cover is well in excess of the level likely to be reached were they to provide such a service.

    The AHA asked the district management team to pursue with the general practitioners the possibility of rearranging the sessions currently worked so as to provide fuller cover at the hospital. This might have involved, for instance, transferring one of the three sessions from the morning period. As the hon. Gentleman is aware, the general practitioners have rejected this approach. The AHA also resolved to delay any final decision on the general level of remuneration payable to general practitioners in cottage hospitals pending the outcome of discussions on the consultants’ contracts.

    The hon. Member may like to know that a joint working group made up of representatives from the health Departments—DHSS, Scottish Home and Health Department and Welsh Office—representatives from NHS management and representatives from the British Medical Association has recently been set up to discuss the work of general practitioners in hospitals with particular reference to the implications for the remuneration general practitioners receive for this work which obviously is directly relevant to this problem. The payment of general practitioners for casualty work in general practitioner hospitals and units is one of the subjects being considered by the working group. The health Departments have made certain proposals on this to the BMA; these include the setting up of a special casualty fund, on the lines of the existing staff fund, to remunerate these casualty services. I cannot say more at ​ this point on progress in the working group or of the shape of any future agreement, but I can assure the hon. Member that we hope that an agreement may be possible in the reasonably near future.

    We must hope that these national discussions lead to a generally accepted basis for this type of remuneration. In the meantime, however, it is for the health authority and the general practitioners locally to agree on an acceptable level of service and of remuneration to the general practitioners for providing it, taking account, obviously, of the needs of the residents of Redditch and of the requirements of the pay policy that extra pay can be justified only by identifiably additional work.

    I ought perhaps also to draw attention to the long-term solution to the problem. As the hon. Gentleman knows, the West Midlands regional health authority is firmly committed to the provision of a major new district general hospital in Redditch. Its first phase is expected to include some 330 beds, together with a full consultant-staffed accident and emergency department. The question of the site for the new hospital has now been finally resolved and it is expected that construction will start in early 1983 with a view to completion of the first phase by 1986.

    A number of points were raised by the deputation which the hon. Gentleman brought to see my right hon. Friend the Minister of State on 20th July. I should like now to deal with these points. I hope that the hon. Member will treat my remarks as a further reply to his recent letter and parliamentary Question.

    Perhaps the most serious point raised was that unless the general practitioner’s remuneration was improved there was a danger that insufficient doctors would be prepared to participate in the scheme and the service might collapse altogether. I hope that the remarks I have made this afternoon about the comparison between the amount paid to Redditch general practitioners and that payable in other hospitals in the area will go some way to avert that danger. I should like to take this opportunity to say that there is no doubt that the local general practitioners are providing an extremely valuable service for their town.

    It was also suggested that the AHA might make its own arrangements for providing an extended casualty service, perhaps by advertising for additional staff. It must be said, however, that this is no more than a theoretical possibility. There would be very great difficulty in attracting suitable applicants for such a post and it is by no means certain that proper consultant supervision could be arranged.

    The deputation raised the possibility of a reduction in the number of new attendances on which the payment was based. I have already said that the AHA felt unable to depart from its general basis of one session for each 600 new attendances.

    Finally, the deputation spoke of the refusal of the Hereford and Worcester family practitioner committee to pay night visit fees for the work formerly undertaken after 11 p.m. by the general practitioners at Smallwood hospital. The statement of fees and allowances payable to general medical practitioners provides that a night’s visit fee will be payable subject to the relevant conditions being met where in the patient’s interest the general practitioner provides specific treatment at a general practitioner hospital, provided that the doctor is not on duty at or on call for the hospital at the time, and that the request for the patient to be seen did not come from the hospital. I think it is clear that those conditions were not satisfied and that the decision of the family practitioner committee not to pay a night visit fee was, therefore, correct.

