HC Deb 12 December 1986 vol 107 cc748-56

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

2.28 pm
Mr. Nigel Forman (Carshalton and Wallington)

On Tuesday 11 November, the Merton and Sutton district health authority decided to recommend to the South-West Thames regional health authority the closure of acute services for children at Queen Mary's hospital in my constituency, and the future provision of those services on an enlarged site at St. Helier hospital, which is also in my constituency.

On Sunday 16 November, I issued a press release deploring the recommendation and recalling that I had consistently favoured the option of rebuilding and modernising acute services for children at their present site at Queen Mary's. I drew attention to the high standard of medicine and nursing at the hospital, the popularity with parents of the family-centred care for which it is renowned, and the fact that opposition to the relocation and support for the development of those services on their present site was by far the best-supported position taken by members of the public during the recent consultation process. I also emphasised that I would make further representations in an attempt to influence the outcome before any final decisions were taken.

It being half past Two o'clock, the Motion for the Adjournment of the House lapsed, without Question put.

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

Mr. Forman

I am so committed and concerned about this subject that, perhaps, I jumped the gun.

This debate is an important part of the further representations that I have mentioned as I want the Minister whom I warmly welcome to her new responsibilities, to be fully aware of the shortcomings of the district health authority's recommendation and of the powerful reasons why I favour a different course of action.

The district health authority eventually decided to recommend what was identified as option 1 in the pink document that it published following formal consultations on the earlier proposals, which were contained in a document entitled "The Strategy for Acute Services, 1986–94". Option 1 amounted to closing acute services for children at Queen Mary's, rebuilding them on an enlarged site at St. Helier and providing acute services for adults at St. Helier, Sutton and Nelson hospitals. I intend to concentrate on the shortcomings of the proposal with regard to acute services for children.

The first point of criticism of the district health authority's recommendation is that its preferred option 1 would not be the cheapest in terms of capital cost at a time when that consideration is bound to be an important factor in the regional health authority's mind. In terms of the four options which were deemed realistic by the district health authority, option 1, at something over £23 million, would be the most expensive in terms of capital cost according to the district health authority's estimate.

The second point of criticism is that there is nothing to choose between option 1 and option 2 according to the district health authority's estimates of the revenue consequences of each in 1993 and 1994. Indeed, both options, to use the words of the district health authority's report, meet the 1993–94 targets, as near as needs to be. There is, therefore, no decisive financial advantage for option 1 over option 2 on revenue-saving grounds.

The third point of criticism is that the district health authority recommendation was arrived at by fairly dubious statistical methods, dressed up in the usual pseudo-scientific language of cost-benefit analysis. When one takes the trouble to look into this bureaucratic mumbo jumbo more closely, it soon becomes apparent that the figures used are highly tendentious and certainly open to challenge on grounds of their inevitable subjectivity, especially in terms of the weightings given to the various factors.

For example, according to something called the sensitivity analysis on the cost side, option 2 leads the field if the revenue savings on all of the options turn out to be 95 per cent. or less of the forecast for 1993–94 and if the capital costs turn out to be 105 per cent. or more of the forecast for that same year.

In view of the well-known fragility of all such financial forecasts over a period as long as seven or eight years, it seems wise to question any dogmatically expressed preference on these grounds alone. When we examine the benefit side, the outcome seems to be even more subject to the arbitrary weightings and value judgments of those who drafted the district health authority report. For example, the figures used appear to penalise any tendency towards centralisation of provision when, logically, that ought to be the hallmark of any rationalisation scheme.

In the scoring for quality of service for children it is not clear why Queen Mary's hospital scores lower than St. Helier when the former is a specialist children's hospital with an established international reputation. It is not clear why bureaucratic considerations, such as planning flexibility, scores 12 points, timing 12 points and compatibility with other strategies seven points. Together they amount to 31 points, yet the much more important consideration of public acceptability and staffing acceptability are weighted as low as seven and five points respectively.

The fourth point of criticism concerns the apparent inconsistency between what we know to be the policy of the regional health authority and indeed of the Government, in favour of concentration of services, and what appears to be the district health authority's preference, in option 1, for dispersing its acute services among no fewer than three different hospitals in the district. The merits of centralisation, when resources are scarce, were clearly recognised in paragraph 19.3 of the regional strategic plan 1985–1994 and included the need to rationalise capital-intensive radiological services, the concentration of high technology facilities and making the most effective use of specialist skills and equipment. All those factors strengthen the argument for option 2 in the district health authority report rather than option 1.

The fifth point of criticism concerns the failure of the regional health authority to ensure the most cost-effective and rational provision of acute services for children within its region. This may have been achieved by preventing Mayday hospital at Croydon from developing its children's unit at the expense of Queen Mary's and by discouraging the mid-Surrey district health authority from following suit and building its own children's unit at Epsom general. Such replication of expensive, specialist facilities, within a comparatively small geographical area, does not appear good policy at a time when resources are inevitably scarce.

