§ Mr. John Cartwright (Woolwich, East)I welcome this opportunity to draw attention to the future of health services in the London borough of Greenwich. This is not the first time that the matter has been raised in the House, and I suspect that it wil not be the last.
Almost from the day of its birth in 1974 the former Greenwich and Bexley area health authority seemed to lurch from crisis to crisis. There were continual reports of overspending, threats of closure or major reductions were made to almost every hospital in Greenwich, and relations with the community went from bad to worse.
In December 1975, the area health authority put forward its first tentative proposals for cutting services and closing hospitals. Over the succeeding months, these were changed more than once as the authority's members tried to bridge the gap between what the public wanted and what their resources could fund. This led to a long, bruising and at times bitter confrontation which finally had to be settled by the then Secretary of State, the right hon. Member for Norwich, North (Mr. Ennals), in May 1978.
The wounds of that conflict took some time to heal, and some of the changes have still not been implemented. Yet the people of Greenwich are now threatened by ever more savage cuts to local services proposed in a draft strategic plan put forward by the new district health authority which seems determined to follow the example of its predecessor, the area health authority.
There is also the long-running saga of the cardiac unit at the Brook hospital. That was first threatened as long ago as 1976 and, once the long-drawn-out processes of examination, evaluation and consultation had finally been exhausted, the South-East Thames regional health authority proceeded to dither about the proposals for a further six months. This long delay had an unsettling effect on the hospital staff. It made planning decisions difficult for the district health authority, and it had a major impact on local people who began to wonder how much of their health services would survive these constant reexaminations.
I pay tribute to the Minister for Health, who made it clear that he disapproved totally of this continued delay and wasted no time in rejecting the closure proposal when the plans finally reached his desk.
Hardly had we finished congratulating ourselves on a successful community campaign to defend an essential and popular local facility, when we found ourselves back in the fight with the publication of this latest draft strategic plan.
For some years, Greenwich community health council and many local people have urged the need for a far-reaching strategic examination of the health needs of the borough. They have now been given a programme for major cuts in services not supported by any compensating fall in the health needs of the area. The reason given by the Greenwich health authority for putting forward a document, which it acknowledges "makes sombre reading", is the district's continuing financial problems. Greenwich is claimed currently to be 22 per cent. above its spending target, although very few of my constituents accept that they are over-provided with health services. As a result, the South-East Thames region is seeking an average reduction of 0.9 per cent. or £420,000 in real terms every year. That means a total cut of £3.8 million 1098 a year by 1991–92. To that must be added Government-applied efficiency cuts of £500,000 a year and the impact of cash planning which does not compensate for inflation and wage settlements.
The Greenwich health authority reckons that it must budget for a drop in its revenue resources of at least £4.3 million a year by 1992. Therefore, it has put forward a package of cuts planned to yield savings of £3.73 million a year. However, the report makes it clear that these will involve a substantial reduction in the standards of services. The number of acute beds, for example, will be cut by one-sixth from 964 to 806. The authority's report makes no attempt to forecast what that will mean for waiting lists in the borough.
The number of beds for the elderly is to be cut from 345 to 228. Admittedly, it is hoped to reduce provision for the citizens of Deptford and Bexley by transferring 66 beds to the appropriate health authorities, but the number of beds for Greenwich citizens is planned to rise by only nine from 247 to 256. With an ageing population in various parts of the borough, there must be considerable doubt about the adequacy of that provision. My constituency casework has revealed a number of occasions when elderly people, judged by consultants to need a hospital bed, have to wait for weeks or months because vacancies simply do not exist. If Bexley and the Lewisham and North Southwark authorities cannot provide for their own citizens, the pressure on geriatric beds in Greenwich will be even greater.
There is also considerable public concern about the future of maternity services in the borough, on which the authority is proposing a cut from 155 beds to only 111 beds. In his decision of May 1978, the former Secretary of State accepted the case for closing the British hospital for mothers and babies at Woolwich, and transferring the service to Greenwich district hospital and Queen Mary's hospital in Sidcup. However, he left the implementation of his decision until alternative facilities had been provided. The Greenwich health authority is now proposing that the British hospital for mothers and babies should close in 1985, when the extension to maternity provision at Greenwich district has become operational.
