HC Deb 08 February 1977 vol 925 cc1395-406

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

12.2 a.m.

Mr. Laurie Pavitt (Brent, South)

I find it extremely disappointing that two and a half years after the Department of Health and Social Security issued its statement "Community Hospitals—Their Role and Development in the National Health Service", we have had no progress whatsoever. I understand very clearly that since that time we have had a situation of general economic and financial stringency, but I do not accept that as an excuse for delay, because in planning the development of hospitals and community services, and indeed in local government at large, it takes quite a time between the concept and the time at which the actual project finds solution in bricks and mortar.

I blame the Health Service administrators. They tend to be hidebound with the past and entirely unimaginative about the future. This is not the first time that I have put forward this point of view in the House. The House will recall that I was very heavily involved in the National Health Service Reorganisation Bill in 1973. During the passage of that Bill I frequently aired my fears about what would happen as a result of the reorganisation—that the hospital administration, which was only one of the tripartite organisations, would become the Big Brother, and that the organisation would be dominated by hospital thought.

However, even more than that, I was concerned at that time, and I am still concerned, with the fact that in the thinking of the administrators who were to be, and have been, handed over from the old hospital administration, there is a tradition of the big hospital, the teaching hospital and the district hospital, the centres of excellence, and all of these things tend to dominate what should be a community development in the provision of health care and health treatment.

Hospitals have tended to be in groups, rather like monastries, inward-looking, self-contained, a world to themselves. The whole purpose of the 1973 Act and of the subject we are discussing—the development of urban community hospitals—was to change the mental climate and the way in which we gave health provision away from the inward-looking hospitals treating illness into a community service which would regard health and not illness as its predominant requirement.

Thus, the plea in the circular of August 1974 was that there should be development of community hospitals as an integral part of the local area, a built-in two-way traffic where primary care and treatment for patients and others in need should move freely between treatment at home by the family practitioner, treatment in places like urban community hospitals, and, in acute cases, treatment in a district general hospital.

What seems to have emerged in the last two and a half years, however, is that there has been no concept of the involvement of the people concerned. What is needed, and what was the whole aim of the Department in proposing the development of urban community hospitals, is that people should be involved. It was envisaged that they would be participating in actions which took place with regard to their own health services, and that there would be a National Health Service not for the convenience of doctors and administrators but for the purpose of serving ordinary people.

The Secretary of State's document in August 1974 said: This policy can only succeed if public understanding and co-operation is secured … Community Health Councils will be given full opportunity to express their views before final decisions are taken. That is one of the points which affect most community health councils, particularly my own. It concerns whether, before such decisions are taken, they are given full opportunity to express their views". I want to draw attention also to the guidance given in other parts of the document. It says: Where possible health centres and other group practice premises should be closely associated with a community hospital. It goes on to say that they will attract help from voluntary organisations and individual volunteers and thus be closely linked with the communities they serve. On the question of size, the document says: the normal range between 50 and 150 beds, plus day places and out-patients clinics should be provided. It goes on to say: Some existing hospitals can be adapted to serve as community hospitals—those which are sited where they are needed … they will take some of the load off district general hospitals. "… while taking many years to complete the national network, the use of some existing buildings may enable some community hospitals to be established early in the programme. I am seeking to follow the advice given by the then Secretary of State. As an example which could give a lead to the rest of the country, I look to my own constituency, where in Willesden we have all the basic possibilities mentioned in the Secretary of State's advice. I should be very proud if Willesden could be the first urban community hospital in the country developed entirely in line with these modern concepts.

Although they are new, as long ago as 1963 the forward-looking borough which I serve—at that time the Willesden Borough Council—had this in mind. Accordingly, it adjusted its development plans in the vicinity of the Willesden General Hospital to include available land for a service in the heartland of a dense and socially deprived population. Pursuing this ideal—I served on the North-West Metropolitan Hospital Board at that time—in 1965 the hospital authorities spent nearly £500,000 on a new casualty department, a path lab, a boiler house and X-ray departments. In this development, I was fully supported in what I was doing by the leader of my borough council, at that time an alderman of the borough, my right hon. Friend the Member for Brent, East (Mr. Free-son), who is now the Minister for Housing and Construction.

Instead of throwing that £500,000 of the taxpayers' money down the drain, a community hospital in my area could provide a number of services. Through rationalisation, unfortunately, my area has lost 250 acute beds. The problem could be ameliorated if some of the things I have in mind could be developed in a community hospital in the middle of the densely populated Willesden area.

I should like facilities for general practitioners to provide a minor casualty service: there is a modem casualty department already there. I should like to see a general practitioner health centre with all the special services like chiropody, some provision for community dental services, facilities for day surgery, possibly a five-day ward for minor surgical work and beds for simple infectious illnesses like hepatitis, which do not need the elaborate and expensive facilities provided at Northwick Park, another hospital in my area.