    At the start of my speech I said that, if there were time, I would return to the question of the information available to the people of Redditch about the health services provided for them. The difficulties over the Smallwood hospital casualty service were discussed at a recent meeting of the West Midlands regional health authority. The authority concluded that the resolution of the dispute did not lie in its hands but felt that the local residents should be kept in touch with the facilities in the area. I understand that the authority’s public relations department is currently having information compiled about the whole range of these services and that, after discussions with the district management team, the family practitioner committee and the ​ local community health council, it is hoped to issue a comprehensive health information sheet within the next few weeks. It is expected that this will be issued by a professional distribution service on a door-to-door basis to every household in Redditch. Such an information sheet would thus have a wider distribution than the existing leaflet on the family practitioner services which is issued by the housing department of the new town development corporation to all its new tenants.

    One of the items which I should imagine will be included is a description of the hospital services available in Bromsgrove. I understand that there is some confusion about the location of the casualty department in that town. The department is, in fact, at the cottage hospital and not at the larger general hospital. I know that the community health council has suggested that a full accident and emergency department should be provided at Bromsgrove general hospital. The AHA has, however, pointed out that when, as would be inevitable, the unit transferred to the new district general hospital planned for Redditch there might be difficulties in reintroducing a general practitioner service in Bromsgrove.

    I should like to conclude by reiterating what I said at the outset. Our concern is to ensure that the residents of Redditch have the type of accident and emergency service they need as quickly as possible. In that connection I am sure that the chairman of the Hereford and Worcester area health authority will not mind my making public a comment in his letter of 27th February 1978 to the hon. Gentleman. In that letter he said that anyone who had direct information concerning patients who had suffered as a result of the restricted service should let either him or the area medical officer know as soon as possible. I understand that no such cases have yet been brought to their attention but the request for information still stands.

  • Eric Deakins – 1978 Speech on Multiple Sclerosis and the Naudicelle Treatment

    Below is the text of the speech made by Eric Deakins, the then Under-Secretary of State for Health and Social Security, in the House of Commons on 5 May 1978.

    I am glad to have this opportunity of replying to the points raised this afternoon by my hon. Friend the Member for Derby, North (Mr. Whitehead). I know that his interest in this subject—which goes back a number of years—is shared by other hon. Members. Let me say frankly at the outset that there is very little I can add to what my right hon. Friend the Minister has already said on this matter in reply to hon. Members who have written to him and put down Questions in the House.

    The reason for this is that in all fields of treatment and prescribing of medicines one must tread most carefully and cautiously and, as I hope I can show to the satisfaction of my hon. Friend that, in this area particularly, there is very good reason indeed for slow progress. Let me first explain something of the general context in which treatment under the National Health Service occurs.

    Family doctors, under the National Health Service, are free to prescribe any drug or medicine they consider necessary for the proper treatment of their patients, though they may be asked to justify their prescribing decisions, if the cost appears excessive, or if the substance may not be a drug. Only the doctor concerned can decide whether something is necessary for the treatment of his patient and whether that substance is something that should properly be prescribed as a charge on the National Health Service.

    If there is any doubt on the latter point, the doctor will consider carefully whether he would feel able to justify the ​ decision to prescribe a substance if called upon to do so. If he is satisfied on this point, there is nothing to prevent him from issuing the prescription and it being dispensed in the normal way.

    I emphasise that it is the doctor, and only the doctor, who can determine which medicines or drugs should or should not be prescribed for a patient. It is certainly not the Department’s job and it would be quite wrong for it or anyone else—including the patient—to attempt to influence the doctor’s decision.

    My hon. Friend asked about representations from doctors. Over the course of some three years there have been 69 cases of family doctors who have defended their decision to prescribe Naudicelle for multiple sclerosis before their professional colleagues on the local medical committee. In 25 of these cases the doctor concerned was about to satisfy his colleagues that the substance had been properly prescribed in the circumstances.

    National Health Service legislation does not define a “drug”. The question of which items or substances should or should not be regarded as drugs, which form part of the pharmaceutical services under the National Health Service Act, has been considered on several occasions by independent professional committees. Precise terminology has varied, but the basic conclusion of each committee has been that substances of a primarily nutritional nature cannot be regarded as drugs and, because they are therefore “foods”, cannot be provided on National Health Service prescription.

    Often the question whether a particular substance is a drug depends upon the circumstances, and no definition could hold good for every case. However, for practical medical purposes, it is reasonable to expect that, where a substance is prescribed for a patient, the substance will have both pharmacological and therapeutic effect on the condition being treated.