However, the authority points out that that will leave a shortfall of about 34 beds. Its solution in the short term is to provide an extra nine beds at Greenwhich by adapting what it calls "non-bed areas" and to claim some additional beds provided by the Bexley authority at Queen Mary's, Sidcup. However, the authority's document recognises that
difficulties may exist on the closure of the British Hospital for Mothers and Babies.It therefore proposes a further increase of 20 maternity beds at Greenwich district hospital to a total of 100 beds, but says:It may not be possible to enlarge the Greenwich unit and it could be prohibitively expensive.Even by the past standards of the health authority, the thinking behind this section of the document seems extremely confused. On the one hand, the authority is determined to close the British hospital for mothers and babies; on the other hand, it recognises that that will cause major problems to which there may well not be an acceptable solution. Most people would regard it as totally irresponsible to close a popular, well-established and 1099 central unit like the British hospital without cast-iron guarantees that sufficient replacement maternity beds will be available.However, a more fundamental issue is at stake. Even if enough beds could be provided at Greenwich, expectant mothers would be denied any choice about where their babies were to be born. It could be only in a large unit in a large district general hospital, and in a district general hospital which is extremely inaccessible for many of my constituents living in Plumstead, Abbey Wood and Thamesmead.
This problem was recently underlined by the experience of one of my constituents, whose wife was transferred from the British hospital for mothers and babies to Greenwich district hospital just before the birth of her baby. The child was born underweight and was expected to stay in a special care unit at Greenwich for about six weeks. My constituent wrote:
Neither of us had anything but praise for the staff at Greenwich Hospital and the care provided there, but in the meantime my wife has to travel from Plumstead Common to Greenwich every time that she feeds the baby. We have learned that help with transport is not normally provided by the local Social Services or by Greenwich Hospital, and public transport is in this case neither adequate nor suitable over such a distance for a woman discharged ten days after a Caesarean birth, as my wife was.My constituent goes on:The threatened closure of the BHMB would make this a common and unavoidable situation for mothers living in Woolwich whose babies are kept in hospital. Surely such a situation would be unworkable unless wider, and no doubt expensive, provision could be made to bring mothers to and from Greenwich".That illustrates that the Greenwich hospital is at one end of the area it serves, while the British hospital is extremely central. There is also no doubt that the standards of care provided and the individual attention given at the British hospital has made it extremely popular with local expectant mothers. To close such a well-run and well-supported unit would be an act of total insensitivity. It would also inevitably reduce the quality of services provided to local people.St. Nicholas' hospital at Plumstead is another institute whose future affects my constituency. When he had to consider the former area health authority's plans to close St. Nicholas' the former Secretary of State for Social Services made a clear and inequivocal statement on 14 December 1977. He said:
St. Nicholas is a valued hospital, well situated to service a community whose population is growing. It is in Plumstead where social conditions are poor and there are many old people living in bad housing. It is also central for Thamesmead, a locality of industrial development. I do not believe it would be right to close it.After further consultation and detailed consideration, the Secretary of State made a more detailed statement on 5 May 1978 about his proposals for St. Nicholas'. He said:I have agreed that St. Nicholas Hospital should become a Community Hospital providing out-patient and minor casualty facilities; theatre and supporting services for minor surgery with about 20 beds; 20–25 general practitioner medical beds; and the present 41 geriatric beds with perhaps the addition of some further geriatric beds. Consideration should also be given to the establishment of a psycho-geriatric day centre.I am bound to say that I was cynical about the prospect of leaving St. Nicholas to the tender mercies of an area health authority which all along had wanted to close it. That seemed to me to offer a poor guarantee for a lasting future. The Secretary of State sought to reassure me. He wrote me a personal letter on 10 July 1978, saying: 1100I really do not think it is right to contend that the change of use of St. Nicholas means its eventual closure. I told the health authorities that I am not willing to agree to closure and I know that they will make every effort to develop practicable arrangements which will enable the hospital to continue. I cannot believe that the inevitable transitional problems cannot be solved and I am sure that St. Nicholas can become a viable community hospital which will complement the District General Hospitals in the Area and give valuable service to the people of Plumstead and Thamesmead.It gives me very little pleasure to record that my suspicions appear to have been borne out. St. Nicholas' has never been allowed to develop as a proper community hospital. It has been starved of investment and has never achieved the level of provision laid down by the Secretary of State in May 1978. Nevertheless, its record of service to the local community has been impressive against all the odds. During 1981 the minor casualty department dealt with 7,561 cases and its 1982 record is at a similar level. The 16 out-patient clinics handled 29,719 appointments during 1981 and those figures have been well maintained during the current year. The physiotherapy department treated 1,602 new cases in a total work load of 15,369 last year. Again, those figures have been well maintained during the current year. Nevertheless, the Greenwich health authority has apparently rejected suggestions from the regional health authority for the redevelopment of St. Nicholas to provide a package of facilities, including a geriatric day hospital, a day surgery, X-ray facilities, a minor casualty department, a comprehensive range of outpatient clinics, physiotherapy and occupational therapy services. All those services would have been well received in the area.The area health authority argues that continuing services at St. Nicholas would mean closures elsewhere. Indeed, it suggests, without producing a shred of evidence in support, that it could mean the loss of up to 180 acute beds at the Brook hospital with the consequent threat to the neurological and cardiothoracic units and the eventual rundown of that hospital.