It is wrong that in my area of 250,000 people, in spite of the Chronically Sick and Disabled Persons Act 1970 no beds are available for the young chronic sick. They could be provided in the community hospital. It could also provide beds for chronic sepsis cases, arrangements for older patients to come in for two weeks while relatives are on holiday, a rehabilitation department and a preventive medicine unit, which could be the focal point for disseminating information to Brent and for stimulating the practical work needed in homes. It could provide free accommodation for voluntary organisations concerned with better environmental and social conditions in Brent. Already we have plans for more geriatric beds in Willesden Hospital and we need to retain them within the community context. Further out-patient facilities would relieve the heavily burdened Central Middlesex Hospital.

Many other areas are in the same position as mine. They have had to cut back vital services for lack of cash. But in my area—I have recently obtained figures for the area health authority—we have 450 acres of spare unused land. Bearing in mind what can be obtained for an acre of land in London, 450 acres represents a considerable capital resource. In any commercial undertaking or industry that would be counted as an asset against which other capital expenditure could be secured. Instead of cutting back on needed services, that could be regarded as collateral to be developed in order to provide a community hospital and improve other health services.

Why can we not do this in the NHS and thus plan more community hospitals against these assets? In particular, why can we not use this asset in Willesden not to cut back but to increase services in a modern way?

Administrators generally, and in particular in my area, seem to be behaving like headlight-blinded rabbits and reacting to public expenditure cuts out of all proportion to reality and public needs. They seem to be obsessed by formulae such as "X beds per 1,000" and the nonsense that is contained in the abstruse mathematics which led to the first resources allocation working party's report. I think that everybody now realises that was a blunt instrument. It has done nothing for the socially deprived inner city areas or for areas such as Harlesden, Roundwood, Queen's Park and Kilburn where there is a high percentage of social deprivation which ought to have special consideration and an increase rather than a decrease of resources.

There is a need for some improvement in geriatric services. One of the tragedies of the last Administration's separation of health from social services—one under health authorities and the other under local government—means that the whole development since Seebohm under social services departments of services to elderly people still living alone backed by the provision of incontinence pads, meals-on-wheels, home helps and Part 3 homes—not Eventide homes or homes for the elderly—the residential accommodation which enables people who have got on in years to retain their dignity with backing from the social services, is omitted from the calculations. The health services seems to have ignored the figures that one can give for that part of the equation. I presume that my local area health authority has some liaison with the social services department. However, the propositions which are being put forward make me doubt whether it has been effective.

My plea is that we should put health services where they belong—close to the people that they serve—and that, as far as possible, we let the facilities and treatment be taken to the patient rather than meet administrative convenience. Indeed, facilities should be extended to people who wish to visit relatives but in Willesden have to undertake awkward journeys to do so.

I think that the Department has made out a strong case for a complete change in the administration of the hospital services towards urban community hospitals. The Minister has stated that the action which has been taken at the Willesden Hospital is not irrevocable. All the facts and figures show that the Willesden General Hospital should become one of the first and leading urban community hospitals in the country.

12.19 a.m.

The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)

I welcome the prod which my hon. Friend the Member for Brent, South (Mr. Pavitt) is giving towards the development of community hospitals by his Adjournment debate tonight. I note that there is no real difference in policy between my hon. Friend and the Government, although I can understand how he sometimes suffers from a feeling of impatience when he considers the problem. I note his anxiety to have the first urban community hospital in his area. I hope that he will see it before too long, although not quite precisely in the manner in which he envisages it.

My hon. Friend made some penetrating remarks about the Resource Allocation Working Party and its relationship to urban deprivation. I can assure my hon. Friend that whatever might have been the position in the past, there will in future be no desire on the Government's part to overlook the urban deprivation problem in considering the redistribution of resources. Of course, what my hon. Friend says about the division between local authority social services on the one hand and hospital services on the other is a point that we have carefully in mind.

Since 1962 it has been the policy of successive Governments to establish a national network of fully equipped and comprehensive district general hospitals to provide the focus of hospital services for their locality while backed up by community hospitals in supplementation to them.

This idea is to replace the more fragmented hospital specialist services with, for example, separate hospitals for certain types of illnesses, which were inherited from the days before the NHS. The need for a district general hospital arises from the increasing interdependence of the various branches of medicine and the need to bring together the wide range of facilities required for diagnosis and treatment.

It also arises from the need for permanent teams in which doctors and nurses work most efficiently. The concentration of specialties and services enables patients to receive the full range of specialist treatment they need and enables staff to make the most economical use of expensive equipment and buildings. This means that resources saved by not duplicating equipment can be used for other aspects of health care.

To complement the specialist services concentrated in the district general hospital complex the Department's policy is that one or more community hospitals should be provided in each health district for patients who do not require the highly specialised services of the district general hospital. Most community hospitals will be provided by adapting existing small hospitals. They will generally have 50 to 150 beds and provide for a population of 30,000 to 100,000. As they will not provide the specialist facilities of the district general hospital they can be small and more local.

I am sure it would be the desire on the part of the NHS to involve the local community as much as possible in support of the treatment services in these hospitals. For example, GPs would be able to carry on their practice in the local hospitals, and the more voluntary support they can get the better.

Patients who do not require the specialist services on hand can be treated and cared for nearer to their homes. This, of course, would be important in rural areas, but I think the homely atmosphere of a small hospital is no less important—it may indeed be more important—in urban community hospitals than in a rural community hospital.