    In certain conditions, a “food” may have the characteristics of a “drug”. To advise on the circumstances in which items may be regarded as “drugs”—and therefore prescribable at National Health Service expense—the Department and the profession are very fortunate to have the services of an independent professional body chaired by Professor Barbara ​ Clayton of the Hospital for Sick Children. This body is known as the advisory committee on borderline substances.

    The advisory committee plays a continuing role in examining claims of therapeutic efficacy for individual substances and preparations in relation to particular conditions—that is, whether in particular conditions they may be regarded as having the effect of a drug. Such is the prestige of this independent committee of experts among their professional colleagues that any recommendation which is made is usually acceptable to all concerned. However, I must point out again that whatever the committee’s recommendations, the final decision whether a substance should be prescribed for a patient’s condition rests with the doctor.

    The practical effect of this is that if the committee recommends that a substance acts like a drug for a particular condition then, if the doctor prescribes it for that condition, the National Health Service pays for it. If the committee does not so recommend, decisions to prescribe that substance may be challenged, but—and to re-emphasise the point that I made at the beginning about the prescribing freedom of the family doctor—doctors can and often do successfully defend their prescribing decisions, through the machinery laid down in regulations for this purpose, notwithstanding an advisory committee recommendation.

    I have described this framework in some detail, because it is germane to the fundamental question raised by my hon. Friend why the substance known as Naudicelle cannot at present be provided at National Health Service expense in the treatment of multiple sclerosis at home. I say “at home” deliberately, because a patient in hospital is provided with all his daily needs. These include whatever food and toilet preparations may be considered advisable for him and which he would be expected to provide for himself as necessities of normal life if he were living at home.

    As those who have had anything to do with the disease will know—my hon. Friend stressed this matter—multiple sclerosis is a very distressing disease and one which is most difficult to treat. I understand its effects are so variable between individual patients and that the ​ course the disease follows is so erratic that often it is difficult for a layman to appreciate that a multiple sclerosis patient in remission is ill. I am told that many of the features of multiple sclerosis can present—variability, erratic and unpredictable developments—make every patient’s case uniquely individual.
    That being so, formidable barriers are presented to those evaluating the efficacy of particular types of treatment. At any time patients may experience spontaneous remissions of the condition, sometimes of long duration, so that it can be most difficult to know whether encouraging changes are in fact due to treatment.

    Multiple sclerosis is the general term given to cover many symptoms of weakness and loss of use occurring in different parts of the body. Experts differ in their views on the disease, and for this reason no single method to treat the condition or alleviate the symptoms has been arrived at. One view is that if the proportion of saturated fat in the diet were reduced relative to unsaturated fat, it might help a patient’s nervous system function more effectively. To explore the validity of this theory, multiple sclerosis patients have been given oils such as sunflower seed oil which contain the unsaturated fat, linoleic acid. An even less saturated fat, gamma linoleic acid is, I understand, found in the oil of the evening primrose, as my hon. Friend pointed out, and it is this oil which is contained in Naudicelle capsules.

    The capsules are a proprietary preparation manufactured by Bio-Oils Research Limited of Nantwich, Cheshire. From the outset it has claimed that the Naudicelle capsules contain a pre-digested form of linoleic acid which acts more directly and more quickly than other linoleic acid derivatives.

    This claim was included in the evidence submitted to the advisory committee on borderline substances in July 1974. At that time the committee convened a special meeting to consider in detail the whole question of the use of dietary supplements and linoleic acid and its derivatives in the management of multiple sclerosis. The committee examined in great detail all the available evidence published during the preceding years. In addition, it considered the written evidence from several consultants—some of ​ whom participated at the meeting—who were either known to the chairman or who had been recommended by the Medical Research Council as being or having recently been engaged in research into the problem. I am advised that the research for the meeting, the trouble taken to canvass informed opinion and members’ keen interest and sympathy combined to make this probably the most carefully prepared exercise the advisory committee on borderline substances had ever undertaken.