As a result, the authority proposes the total closure of St. Nicholas' hospital, including both inpatient and outpatient services and the sale of the site on the open market. Its document makes it clear that it would
make no provision for a local service and depend on other hospitals absorbing the total workload.I regard that as a cynical abandonment of my constituents who will be forced to depend on two general hospitals which are difficult to reach by public transport and where they would be competing with others for outpatient appointments and beds.It is significant that the proposal will remove services from the only part of the borough in which the population is rising—a point which was recognised by the former area health authority as long ago as 1976 when it commented that St. Nicholas' was
sited within a densely populated area and with direct access to Thamesmead. It is, from a geographical viewpoint, in an excellent location.That proposal for St. Nicholas' hospital makes nonsense of the elaborate and long-drawn-out consultation process which was gone through between 1975 and 1978. If it is accepted, the public in my constituency will have no faith that decisions by Secretaries of State on such matters provide any effective and lasting safeguards.Three points arise from this unhappy situation on which I should like very much to hear the Minister's comments. First, the hon. and learned Gentleman will no doubt point 1101 out that the document before us is only a draft and may be altered. That is underlined by the authority, which suggests that final decisions may not be taken on the outline strategy until March 1984. However, it points out that the closure proposals might well be considered not on a strategic basis but on the annual planning basis, which would involve decisions being reached during 1983. In such a situation short closure decisions made for short-term financial reasons will clearly dictate the strategy, instead of the strategy deciding the short-term policies.
Secondly, does the Minister accept that such a major closure programme is needed in Greenwich? Is he confirming that Greenwich is over-provided with health services, or does he believe that the more efficient operation of the health authority would enable it to operate within its budget, without closing essential facilities? There is some local scepticism about the competence of the health authority, but the financial cuts it faces are very substantial. It would be helpful if the Government told us how they are to be met without further reducing the standard of service available to my constituents.
Finally, and most importantly, will the Minister accept that another long-drawn-out, bitter argument about cuts and closures is the last thing the health services in Greenwich want or need? They have been battered from pillar to post for the past seven years. They are surely now entitled to a period of consolidation and to a respite from further damaging uncertainty and controversy.
I urge the Minister to offer some much needed reassurance both to the Health Service staff and to the long-suffering patients in the borough of Greenwich.
§ The Minister for Health (Mr. Kenneth Clarke)I congratulate the hon. Member for Woolwich, East (Mr. Cartwright) on securing this Adjournment debate on the future of health services in Greenwich. Over the years he has frequently battled on behalf of his constituents and he has made many representations to me during the comparatively short time that I have held my present post.
The hon. Gentleman mentioned that it was recently decided to keep open the cardiac unit at Brook hospital. That was done largely in response to pressures from the hon. Gentleman and other hon. Members who represent the area. Of course, that does not mean that the borough's health services are in any way free from problems and controversy. Once more, the district health authority is having to look carefully at its overall strategy for hospital services in the district. It is often difficult for constituents in a place such as Greenwich to understand why there is a history of continued controversy about the provision of health services in their borough when there is increased spending in the National Health Service and it is being steadily developed.
Of course, we always have to ensure that there is a fair distribution of resources in the NHS and a provision of services that matches need and demand throughout the country. It must be the aim of any Government—and it is certainly our aim—to ensure that there is broadly equal access to patient care and treatment in every part of the country. Greenwich's first difficulty is that it is in the South-East Thames health region, which is well provided for compared with other parts of the country. I am constantly being pressed by Members of Parliament for 1102 constituencies outside London to reduce what they regard as the over-provision of resources in London. Those who represent London constituencies put the countervailing argument that they face great problems. Even within a comparatively well-provided region, such as the South-East Thames health region, there are considerable differences in the allocation of resources between particular districts. With our support and approval, the South-East Thames region is committed to a policy of revenue redistribution between the 15 districts, so that something can be done, for example, to improve the services in the Medway, where there are serious deficiencies in the service. That involves considering a distribution of revenue away from some of the better provided districts, including Greenwich.
