§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Cope.]
1.43 pm§ Mr. Jack Aspinwall (Kingswood)I am pleased to obtain this Adjournment debate today, Mr. Deputy Speaker, because there are many points of which I must make my hon. Friend the Under-Secretary of State aware in support of the campaign to provide improved maternity services and to prevent the premature forced closure of Wendover maternity hospital in my constituency.
I welcome to the debate my hon. Friend the Member for Gloucestershire, South (Mr. Cope). The hon. Member for Bristol, North-East (Mr. Palmer) has asked me to apologise for his absence at a long-standing constituency engagement which he was unable to avoid. He wholeheartedly supports this campaign, which has been running with the support of the community health council since 1975. The constituencies of both hon. Members are in the health district affected.
My comments have no reflection on the doctors, nurses and ancillary staff, some of whom I have had the pleasure of meeting on a recent tour of Cossham, Frenchay, Wendover and Southmead hospitals. The warmth, dedication and caring attitude that I encountered left a deep impression, and the quiet display of skill, particularly in the specialist units, was breathtaking. This is perhaps a good time to place on record on behalf of my constituents at least a note of the gratitude and affection felt by our community for those who care for patients in our hospitals.
I wish to raise a number of points as I believe that the Avon area health authority has taken decisions without adequate research and study of the maternity services in an area where massive housing devlopment has been permitted and where even more land is due for release soon, all without the necessary infrastructure of essential services.
There could be an extra 30,000 people in the Frenchay health district by 1990. The district is roughly square in shape and its widest dimension is 16 miles 1912 across. The population is about 209,000 and rising and the concentration of people is greatest in the south-west of the district. The rough split of population in the three constituencies is as follows: Bristol, North-East 74,000, Kingswood 80,000 and Gloucestershire, South 55,000. Only part of the latter constituency is in the Frenchay district.
A high concentration of new housing development is occurring in the Yate-Chipping Sodbury conurbation in the Northavon district and the south-east of the Kingswood district. Much of this development has been allowed by the Secretary of State after an inquiry and an appeal and the vast majority of new home owners are young people often new to our area and without traditional family support close at hand.
The maternity hospitals used by the health district population are Bristol maternity, Southmead maternity, Wendover GP maternity and Chipping Sodbury maternity. Neither of the consultant hospitals—Bristol maternity and Southmead—is particularly conveniently sited, and in the constituency of Gloucestershire, South the distance from the main centres of population in Yate and Chipping Sodbury is 14 and 12 miles respectively. In my constituency the distance is seven and eight miles respectively. The most direct route from either of these areas to the consultant maternity hospitals does not necessarily coincide with the bus services on available bus routes. People using public transport can expect more than one change of bus on a journey in each direction.
There are 90 general practitioners in the district, all but six of whom are directly involved in the provision of maternity services. A few of the general practitioners based near the western boundary of the Frenchay health district are able to, or could if they wished, exercise clinical responsibility over inpatients in the GP units in the Bristol maternity and Southmead hospitals.
The majority of general practitioners involved in maternity work cannot, because of the distance between their practices and the consultant maternity hospitals and because of the time involved in travelling such distances on urban roads, safely exercise clinical responsibility over in-patients going into labour in the GP units of those hospitals.
1913 Thus, the majority of the general practitioners do not have a close day-by-day working relationship with the staff of the consultant hospitals, though in respect of maternity services all are involved with the care of the same patients for the same purpose. That purpose is the successful outcome of pregnancy.
Some older general practitioners are maintaining expertise in delivering babies by accepting clinical responsibility for deliveries in the home or in the GP hospitals of Wendover and Chipping Sodbury. General practitioners under 45 years of age have been taught to expect good facilities for delivery and close contact with specialist staff who would be readily available should complications occur. These conditions do not exist in the Frenchay health district.
The number of deliveries taking place in the district is 10 per cent. of the total deliveries of the population, and that percentage is falling year by year. Total deliveries in 1978 were 2,661. There were 19 deliveries at home, 263 deliveries in the GP hospitals, 2,374 in the consultant hospitals and five elsewhere.
Given present circumstances, it is inevitable that within a short time the general practitioner input to maternity provision will be confined to ane-natal and post-natal care. Given the age range of present general practitioners, it is anticipated that within 15 years the majority of doctors in the health district will not only not have current experience in deliveries but will have little or no previous experience. It might seem tidy for the GPs to concentrate on the more routine antenatal and post-natal care and for consultant hospitals to concentrate on sorting out and dealing with the more difficult ante-natal problems and conducting all deliveries. There is anxiety that that could affect the GP services adversely in several ways.