    Reluctantly, after much deliberation, the committee decided that there was no evidence which could justify recommending that linoleic acid or its derivatives should be regarded as a drug in the management of multiple sclerosis. The committee was particularly concerned that any advice offered should be founded firmly on scientific evidence. It felt that it would be wrong to offer advice that might raise false hopes among multiple sclerosis patients, their families or friends, that an effective palliative or cure was close at hand—a point emphasised by my hon. Friend. Members noted that research into the value of unsaturated fats in the management of multiple sclerosis was continuing and expressed their readiness to reconsider their decision if and when fresh scientific evidence became available.

    Moreover, in October 1974 a conference on multiple sclerosis, arranged jointly by the Medical Research Council and the Multiple Sclerosis Society of Great Britain and Northern Ireland, reached broadly the same conclusion on the question of dietary supplements as the advisory committee on borderline substances. Furthermore, it is worth pointing out that the Medical Research Council’s annual report for 1975–76 stated:

    “The evidence for a beneficial effect of linoleic acid supplements in the diet is unconvincing but the existing studies should be continued; meanwhile no further trials should be supported.”

    I must take serious note of this view. It is an expert one and is endorsed by my medical advisers in the Department.

    To give the House further evidence of the Government’s constant concern to leave no stone unturned in this matter, I should like to point to my right hon. Friend’s meeting with a deputation from the Multiple Sclerosis Action Group early ​ last year. Particular attention was paid at that meeting to the claims that were being made for Naudicelle capsules and the superior virtues of their active ingredient, gamma-linolenate as compared with those of linoleic acid and to the need for further research. The deputation included a distinguished research scientist who, I understand, is engaged in the field of multiple sclerosis research and who explained the claims for gamma-linolenate very lucidly. However, my right hon. Friend had to tell the deputation that, having consulted the Department’s medical advisers afresh about these claims and the value of further research, he felt that he would not be justified in initiating or supporting more research. He promised to ensure that any new scientific evidence that may appear is placed before the advisory committee without delay.

    I understand that, in addition to the research mentioned in the MRC report that I quoted earlier, a trial financed by the Multiple Sclerosis Society of Great Britain and Northern Ireland of dietary supplements, including Naudicelle capsules, has been undertaken at a hospital in the North-East. The results are expected shortly. The chairman of the advisory committee is in touch with the research teams concerned and hopes to convene at an early date a meeting of the committee, augmented by other experts invited for the occasion to consider these results. Of course, we can make no assumptions yet about the outcome of the trials.

    Since the submission to the advisory committee in 1974, Bio-Oils Research Limited has applied for and been granted a product licence for Naudicelle capsules under the Medicines Act 1968 as

    “dietary supplements where unsaturated fatty acids are needed”.

    Aside from the researches sponsored by MRC and the Multiple Sclerosis Society, I understand that Bio-Oils Research Ltd. has been granted a clinical trial certificate to enable it to have its product tested in relation to multiple sclerosis. The certificate is valid until November this year. Naturally, if the firm were then to produce evidence of the efficacy of its product in relation to multiple sclerosis, it would be open to it to apply for its existing product licence to be varied so as to specify the disease.

    If such a variation were granted there would be no question that Naudicelle might be regarded as a drug in the management of multiple sclerosis.

    The Government regard the promotion of health and the prevention and eradication of disease as a prime responsibility of my Department. However, we cannot will the results or the developments that we desire. I know of nobody who does not wish that a drug that would cure or alleviate multiple sclerosis were available.

    Certainly the moment any substance or preparation is shown scientifically to have a beneficial effect, then, whatever it is, it will be made available as soon as possible as a drug for the treatment of the disease. However, I am bound to remind the House, as I implied at the outset, that ​ the history of research into multiple sclerosis is one of repeated disappointments.

    My hon. Friend has raised a number of issues including early diagnosis and the possibility of the Department having field trials about which I shall write to him. In the meantime, let me repeat that the reason why Naudicelle would be challenged if prescribed by a family doctor at National Health Service expense is that we are advised that the only scientifically reliable evidence that we have does not justify the belief that dietary supplements such as Naudicelle capsules are helpful in the management of multiple sclerosis.