HC Deb 22 June 1978 vol 952 cc872-86

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

10.58 p.m.

Mr. John Cartwright (Woolwich, East)

I am grateful for this chance of raising the subject of the St. Nicholas Hospital Plumstead, which has been threatened by a variety of rationalisation proposals for the past seven years.

At the outset, may I say how much I regret the absence of my right hon. Friend the Secretary of State. I know that because of his personal involvement in the case he wanted to reply to the debate. It is a matter of great regret that his presence in hospital prevents him from so doing.

St. Nicholas is not, as are most other threatened hospitals, a small run-down unit in a decaying area. On the contrary, it is a 300-bed district general hospital serving the greater part of my constituency, one of the few areas of inner London to have a growing population.

The story begins in late 1971, when the South-East Metropolitan Regional Hospital Board announced a plan to develop the Brook as the district general hospital for the Woolwich area and to rationalise services at St. Nicholas. This rationalisation, like all the others which were to follow, simply meant cutting the services provided to my constituents. St. Nicholas was to become a complementary community hospital providing a few bits of minor surgery and out-patient services under the general umbrella of the Brook. There were widespread public opponents of this scheme, and it died with the regional hospital board in 1974.

However, no sooner had the new National Health Service administrators settled into their spacious new offices than we were once again being told that the area had too many hospital beds. In an unofficial discussion document produced in December 1975, the Greenwich and Bexley Area Health Authority suggested scrapping all but 20 of the 287 acute beds at St. Nicholas and adding 87 for psycho-geriatric care and a further 120 for mental illness.

The regional health authority went still further. It wanted to remove all the acute beds and to replace them with 100 for geriatrics and 87 for psychogeriatrics. The area health authority took little notice of the public opposition in drawing up its formal consultation document, issued in November 1976.

Faced with the unyielding mathematical dictatorship of the regional bed norm, they decided that acute beds had to be cut. The two super-colossal prestige hospitals, Queen Mary's, Sidcup, and Greenwich District, were sacrosanct, and the choice for the chop therefore lay between the Brook and St. Nicholas.

The Brook had the advantage of massive new investment in the recent past, plus the siting of the regional units for neurology, cardiothoracic and neuro surgery. The AHA therefore decided that The retention of acute services at St. Nicholas Hospital cannot be justified. However, the discussion document did enter one caveat. If the regional units were to leave the Brook the whole question of the future of the two hospitals would have to be re-examined. In what has become one of the most quoted statements in the discussion document, the AHA conceded: This is acknowledged to be perhaps the most difficult area for recommendation and decision, particularly as St. Nicholas Hospital, sited within a densely populated area and with direct access to Thamesmead, is from the geographical viewpoint, in an excellent location. In other words, a hospital ideally sited to meet the needs of a genuine local community was to be closed in order to direct patients further afield.

Faced with the total opposition of a community, the AHA hesitated. On 25th May 1977, it issued a statement referring to the public reaction generally and particularly the support for the retention of St. Nicholas Hospital. As a result, the AHA asked its officers to examine the possibility of retaining at St. Nicholas general medicine, general and orthopedic surgery, gynaecology and maternity beds, together with the geriatric unit.

However, on 12th July there was yet another U-turn, when the area authority confirmed its previous policy of total closure of all the beds at St. Nicholas. This decision was rubber-stamped by the regional health authority within a week, and the problem then landed on the desk of my right hon. Friend the Secretary of State.

To his credit, my right hon. Friend received a number of deputations and he also visited Plumstead to see for himself not only the hospital but the area that it serves. As a result, he wrote to the chairman of the regional health authority on 13th December 1977, saying: I do not believe it can be right to close this hospital and I am unwilling to do so. He went on: It seems to me that the best course is to link St. Nicholas with Greenwich District Hospital and provide at St. Nicholas a viable acute service of, say, 50 medical and 50 surgical beds together with an out-patient unit and daytime casualty service. He added that it would be advantageous to concentrate other services at St. Nicholas. He proposed the retention of obstetrics and the gynaecology unit.

In his public statement issued on 14th December 1977, my right hon. Friend justified his decision by saying: St. Nicholas is a valued hospital, well situated to service a community whose population is growing. It is in Plumstead where social conditons are poor and there are many old people living in bad housing. It is also central tor Thamesmead, a locality of industrial development. The local reaction to this decision was one of quiet satisfaction. At last, a Cabinet Minister had listened to ordinary people rather than anonymous officials. At last, patients were being seen as real people in need and not just decimal points in the lunatic logic of the bed norm formula.