It would be much more sensible to continue to take full advantage of Queen Mary's reputation for excellence in child services and to regard it as a specialist, regional centre for children in much the same way as St. Helier hospital, also in my constituency, is regarded as a regional specialist centre for renal dialysis and kidney patients.

A letter from Mr. Rolls, the director of planning for the mid-Surrey district authority, to my personal assistant, Mr. Robert Marshall, made it clear that facilities such as the Guthrie unit at Queen Mary's, which screens babies for physical and mental handicap, are complemented by the general paediatric provisions at the hospital. That hospital undertakes 25 per cent. of the total paediatric work load in mid-Surrey. Mr. Rolls refers to: the disadvantageous effect upon Mid-Surrey of a reduction in services from Queen Mary's. A similar point in support of Queen Mary's was made during the consultation process by the general manager of the Royal Marsden hospital of London and Sutton, who expressed concern that the district health authority document does not take account: of the increasing needs of this Authority for paediatric services currently provided at Queen Mary's. Once again, here is an example that concerns the care of children with leukaemia and solid tumours and which supports the many ways in which Queen Mary's, at its present site, provides an invaluable service for the whole region.

The sixth and final point of criticism—this is perhaps the most problematic aspect of the entire proposal—is that there seems to be considerable doubt and obscurity surrounding both the feasibility and the timing of the proposed translation of acute services for children from Queen Mary's to an enlarged site at St. Helier.

With regard to feasibility, it is already clear that capital shortages, especially for bridging finance, are worrying the regional health authority notably for the years between now and 1990. The regional strategic plan states:

The full amount is unlikely to be affordable. That means that any scheme, such as the district health authority's option 1 that is forecast to cost £23 million, must be regarded as financially doubtful. That does not take into account the other difficulties that may arise from the need to obtain planning permission for the development and extension of St. Helier hospital on what is now classified as metropolitan open space. Naturally, the London borough of Sutton wishes to protect that land as green belt for the benefit of the local community.

Even if all the other problems could be solved, great doubts would still surround the period of transition. For example, if the existing acute child services at Queen Mary's were reduced too soon or if the new services proposed at St. Helier were delayed for any reason, there would be serious problems for the children of mid-Surrey and elsewhere in the short to medium term.

Equally, the transfer of specialist staff and equipment from one hospital to another is always problematic and often results in poorer quality or less extensive provision for the patients during the transition period. I suggest that that would be another form of disruption and dislocation from which the children concerned should be protected.

For all those reasons, I believe that it would be wrong to go ahead with option 1 in the district health authority's document. In my view it would be far better for the regional health authority to endorse option 2 or something like it, as that would involve the rebuilding and modernisation of acute services for children at Queen Mary's hospital on its present site or, conceivably, on part of its present site and the concentration of all other acute services in the district at St. Helier, which would be consistent with the principle of centralisation.

That solution would be cheaper in capital costs and about the same as option 1 on revenue savings. It would enable Queen Mary's to continue as a specialist child services centre for the entire region and beyond. It would be more cost-effective than allowing the duplication or triplication of acute child services in quite a small geographic area. It would also be less likely to fall foul of planning difficulties than would some of the other proposals.

Above all, option 2 or something like it would be popular with the children, their parents, the nurses at Queen Mary's hospital, whom I know, as I have visited the hospital on many occasions during the time that I have had the honour to be a Member of Parliament, with the league of friends and with the general public in my constituency.

Therefore, I urge my hon. Friend the Under-Secretary to see that if the matter is referred to her Department the best decisions are taken in the interests of the children and all who care about them.

2.42 pm
The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I congratulate my hon. Friend the Member for Carshalton and Wallington (Mr. Forman) on his success in the ballot and I thank him for his kind personal comments. My hon. Friend has again shown the great dedication and care that he devotes to his constituents, and I am sure that they know what efforts he has put into securing good NHS services for them.

I pay tribute to a long-established centre that provides specialist services for children. Queen Mary's hospital in Carshalton has been a special children's hospital for more than 70 years and I have no doubt that in the early years of this century the same agonising went on about what sort of services should be provided, the location of the unit, whether the money could be raised, and so on. We are seeing what is almost a 70-year cycle.

I also join my hon. Friend in paying tribute to the marvellous caring work done by all the staff at the hospital. Their dedication and expertise must be given the praise that they deserve.

I start by picking up a comment made by my hon. Friend. This is not a closure, and we should not use the word "closure". It is a reprovision of services in, we hope, new facilities and possibly on a different site. If we do nothing, it is certain that sooner or later Queen Mary's hospital will fall down. Given the age of the buildings, that will probably be sooner rather than later.

We have an obligation not to close the hospital or to have a closure forced on us by the poor condition of the buildings, but to make adequate and timely planning and provision so that the services can continue into the next century in more modern facilities.