As the hon. Gentleman acknowledged, Greenwich is regarded as having 22 per cent. above its target for resources on the long-established resource allocation working party formula that we use. Therefore, it is being asked to make the second greatest contribution to the revenue needs of the more deprived districts within the region.
When one describes the over-provision of resources in a borough, one must identify that over-provision. In answer to one of the hon. Gentleman's specific queries, it has been judged during the years that Greenwich is over-provided with acute beds. That does not mean that it is free from health problems, many of which arise from the difficult social circumstances that he described in Plumstead and elsewhere. However, an objective appraisal of Greenwich shows that it has too many acute beds. That underlying problem is the background to the recurring debates and controversies that the hon. Gentleman described carefully and that have continued for the past six to seven years.
Why is Greenwich considered to be over-provided? I shall set out the historical reasons. As in similar areas of London, a range of hospitals was built there at different times for different purposes, and they do not altogether match the present distribution of population. For example, St. Nicholas' hospital and St. Alphege's hospital, which is the forerunner of the present Greenwich district hospital, were both original workhouse infirmaries—one in the former borough of Woolwich and the other in Greenwich. The Brook general hospital on Shooter's Hill was built as an infectious diseases hospital and its role did not change until after the Second World War. The result of the provision of hospitals in the area was that, by the early 1970s, Greenwich district had three fairly large acute hospitals to serve a declining population.
The two other acute hospitals in the district were not designed primarily to care for NHS patients. They are the Dreadnought seamen's hospital that provides an international service to British and foreign merchant seamen, but also provides some beds for local patients. The Queen Elizabeth military hospital, which was opened in 1977, provides a burns service to the civilian population and also accepts referrals and acute specialities from local general practitioners when military requirements allow.
That total pattern gives rise to an over-provision of acute beds. Attempts to rationalise the acute services go back to 1975, when the present district formed half of the then Greenwich and Bexley area health authority.
I shall not go over the long period of consultation and the agonies described by the hon. Gentleman that were suffered between 1975 and 1978 when the area health 1103 authority closed several old hospitals in Bexley. They were replaced by the new Queen Mary's hospital at Sidcup. The Miller general hospital was also closed and its services were absorbed into the new Greenwich district hospital. The authority also proposed the closure of St. Nicholas' hospital, which aroused considerable opposition. In 1978, the then Secretary of State for Social Services visited St. Nicholas' hospital, reprieved it and made alternative suggestions. He proposed that it should become a community hospital with outpatient and minor casualty facilities, theatre and supporting services for minor surgery, day surgery, general practitioner and geriatric beds. The result was that, between 1978 and 1979, most of the acute and maternity beds were closed, the number of geriatric beds increased and GP beds opened.
The former Secretary of State also decided that the British hospital for mothers and babies at Woolwich should close when the new maternity provision at Queen Mary's hospital in Bexley was opened. He also decided that inpatient and outpatient services at Eltham and Mottingham hospital should be closed. Those decisions have not yet been implemented, as the hon. Gentleman said, but it seems likely that the British hospital for mothers and babies will close when alternative provision is available. Eltham and Mottingham hospital is temporarily closed, although no ministerial approval for permament closure has been given. The previous Secretary of State responded to the hon. Gentleman and his constituents in 1978. With respect to the decisions taken, it is obvious in the light of subsequent events that the problems were not solved. The underlying problem of the over-provision of acute services, as well as serious management problems in the old area health authority, gave rise to further unhappy events.
In September 1981, the area health authority issued yet another strategic plan. Since its days as an authority were numbered, it presented the plan not as a consultative document but as a review of the position to be used by the new district authority when it took over and began its initial planning. The area health authority's proposals were that surgical inpatient services at St. Nicholas' hospital should cease and that day surgery should be reduced from the 20 beds agreed by the former Secretary of State, because it had never been possible to fill the 20 beds that he said should be provided.
The authority proposed that the Eltham and Mottingham hospital should either reopen for inpatients if the general practitioner medicine beds at St. Nicholas' hospital closed, or be made available to a voluntary consortium for use as a residential day centre for the physically disabled. It also proposed that the number of acute beds should be reduced at the Greenwich general hospital, that acute beds at the Dreadnought seamen's hospital should be reduced from 123 to 85 by 1992, that the regional neuro-science unit should stay at the Brook general hospital, that all in-patient beds for geriatric patients should be closed at the Memorial hospital and that the outpatients' department should stay.