Not surprisingly, the Health Service mandarins were less pleased. In fact, they were furious. They claimed that St. Nicholas in its new form would be no more than a second-class hospital and that it would cost at least £1 million to bring it up to standard, thus giving ample proof of their policy of deliberate neglect of the hospital over the years.

So we had deadlock. The area health authority wanted to shut the hospital; the Secretary of State wanted it kept open. Suddenly, help appeared on the horizon. Galloping to the rescue, like the US Cavalry in the last reel of those well-loved Westerns, came the regional health authority, clutching a so-called compromise formula. It turned out to be a very strange compromise. It kept the hospital open, but only just. The 235 acute beds were to be cut to just 20 for minor day surgery, plus another 20 to 25 for the use of GPs. There were to be minor casualty facilities and the possibility at some unspecified date of a psychogeriatric unit, first suggested in 1975.

With a sigh of relief which was audible all the way from the Elephant and Castle to Plumstead High Street, my right hon. Friend fell on this plan as the best way of getting himself off an increasingly embarrassing hook. It was produced by the regional authority on 20th April but by 4th May the Secretary of State had accepted it—lock, stock and psycho-geriatric unit. What my right hon. Friend has so far failed to explain is how this pale shadow of a hospital can possibly provide the "viable acute service" which he believed was needed last December.

How will it help with the poor social conditions? What contribution can it make to the growing population? What will it do for the many old people in bad housing? How can the needs of local industry be met by minor casualty facilities?

The medical staff at the hospital are quite convinced that the compromise cannot and will not work. The surgeons discredit the idea of day surgery being undertaken at an isolated hospital, possibly by unsupervised junior staff. The local GPs have dismissed as "unwanted" the proposed general practitioner beds. The geriatrician believes that the services for the old will be substandard.

Perhaps the most damning rejection of the whole idea came from the area health authority itself in November 1976 when it withdrew its own earlier proposal to make St. Nicholas a community hospital. it said then: the combination of geriatric work, some GP medicine and day surgery…would not, of itself, constitute a viable hospital for in-patients. From a medical and nursing staff viewpoint, very grave doubts have been expressed as to whether the minimum requirements by way of recruitment would be achieved. Yet it is just this role that my right hon. Friend has now imposed upon St. Nicholas. Why? First, because it will save money. The regional health authority suggests that £550,000 a year will be saved by dismembering St. Nicholas. The latest available figures show that the cost per in-patient day at St. Nicholas is £34.88 compared with £36.56 at Greenwich District and £41.82 at the Brook. In other words, the beds to be closed are currently the least costly to operate. As always, the figures are totally one-sided.

We are not told what would be the capital or running costs of the regional authority's proposed psychogeriatric unit. They will obviously eat substantially into the savings. Nor are we told what is to happen to the rest of the St. Nicholas buildings if only 80 beds are to be kept in use However, there is a clue in the region's assumption that £125,000 will be saved by transferring staff from rented offices to vacated hospital buildings. That would mean giving up all the space that is now rented at Marlowe House, Sidcup, and Morgan Grampian House, Woolwich, amounting to 25,000 square feet. That we can seriously contemplate turning purpose-built hospitals into offices seems to be a sad commentary on the present priorities of our National Health Service.

The second reason for this massive cut-back at St. Nicholas was underlined as recently as this week by my right hon. Friend the Secretary of State when he again claimed that the main problem facing the area was the over-provision of acute beds. I very much doubt whether those of my constituents who are waiting for operations would agree, particularly when the downgrading of St. Nicholas will remove at a stroke over 200 acute beds. Faced with a cut of this magnitude the question must arise: what will happen to all the patients now being treated at St. Nicholas? The beds to be lost are not empty. They are full of warm bodies.

If the area is so seriously overburdened with acute beds one would expect waiting lists to be insignificant. Yet the latest available figures show 363 people awaiting admission to St. Nicholas for general surgery. Compared with 311 five years previously, that indicates no slackening of demand. The total number on the St. Nicholas waiting list is now 488 and there is no obvious slack to be taken up at the neighbouring hospitals, with 506 people waiting for beds at Greenwich District and 392 at the Brook.

Although waiting times have certainly improved, for general surgery they still range from three months at Greenwich District Hospital to seven months at St. Nicholas. The scrapping of so many beds at St. Nicholas can hardly fail to make those lists longer still.

This is the central core of the argument. Despite all the thousands of words that have poured out from every Health Service level about the need to cut services in Greenwich and Bexley, no one has yet produced any assessment of the end result on the people who matter, the patients. The beds that are to go are not now empty; they are fully used. Their removal must therefore mean a cut in the number of inpatients being treated in the Greenwich and Bexley area.