Involvement in delivery is an attractive aspect of maternity work. Restricting the GP to ante-natal and post-natal work might reduce the number of GPs who are willing to participate in the maternity services. Complications commonly occur at the time of delivery. Therefore, involvement with and clinical responsibility for delivery strongly reinforce the need for a high standard of ante-natal care. If general practitioners are not involved 1914 in deliveries and have little or no regular contact with consultant maternity hospital staff, other ways will have to be developed to ensure that they maintain high standards and are able to identify patients requiring referral to consultant services.
The Frenchay health district employs midwifery staff, some of whom work at the Chipping Sodbury maternity hospital. There are also 12 community district nurses, midwives and eight community midwives who deal with all ante-natal and post-natal patients in the health district. With the handful of home deliveries, the community staff are working to capacity. Their work load is managed by the health district and is prone to alteration without warning whenever Bristol maternity hospital or Southmead maternity hospital finds it necessary to increase early post-natal discharges to accommodate admissions.
Births to Frenchay district residents in 1979 totalled 2,744. They represent between 25 and 30 per cent. of births in the Avon area health authority. As in the rest of the area, births increased by 11 per cent. between 1977 and 1979, and the higher level is being maintained. Each mother-to-be is encouraged to book with the services in the third month of pregnancy. They remain patients of those services for six or seven months.
From that background, it is clear that there is anxiety about the medium and long-term availability and acceptability of maternity services. It is expected that the birth rate will continue to rise, although nobody knows by how much. Therefore, the maternity service provision must be flexible enough to cope with an increase in work load.
Delivery, ante-natal and post-natal obstetric care and paediatric care of the newborn must be provided and must be of a high standard. The general practitioner and community inputs into the services will arise from services based on the health district. The consultant maternity hospital which makes an input may or may not be sited within the area but must provide services which are available and easily accessible to the population.
In April 1979 the Frenchay district management team made a proposal as a contribution to the area health 1915 authority's consideration of the whole of the maternity services for Avon. The proposal was for a general practitioner consultant maternity hospital with an outpatient department and 60 in-patient beds providing a focus for the general practitioner and community midwifery services and ensuring the development of integrated general practitioner, community midwifery and consultant services which would be more accessible than the present maternity hospitals and which would be motivated to ensure that all those needing services had access to them. This proposal would be welcome if the site was right.
The area health authority's proposals to close Wendover and to increase the size of and upgrade Southmead is an unreasonable decision in that there has been no complete study of the maternity services in the Frenchay health district for either the medium or the short term. The authority has chosen to impose a large hospital.
The proposed closure of Wendover maternity hospital is of vital importance. Under the procedures set out in circular HSC(IS)207, Ministers are called upon to make a final decision. No closures will be agreed unless it can be shown clearly that they are in the best interests of local health services. How could a Minister agree, given those facts?
I am sure that my hon. Friend the Under-Secretary will agree that health authorities are well placed to determine the best pattern of service in their areas, taking into account the services available, but what happens when the district management team and the community health council disagree with the AHA proposals and there is a massive public protest?
I can appreciate the dilemma of an AHA which is required to make savings and provide a more efficient and cost-effective service—a highly commendable principle, but not at the expense of my constituents and those of my hon. Friends. A £1 million-plus extension and upgrading at Southmead are not the answer.
A particular medical philosophy—that of the gigantic baby farm—is being imposed by the AHA, and already the Bristol maternity hospital is under threat. Southmead is taking cases from that 1916 hospital, and to cope with the rising birth rate an early discharge policy has been established. Some mothers have been discharged after six hours.
The AHA, planning for a predicted rise in birth rates, intends to cope with an increase by adopting a discharge policy of three days for 50 per cent. of the patients as against, at present, 30 per cent. who stay up to three days. The estimated increase in numbers at the Bristol maternity hospital would be 32 per cent. and at Southmead 43 per cent.
This proposal would create a high-production " baby factory " system—more impersonal, dangerous, geographically wrongly sited, with poor transport, creating additional demands on already pressurised midwifery and community nurses who have to deal with the problems back in the community.