My hon. Friend suggested a number of activities that might be carried on in community hospitals. Certainly we want to adopt a flexible approach. However, I am afraid that I cannot hold out much encouragement for some of the surgical operations being undertaken there, as my hon. Friend suggested.

There are, of course, a number of small acute hospitals existing at the moment. Some of them are providing general surgical services which, if discontinued, could not, under present circumstances, be undertaken in associated district general hospitals.

Therefore, it will be necessary for some community hospitals to continue to provide general surgical services until such time as alternative provision can be made at the district general hospital. This is likely to be the position for at least 20 years because it will be somewhere around the end of this century before the full scheme of district general hospitals and community hospitals is in full working order. But there will be full opportunity for general practitioners to carry out the sort of surgery that they might carry out at community hospitals.

Mr. Pavitt

Is my hon. Friend aware that hernia and varicose veins, which are both cold surgery problems, could be dealt with adequately in the operating theatre of the kind of hospital that I have been discussing, and that the longest waiting lists in the district general hospital are for this kind of speciality? Given coordination with the district general hospital, it would be possible immediately to reduce the length of the long waiting lists for the treatment of these non-killing diseases which nevertheless are extremely unsatisfactory diseases of the human body?

Mr. Moyle

Yes. I am sure that, so long as there is pressure on the resources of district general hospitals, there will be the provision of these surgical services to some extent in community hospitals. But the best advice is that surgery should be undertaken with a full range of equipment and appropriate surgical teams with back-up nursing. In the long run, we must envisage a situation where, apart from general practitioner surgery, there will be a move to the district general hospitals for the main surgical provision in our communities.

The nature of the community hospitals will mean that a high proportion of the patients in them will be elderly, bearing in mind that about one-half of all hospital patients are elderly, and the patients in these hospitals will be there for longer rather than shorter stays as would be the case with district general hospitals. The aim is that patients of all ages—excluding children—may be admitted to community hospitals or transferred to them after treatment at the district general hospitals until they are ready to go home.

Community hospitals are expected to provide active treatment and rehabilitation for all patients according to their conditions, and there should be a continuous flow of admissions and discharges which should contribute to the high moral of patients and staff. But, again, highly specialist in-patient facilities will not be provided, although out-patient clinics in some acute specialities will be held at some community hospitals.

In all that I am saying, of course, we should not vitiate a flexible approach to the provision of community hospitals, and obviously we shall endeavour to adopt that approach. One of the important factors is that, in moving towards a rationalisation of services along these lines, there is a need to bring the community along with the adjustments, as I have suggested. In my hon. Friend's area especially, it is important to bear in mind the consultation provisions which we feel should be followed in carrying out this reorganisation, and it might therefore be worth while, from my hon. Friend's point of view, setting out exactly what we have in mind.

First, the health authority should produce a consultation document giving reasons for the proposals, setting them in the context of wider planning, evaluating alternatives, and considering implications for patients and staff affected.

Secondly, community health councils, local authorities, staff and other interests concerned should be given three months to comment. Local Members of Parliament should be informed and a Press statement issued.

Thirdly, the area health authority should produce its observations and conclusions on comments received, and seek the views of the community health councils concerned on all this material. If the community health council does not agree to a proposed closure or change of use, it should produce constructive counter-proposals.

Fourthly, if agreement cannot be reached between the community health council and the area health authority, the matter is referred to the regional health authority, which may decide in favour of the community health council's counter-proposals or, failing that, refer the matter to the Secretary of State for his final decision. The Secretary of State, of course, will consult local interests and fully inform himself of all the local implications before deciding what to do.

All this means that the community health councils have a key and powerful rôle in the procedures for re-organisation, and I hope that the public will realise this and make full use of them. So far as we can see at this stage the public are making full use of the powers given to the community health councils. The councils themselves are being brought into the consultative procedure very fully and are playing a leading rôle. I hope, therefore, that my hon. Friend will realise that the Government have done a great deal to ensure that the community is involved with the emergence of the community hospitals, especially in the urban areas.

My hon. Friend referred to a substantial amount of land owned by the hospital service in his area—namely, 450 acres. He wondered why it has not been exploited by the National Health Service. It is the deliberate policy that land held by the hospital services, when it is surplus to the use of the Nation Health Service, be sold and that a proportion of the funds—the funds that used to go entirely to the Treasury in the old days—stay within the region to be used by the region. I have been trying to discover the proportion but I cannot satisfy my hon. Friend directly tonight. His area will have to fight for some share or por tion of the funds, but at least the situation is better. We are directing our attention to resolving the problem to which my hon. Friend drew attention.

My hon. Friend drew my attention yet again to a letter I wrote him on the future of one of the hospitals in his area. I do not wish to retract any words that I used in a letter to my hon. Friend. I stand by them in respect of the future of the hospital and its reopening. Certainly it is not an irrevocable closure that has taken place, but I reiterate that to reopen it and to get it under way again would be difficult and I—

The Question having been proposed after Ten o'clock on Tuesday evening, 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-eight minutes to One o'clock.