I know that my right hon. Friend denied this in a radio programme earlier this week, but he should look again at the sums. I had some calculations done for me which show that it is physically impossible to treat the number of inpatients dealt with in 1976 with the number of beds that will be left after the cuts at St. Nicholas and elsewhere.

Assuming that the remaining beds are 90 per cent. occupied, I am advised that there will be a shortfall of 33 in general medicine, 61 in general surgery, 21 in gynaecology, and 42 in orthopaedic surgery, making a total deficiency of 157 beds. Put another way, the reduced number of beds available will be sufficient to take only 5,400 fewer patients than were treated in 1976.

I have deliberately been generous in assuming a 90 per cent. bed occupancy. At 85 per cent., which is much more likely, the shortage of beds rises to 211, and the shortfall of patients treated goes up to 6,780. The shortage of beds revealed in these calculations is roughly equivalent to the number to be lost at St. Nicholas, which is why the future of this hospital is so important to so many people. I hope that my hon. Friend will not give the easy answer that the shortage of beds can be made good by cutting the time spent in hospital. That would assume an improvement in primary care and community health services which is just not happening.

I repeat that this is the central question, which I hope my hon. Friend will try to answer. What is to happen to the patients who are now being treated at St. Nicholas when their beds have gone? I hope my hon. Friend will not seek refuge in the antiseptic anonymity of the regional bed norm. I am concerned about real flesh and blood human beings who need hospital care.

Two other issues arise. St. Nicholas is frequently on call for the whole Greenwich district when the hospitals are full. At present, for example, it is accepting emergency cases because the operating theatres at the Greenwich District Hospital have been closed by the unfortunate industrial dispute there. Clearly, that facility will be removed with the downgrading of St. Nicholas. Where will the emergencies go then?

Secondly, the area health authority made it clear in November 1976 that it would want to re-examine the future of St. Nicholas again if the special regional services were removed from the Brook. It therefore regarded the closure of St. Nicholas as being provisional. In a Written Answer on 26th October 1977, I was assured by my right hon. Friend the Minister of State that the regional health authority was not currently proposing the transfer of these specialties. However, on 26th May this year, I was told in another Written Answer from my right hon. Friend that the future of these units was being examined by the regional medical committee with a view to putting proposals to the regional health authority. I must say that there will be very considerable suspicion and cynicism if these regional units are removed from the Brook when it is too late to re-open the future of St. Nicholas.

I have raised a number of detailed questions. I realise that my hon. Friend may not be able to reply to them all. Nevertheless, I hope that answers will be forthcoming quickly, because, after seven years of talk and double talk and twists and turns, the people of Plumstead and the staff of the hospital are entitled to some straight answers on these vital questions.

Finally, I underline again the total opposition of the medical staff to the current plan for St. Nicholas. If it is imposed, it will be against their advice, and they do not believe that it can provide an acceptable level of service. Nor are they willing to co-operate in a phased rundown of services. If the cuts are forced through, therefore, I believe that there is a real risk of a total withdrawal by all the present consultants. On that ground alone, I believe that my right hon. Friend should think again, even at this late stage, and honour the public commitment he gave last December to retain the viable acute service at St. Nicholas.

11.14 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)

I must first apologise to my hon. Friend the Member for Woolwich, East (Mr. Cartwright) that I am replying to this debate. My right hon. Friend the Secretary of State intended to do this himself in view of his personal involvement in the discussions which led up to his decisions last May. Unfortunately, as my hon. Friend has acknowledged, the Secretary of State is now in hospital him-self and cannot be here tonight. I apologise for him.

I welcome my hon. Friend's action in raising the subject of St. Nicholas Hospital tonight in the House and giving me the opportunity to clarify how the decisions were taken and why my right hon. Friend has agreed to the change of use of this hospital. I must also congratulate my hon. Friend on the skilful and balanced way in which he has presented the case for maintaining the present level of services at this hospital.

The reduction of services at St. Nicholas Hospital must be seen in the context of the provision of health services in the South East Thames region as a whole and in the Greenwich and Bexley area. My right hon. Friend has made it very clear that we are determined to achieve a much greater measure of fairness in the distribution of resources and move towards much greater equality of access to health care. To do this there needs to be redistribution of resources not only between regions but within regions, as some of the biggest inequalities are between over-provided and under-provided areas in the same regions. My right hon. Friend has asked regional health authorities to assess resource targets for areas to provide a measure of relative needs. I am sure that the House and my hon. Friend would not wish me to spend time now in explaining how these targets are assessed.