The present maternity facilities in the Frenchay health district are insufficient and inconvenient and costly to the vast majority of families. The proposal to close Wendover has been a fiasco. This hospital is controlled by another health district. As soon as proposals were put forward for its closure, uncertainty was created. Local doctors did not know where to send expectant mothers. Because of this peculiar state of affairs, the waste increased due to lack of proper direction—with dedicated and qualified staff being under-employed and facilities under-used due to a self-imposed problem. Many of the staff were placed on short-term contracts, which produced low morale and uncertainty.
There is still strong support to keep Wendover open, to increase its use and to make its operation viable. The postnatal care provided there is extremely important. Who can assess the relationship between baby battering, infant mortality, domestic tension and the early discharge of mothers and babies to homes without sufficient support? What is the cost to society?
Many mothers now demand home confinement rather than go into a big impersonal unit. Many doctors believe that Wendover is a safer alternative to home delivery. Let us keep Wendover, with its congenial, homely and peaceful family atmosphere, until there is a viable alternative. Economic viability can be achieved if all the parties concerned make the 1917 effort. There is a need without a doubt for this excellent hospital.
During the five-year campaign to provide improved maternity services, I must express my thanks for the determined way that the Fenchay community health council and particularly its very able secretary, Mrs. Mary Aitchison, have doggedly pursued this campaign. I should also like to express my thanks to the many mothers who wrote personally to me, to the women's institute branches, to the mothers and toddlers clubs, church organisations, playgroups, some of the young people now settling in on the new estates in my constituency and to the GPs, community nurses, midwives and staff at the hospitals, particularly Dr. Pauline Begley, who is the district community physician for the Frenchay health district, who gave me much recent factual information.
I also welcome the representations made by the Confederation of Health Service Employees and others and would say to them that there is no political capital to be made out of genuine problems. Our Government want the best provision of maternity services that is possible within the resources available.
In conclusion, I ask for a full inquiry into the provision of maternity services in the Frenchay health district and for the area health authority to keep Wendover open and fully operating until an inquiry has taken place, improving its viability by arranging for more mothers to go there and creating the conditions in which they can do so; to look at the possibility of providing a consultant obstetric unit at Cossham with the provision of pathology and laboratory facilities for joint use with the existing facilities, thereby ensuring the continued viability and future of Cossham hospital; or the scheme proposed by the Frenchay health district management team for a unit at Frenchay, because of the availability of laboratory and specialist X-ray facilities and the constant presence of anaesthetics.
A realistic view of the maternity services provisions must be taken in my constituency and that of the Frenchay health district. Getting the balance right between medical and other considerations is a vital factor. Getting it wrong can produce untold misery, unhappiness and inconvenience.
1918 I hope also that my hon. Friend the Minister will meet a small delegation from the Frenchay community health council to discuss at ministerial level the real fears of the community on this subject.
§ 2.1 pm
§ The Under-Secretary of State for Health and Social Security (Sir George Young)I congratulate my hon. Friend the Member for Kingswood (Mr. Aspinwall) on securing this debate today about the proposed closure of Wendover maternity hospital and the alternative provision of maternity services. He made a forceful speech and a useful one, as might be expected by those who know him, and he spoke well on behalf of his constituents. His interest in the Health Service is well known in the House, as he is secretary of the Back-Bench committee on health and social security. I am also pleased to see in his place my hon. Friend the Member for Gloucestershire, South (Mr. Cope), perforce silent in this Chamber but active behind the scenes both in the House and in his constituency to improve the delivery of health care to those whom he represents.
I well understand the anxieties that can be aroused locally by proposals to close hospitals, and I am grateful to my hon. Friend for giving me the opportunity to set out the background—as I understand it—to today's debate and to give an account of the procedures that have to be followed when the closure of any hospital is proposed. I assure him that the procedures are designed to ensure that decisions are only taken after a full and searching examination of all the relevant facts, especially those which he mentioned.
I should say at the outset that no decision has yet been taken to close Wendover maternity hospital, nor, indeed, is any final decision imminent. I shall be referring later in my speech to the various stages that must be gone through before a hospital can be closed. If local agreement cannot be reached—in particular, if the local community health council objects—the final stage in the process involves decision by Ministers. It would not, of course, be proper for me to pre-empt that decision this afternoon or to seek to influence at this stage the views of the relevant health authorities. I can, however, indicate our national 1919 policy so that proper account can be taken of it in local discussion.