There was considerable reaction to those suggestions locally. The hon. Gentleman was in the forefront in putting forward his constituents' views. Earlier this year the problem was made even worse when considerable anxiety arose about the financial position of the Greenwich and Bexley area health authority, which was considerably overspent. The hon. Gentleman and myself have had 1104 exchanges about some of the background to that on the Floor of the House. I am happy to say that the problems have now been resolved with the help of the region and through the efforts of the district's own treasurer.
Having resolved the immediate overspending problems, the new district produced an outline strategy—it was issued in October—in response to the need to try to arrive at a final resolution of the continuing unhappy problems of providing the right service for the population of Greenwich. Among the proposals is the complete closure of St. Nicholas' hospital. The document that has been issued is a draft. It will be reconsidered in the light of all the comments that have been received on it. That will happen when two months have passed. After amending its draft, if that is necessary, the authority will issue an outline strategy for the next 10 years. I am expecting to receive a copy of that strategy. It will then begin work on a full strategic plan within the bounds of the outline, which will cover every aspect of the authority's services.
I know that the authority is consulting on its draft and considering it finally. I must allow it considerable leeway in discussing matters locally and in drawing up its own policies. It is charged with a difficult responsibility in sorting out health provision for the borough. I am keeping in close touch with what is happening and at, this stage I do not think that a direct ministerial involvement that overrules its planning process is called for. If the authority finally proposes closures or major changes in the use of Health Service premises and these are opposed by the local community health council, the decision must, under the closure procedures, come to Ministers for a final decision. I shall carefully consider any proposals of that sort if any eventually come forward.
In the meanwhile the problems will not go away. The authority has to continue to reassess the use of acute beds at St. Nicholas' hospital and elsewhere. I have already said that it was proposed in 1978 that 20 day-surgery beds should be retained at St. Nicholas' hospital. That proved to be an overestimate of the demand and it was reduced following the proposal of the former AHA. It submitted a formal proposal to my predecessor to reduce the number to five, which was all that demand had ever justified. I am told that no more than five beds have ever been in use.
When the formal proposal was put to my predecessor, he met the chairmen of the AHA and the South-East Thames regional health authority in January. He told it that he was unwilling to accept the proposal in isolation. He told it that he wanted it to produce a hospital strategy for the whole of Greenwich, so that a sensible, overall view could be taken of the problems. That is the approach that the hon. Gentleman advocated.
My predecessor met the hon. Gentleman to discuss the future of St. Nicholas' hospital and put forward various proposals for consideration. He thought that consideration might be given to retaining the hospital for community use, day surgery, as a geriatric day hospital, for occupational therapy, physiotherapy, x-rays, minor casualty treatment and for a comprehensive range of outpatient clinics. I can assure the hon. Gentleman that that proposal has been considered by my Department and the regional health authority. A great deal of work has been done in looking at the cost and service provision at St. Nicholas' hospital.
The strategic plan came out in October for consultation, following the re-examination. The draft discusses in detail the possible options for St. Nicholas'. It concludes that day 1105 surgery and a geriatric day hospital on the site cannot be justified because there is already more than enough such provision in the district. It also recommends that the minor casualty department should be closed on the grounds of economy and that the outpatients department should close also. That would mean that the site, apart from the small portion giving access to Plumstead health centre, could be sold and the proceeds released for reinvestment in health services.
I have already described the status of the document. It is a draft document and is being consulted on locally at the moment. The authority has to decide whether it wants to amend it. It will reach its final conclusion early in the new year.
I shall follow the events closely, just as I have listened closely to the arguments of the hon. Gentleman. I agree with one point that he made at the end of his speech, that continued uncertainty, debate and controversy can be seriously demoralising for all those who are trying to improve the health services of the borough and who make a proper contribution to the health care of the population. Therefore, I hope that eventually the debate will be concluded, that we have a clear strategy to look at, and that firm decisions will be taken, about which everyone can be confident for the future. In reaching those decisions, insofar as anything comes to me such as closure proposals or a major change of use, I shall pay particular attention to the opinions of those who live in the district and the arguments of the hon. Gentleman who represents them. At this stage the consultations must go ahead. The district is entitled to consider its strategy. It must find a solution to the underlying problem that, for historical reasons, there is an over-provision of acute services in hospitals in the Greenwich area.