The principles adopted are those recommended by the Resource Allocation Working Party and have been explained to the House on previous occasions. I should make it clear, however, that we do not believe that targets worked out in this way can be used without modification in allocating resources, particularly to areas and districts. There are a number of factors which cannot be fully taken into account. For example, housing, environmental health, employment and even transport facilities may have relevance to the needs for health care. My hon. Friend emphasised a number of these points in his quotation from the Press notice of December last year.

We should also like to develop a more accurate measure of morbidity. Accordingly, we have told the authorities that they should not seek to apply mechanistically a formula or a predetermined rate of change from existing allocations towards targets. The pace of change must depend on the ability of above-target areas to rationalise services without unacceptable disruption to the existing level of provision or to teaching or other specialist needs. Nevertheless, my right hon. Friend has said that he expects to see significant progress towards the redistribution of revenue resources. This is our general policy.

The South East Thames Regional Health Authority has calculated targets for its areas which show that there is a wide disparity between the present resources available to those areas. Lambeth, Southwark and Lewisham teaching area is £28 million above target; Greenwich and Bexley is £6 million above target; while Kent is £27 million below target and East Sussex £7 million below target. These targets are, of course, based on catchment population and not just resident population. Even allowing for the crude nature of mathematical targets, there can be no doubt that there needs to be substantial redistribution of revenue within this region.

My right hon. Friend is engaged in discussions about how quickly, and to what extent, expenditure in Lambeth, Southwark and Lewisham teaching area can be reduced without damage to essential teaching and specialist needs and without unacceptable disruption to existing services. The House, I know, would not wish me to dwell on this aspect of the situation but would prefer me to concentrate on the Greenwich and Bexley area, and, in particular, on St. Nicholas Hospital.

The central problem facing this area, as my hon. Friend recognised, has been the over-provision against national standards of acute beds. The construction in this area of two new hospitals over a period of years left the area with over 300 acute beds more than national standards would indicate it needs. The area health authority and the regional health authority, after prolonged consultation, submitted to my right hon. Friend a plan for concentrating services in the area and this joint plan included a proposal to close St. Nicholas Hospital altogether. As my hon. Friend knows, my right hon. Friend visited the area and spent some time at St. Nicholas Hospital. He has met staff of the hospital, the community health council, and has, I know, had discussions with my hon. Friend. He also considered the representations made to him by local organisations and petitions and letters signed by individual members of the public.

Last December my right hon. Friend announced that he did not believe it could be right to close this hospital and that he was unwilling to do so. He agreed that it was exceptionally welt sited in a locality where the population is expected to increase and where it provides effective and valued service to the local community. At that time, my right hon. Friend gave no specific undertakings about the future use of the hospital. However, he made it clear then that there was scope for a significant reduction in the number of acute beds at the hospital, and he said clearly that he could see no justification for retaining a full accident and emergency service in view of the major accident and emergency departments a short distance away at the Brook and the Greenwich District Hospitals.

He asked the health authorities to consider whether a practicable plan acceptable to both authorities could be prepared on the basis of retaining at St. Nicholas Hospital a viable acute medical and surgical service, the obstetric and gynaecological unit, out-patient department and day-time casualty service. This proposal was linked with a request to the authorities to consider the practicality of transferring geriatric provision fom the Memorial Hospital to St. Nicholas Hospital and closing the Memorial Hospital, and with the closure of the British Hospital for Mothers and Babies.

The area health authority considered these proposals carefully, and came to the view that it would be wrong to transfer the geriatric services from the Memorial Hospital to St. Nicholas Hospital. The authority told my right hon. Friend that the necessary ward adaptation would involve further capital cost of approximately £500,000 and that even then the environment would inevitably not equal the standard of care at the Memorial Hospital. The area health authority regards the continuing care services for the elderly at the Memorial Hospital as amongst the best in the region and wishes to see them developed still more in the future. The authority could not accept that these services should be transferred to accommodation at St. Nicholas Hospital, which could not be as satisfactory.

On maternity provision, the authority did not consider that the retention of the obstetric beds at St. Nicholas was desir able as the ward is sub-standard and uneconomical of staff. Paediatric medical cover is not satisfactory and the unit is not approved for midwifery training. The authority also wished to correct the imbalance in maternity beds between the Greenwich district and Bexley district. The area health authority's view was still that the sensible course in the situation it was facing would be to close St. Nicholas Hospital.

The regional health authority, however, after its own officers had analysed the situation again, felt that the strong local case for the continuation of hospital services on the St. Nicholas site should be met. Accordingly, the regional health authority proposed a compromise and suggested that St. Nicholas Hospital should change its role to become a community hospital having out-patient and minor casualty facilities, theatre and the supporting services for day surgery, 20 to 25 general practitioner medicine beds and also retain its two geriatric wards of 41 beds. The authority also suggested that as soon as practicable a psychogeriatric day centre should be established on the St. Nicholas site.