I should also make it clear that any proposal to close this hospital in no way reflects adversely on the high standard of care that past and present members of the hospital staff have given to their patients. I am well aware of the dedicated work that is carried out in hospitals such as Wendover, and I am grateful for this opportunity to pay tribute to the staff involved.
At present, hospital births in Avon take place in either consultant maternity units or in peripheral general practitioner units, and it may be helpful if I digress for a moment and explain the difference. In a consultant maternity unit, the expectant mother comes under the care of a consultant obstetrician who works from a particular hospital or hospitals. She may well attend ante and post-natal clinics run by the obstetrician and his staff, and the delivery of her baby will be supervised by the consultant's team, which will include resident medical staff. Such care is especially desirable—for example, in a mother-to-be's first birth—when it is anticipated that the special skills of a consultant obstetrician and full hospital facilities, such as anaesthetic, paediatric or pathology services, are, or might be needed. Where this is not the case, deliveries may take place in a general practitioner maternity unit. Here, mothers-to-be may remain in the care of their general practitioners throughout their pregnancies and hospital facilities are provided as and when appropriate. Usually in a general practitioner unit, there is no resident member of medical staff.
At present there are three consultant maternity units in Avon—at the Bristol maternity hospital, at Southmead hospital and at the Weston general hospital—and four peripheral general practitioner units, including Wendover maternity hospital. In 1979, 92 per cent. of births in the area took place in the consultant units and just over 7 per cent. in the peripheral units. A distinct change in pattern has occurred since 1975, when only 74 per cent. of births took place in consultant units. I should stress that this change has occurred not by direction of any health authority but by more and more mothers, no doubt in consultation with their general practitioners, electing 1920 to have their babies in one of the consultant units in preference to a general practitioner unit.
At first sight, it may seem somewhat paradoxical that the Avon area health authority, which is responsible for health services in my hon. Friend's constituency, is considering a proposal to close Wendover maternity hospital at a time when the birth rate in Avon appears to be on the increase. The previous decline in the area's birth rate ended in 1977, and there was a dramatic upswing in 1978. This was sustained in 1979, and over the two-year period there was an increase of 11 per cent. in births. Just over 10,000 births took place in 1979 and, judging by latest predictions, it is now necessary to plan for a peak of about 14,000 births per year in the period 1986 to 1991.
Sensibly, the health authority has reviewed its obstetric policies in the light of this increase. It has decided to make contingency plans for increasing obstetric facilities and to monitor the effectiveness of the general practitioner units. It was decided that the increased number of deliveries could be undertaken by the two consultant units in Bristol, with some support from the peripheral units, if a delivery suite was constructed at South-mead and approriate increases were made in nursing staff as the birth rate rose. It was also recognised that an increased number of community midwives would be required if the average length of stay in hospitals was reduced to accommodate the expected increased number of deliveries. The authority had previously emphasised the useful role that general practitioner maternity units could play and had advocated that both consultants and general practitioners should book suitable cases into the peripheral units to relieve pressue on the consultant units.
Despite all that, I understand that the use made of Wendover hospital—which has 16 beds—has declined. The work load has gradually transferred to the consultant unit at Southmead hospital, which is about three miles away. In. 1978 there were only 128 deliveries at Wendover, an average of fewer than three a week, and this serious under-utilisation naturally led to low staff morale and staffing difficulties. Because of staff resignations, the hospital was temporarily unable to provide safe delivery cover, and in September 1978 the health authority decided 1921 to close the hospital temporarily for deliveries and to use it for post-natal care only. There was no intention at that time to close the hospital permanently, and deliveries were resumed two months later as soon as a full complement of staff was recruited.
The expectation was that, with the increase in the birth rate, the unit's facilities would be more fully used. However, despite encouragement by the district management team, this did not happen and there were only 119 deliveries in 1979.
The position, as seen by the area health authority, is now as follows. That authority reviewed the situation in April 1980 and decided that, as Wendover hospital was not making any significant contribution to obstetric services in Avon, its closure should be proposed. By then, the average number of deliveries was only about two per week, compared with a potential of 19, and, in the authority's view, while the hospital remained open it was tying up valuable resources of staff that could be more economically deployed elsewhere. Because of the low volume of throughput—if that is the right word—the average cost of a delivery at Wendover in 1979 was £1,100, compared with a range of £388 to £600 for the other maternity hospitals managed by the authority. The total current cost of running the hospital is £130,000 a year, and the authority felt that these resources were urgently needed to meet the increasing pressures upon the consultant maternity units and upon the community midwife services.