My right hon. Friend accepts the view of the regional health authority that the proper function of St. Nicholas Hospital is to be a community hospital providing treatment in the local community for those patients who do not need the full resources of the district general hospital. It really is not practicable to retain in a single district three district general hospitals, and it is obviously essential that full use is made of the new facilities at Greenwich District Hospital.

In this connection, I think there may be some misunderstanding about what a community hospital is. I know my hon. Friend would not object to a community hospital. I think that his objection is to the facilities which are provided in it. The simplest definition that I can quote is in our planning guidelines which we sent out in March of this year to area and regional health authorities. These guidelines comment on the standards set out in our two priorities documents of the past two years: …a community hospital should be regarded as a local hospital which…it is intended to retain to provide services for patients living locally who do not need the full specialist facilities of a DGH; does not form part of a DGH complex; provides services for patients under the care of general medical practitioners as well as patients under the care of hospital consultants (precise arrangements for the management of medical care are for local discussion); is not confined to one specialty; where appropriate and practicable, provides, among other services, rehabilitation and continuing care of elderly patients, including the elderly severely mentally infirm. I know that local people and local industries and organisations in Plumstead and Thamesmead think highly of the accident and emergency service at St. Nicholas. But there are major accident and emergency facilities at both Greenwich District Hospital and the Brook Hospital. Much has been said about the time it can take an ambulance to take patients to these hospitals. Even at the most pessimistic assessment, the time cannot be regarded as unacceptable by national standards.

The day-time casualty service will provide treatment for minor injuries and this will minimise the inconvenience to patients who suffer such injuries, whilst those who need the full resources of a major accident and emergency department can be taken by ambulance to where such facilities are available. There have been difficulties in manning the accident and emergency unit at St. Nicholas Hospital, and it really is better for patients for services to be concentrated so that reliable cover in fully-equipped departments can be provided. This is more important than a small saving in time in getting a patient to an accident and emergency unit, particularly as ambulance crews are trained in first aid measures.

On obstetric services, my right hon. Friend fully recognises that many mothers would prefer to have their babies near to home. It is understandable. But the retention of a small maternity unit at St. Nicholas is not necessary to provide for the number of births in the district and concentration of maternity facilities in hospitals where the full resources of modern medicine, including paediatric care, are available is in accord with professional opinion and national policy. It would not be realistic to leave gynaecological provision on its own once the maternity service is concentrated and, therefore, retention of the obstetric and gynaecological service at St. Nicholas is not justified.

My right hon. Friend is satisfied that by making full use of the new hospitals in the area, supplemented by keeping the hospital as a community hospital, a good service can be provided for my hon. Friend's constituents. Clearly the reduction of acute beds will have some effect on waiting lists at the other hospitals. The area health authority will need to consider some changes in bed provision at Greenwich District Hospital and the Brook Hospital and ensure that full and intensive use is made of the facilities at these hospitals.

My hon. Friend has mentioned figures comparing the utilisation and costs of hospitals in the district. I do not believe that it would be helpful for me to follow him in these sorts of comparisons. So much depends on the mix of specialties and case load that comparisons based on statistics of individual hospitals can often be misleading.

We recognise that there will inevitably be transitional problems in changing the role of the hospital, particularly in resolving medical staffing difficulties. It is for the area health authority to work out, in consultation with its advisory committees, community health council and the staffs of the hospitals affected, the right solutions to these problems. I know that some clinicians have expressed doubts about the viability of the plan—a point emphasised by my hon. Friend—but the problems are still being considered by the various professional advisory committees and it should not be impossible for the difficulties to be resolved in these local discussions. However, I take note of my hon. Friend's point, which is a matter of practicality, which will obviously affect the final outcome of the discussions.

Given the firm objective of retaining an effective hospital, albeit with a reduced number of beds, as a community hospital, these problems can surely be overcome.

My right hon. Friend believes that the authority will make every effort to establish St. Nicholas as a viable and effective community hospital. We feel confident that the authority will be helped in this task by the affection my hon. Friend's constituents have for their local hospital and the enthusiasm they have displayed in the "Save St. Nicholas" campaign. St. Nicholas' Hospital has been saved, but the best way now of making sure that it continues is to support it in its new role and show just how effective a community hospital can be in meeting the needs of the local community.

Question put and agreed to.

Adjourned accordingly at twenty-eight minutes past Eleven o'clock.