It would not be right for me to comment at this stage on the validity of the case put forward by the health authority, other than to say that I am well aware of the strength of feeling that can be aroused among mothers-to-be, professional staff and others by proposals to vary maternity services. Factors such as reducing costs, maximising safety, providing a friendly, homely and sympathetic environment, and the convenience of patients and visitors do not always pull in the same direction and have to be balanced locally with tact and sensitivity.
I have so far concentrated on describing the local background to this debate, but it might be helpful if I set the matter into a wider context by referring briefly 1922 to the general financial position of the NHS and its relevance to closures and to our recent proposals on the future pattern of hospital provision.
Money is tight in the Health Service, although, as the White Paper on public expenditure made clear, we are standing by our manifesto commitment to maintain the level of spending on the Health Service planned by our predecessors. In 1980–81, health authorities' cash limits provide for a real growth of ½ per cent., compared with the planned level of spending in 1979–80, but because of the cash limit squeeze in the last financial year this means an increase of over 3 per cent. in real terms. The level of additional resources that can be provided for the NHS depends, of course, on how soon the national economy responds to the Government's policies.
The Government attach the greatest importance to controlling expenditure, and we have stressed the need for health authorities to stay within their allocations. I know that many authorities are now searching for ways to save money, and, as a last resort, closure may seem to be the only option. However, my fellow Ministers and I have repeatedly made it clear that we will not agree to permanent closure as a way out of short-term difficulties. As I have said before, permanent closures can reduce the Health Service's precious stock of hospitals at a time when the country can ill afford to make good the loss, and the cumulative effect of a number of small closures can be substantial. Thus, we are quite firm that permanent closures should occur only as part of agreed long-term plans for the development or rationalisation of health services in a particular area.
We have recently published a consultative paper about the future pattern of hospital provision in England. We recognise in that paper that there are sound medical reasons—and some financial ones—for concentrating some services in district general hospitals. Among other advantages, such hospitals can provide a much greater range of services and up-to-date expensive facilities, thus improving patient care. But there is a real risk of concentrating services more heavily than the advantages strictly justify to the detriment of other considerations, such as the accessibility of hospitals to patients and visitors and the sense of identity 1923 which many local communities have with their local hospital. What we are anxious to avoid is centralisation for the sake of it, and we consider that health authorities should take a long, hard look before deciding that big is best. Having said that, there is, of course, no point in providing local facilities that are not used.
To turn back to the main subject of this debate, what procedures must now be followed before any proposal to close Wendover maternity hospital can be put into effect? DHSS circular HSC(IS)207 sets out the answer. Briefly, the area health authority must have issued a formal consultation document setting out its proposals to the relevant community health council and to local authorities involved and to staff and professional interests. Three months are allowed for comment, and all comments must then be passed to the CHC for any further observations it may wish to make.
If the CHC does not object to closure, the AHA considers all the comments on its proposal and decides whether to close. If the CHC does object—and this is important—it has to submit a counterproposal to the area health authority. If the authority still wishes to proceed, it must then refer the matter to the regional health authority. If the RHA supports the case for closure, it submits the case to Ministers for a final decision. We have made it clear that, in cases where we are called in to intervene, Ministers would not support any case for closure unless 1924 it could be clearly demonstrated to be in the best interests of local health services and the community they serve.
But we are, of course, as yet a long way from that point in this case. Perhaps for that reason I may postpone a response to my hon. Friend's request for a meeting. The AHA is only just about to issue its consultation paper, which, as I have just explained, is only the start of a long road which does not necessarily lead to a closure. I assure my hon. Friend that the procedures are designed to be as scrupulously fair as possible, and very careful consideration will be given to comments received at all points in the procedure. I shall ensure that the area health authority receives a copy of the Official Report of this debate.
All comments that are received during the consultation process will, of course, be carefully studied by the area health authority and, if appropriate, the regional health authority, Additionally, I know that all concerned will give full consideration to the points that have been expressed here this afternoon, especially those that demonstrate the strength of local feeling on this issue.
I say again to my hon. Friend how grateful I am to him for having raised this matter today.
§ Question put and agreed to.
§ Adjourned accordingly at fifteen minutes past Two o'clock.