I understand that the fabric of the building at Queen Mary's is substandard and is giving some cause for concern. The heating, electrical and building services need renewal. The wards alone might cost about £8 million to upgrade and, even then, the district would be left with an old shell and an inappropriate collection of buildings. I understand that many involved, including the staff and the community health council, have recognised the need.

The changes for paediatric services are part of Merton and Sutton district health authority's strategy for acute hospital services. Like every other district health authority in the country, Merton and Sutton has had to draw up a strategy for its health services up to 1994. This must take account of demographic changes, the needs of priority groups such as the elderly, the mentally ill or mentally handicapped, and flows of patients into and out of the district. Unfortunately, Merton and Sutton are some way behind most other districts in finalising their plans for acute hospital services. The DHA endorsed the proposals only a month ago, and they were considered by the region, as my hon. Friend said, only two days ago.

The district has about 1,000 acute beds for a catchment population of just under 250,000. That is a lot of beds. The problem today lies in the fact that they are spread over five different sites. This is costly in terms of overheads, and it means that essential diagnostic and back-up facilities have to be spread thinly or are sometimes available not at the levels that are required. The district decided that it wants to concentrate acute services on three sites in future instead of five. They are St. Helier, the present DGH; Sutton in the south of the district; and Nelson in the north. They propose to make the Wilson hospital a specialist hospital for the elderly, and indeed expect to increase beds for acute geriatrics and rebuild the acute part of Queen Mary's hospital on the same site as St. Helier.

There are three components to the services at Queen Mary's. They are general paediatrics, child psychiatry and regional specialty surgery for children. The hospital now provides some services for children from neighbouring districts. Future needs for child psychiatry will depend on the results of the option appraisal which the regional health authority is conducting on its policy document. A policy review is being undertaken for the region as a whole on facilities for surgery for children—that is, paediatrics and neonates. It is not on general paediatrics.

The people of Merton and Sutton, and especially the children, enjoy a high level of health services. Waiting lists are among the shortest in the country, plenty of beds are available, and they are well staffed. This is partly due to the determined advocacy and great efforts of all concerned, including the efforts of my hon. Friend the Member for Carshalton and Wallington. But some factors suggest that there might be room for improving efficiency. For example, the turnover interval in paediatric beds—that is, the time when they are empty—is way above the national average. In fact, it is higher than the length of stay. Consequently, bed occupancy is about 59 per cent. at Queen Mary's and only 34 per cent. at St. Helier. The throughput of patients is low and the incidence of day cases is also low. There are nearly 200 beds at Queen Mary's. They are clearly not being used as they might be. This raises several questions. Either the beds are over-provided or the patients are not being counted,—they could be there but are not forming part of the hospital census—or the patients are not being served. Something needs to be tackled. Nurse staffing levels in Queen Mary's are nearly three times the national average, and they have much higher doctor-patient ratios than average. That might be because of good working conditions, high morale and so on, but the fact is that the health authority has to consider whether that pattern of service provision may be draining resources from elsewhere in the district, where they are also needed.

I understand that, at its meeting on 10 December, the regional health authority received the acute services strategy for 1986–94 from Merton and Sutton district health authority. After discussion, the region agreed to support the central principles of opton 1, that is moving the children's services to the St. Helier DGH site and providing adult acute services on fewer sites within the district. It was agreed that the officers of the region and district should undertake further detailed work on the feasibility of this option, in terms of most of the points that my hon. Friend raised such as revenue, capital, land resources, and so on, and make a further report.

Given that that is going on—I am sure that our comments will be taken into account—I shall answer the eight points that my hon. Friend made. He said that option 1 would not be cheapest in terms of capital cost. That is true, but the trouble is that none of them will be cheap. Option 1 would cost £20.5 million, option 2 £18.8 million, option 3 £19 million, and option 4 £19.6 million. None will be feasible unless the money can be found. Therefore, the difference between them is not great. My hon. Friend said that options 1 and 2 are approximately equal in terms of revenue.

Mr. Forman

Revenue savings.

Mrs. Currie

That is right. His statement is not strictly true. The revenue savings on option 1—if they are accurate—are about £2.79 million a year and on option 2 about 1.9 million a year. There is a difference of not quite £1 million, but it is still a fair amount.

My hon. Friend in his seventh question asked about land availability and option 2. It is worth pointing out that, if option 2 is pursued, it will mean the closure of three hospitals—Nelson, Wilson and Sutton. I have no doubt that that will mean at least three Adjournment debates on the subject. This will mean that even more land at St. Helier would be needed to take on board orthopaedic, psychiatric and geriatric facilities provided at those hospitals, and they tend to be land-hungry specialities. If there is a problem in getting land for some children's services at St. Helier now, there will be tremendous difficulty in getting even more land for those other services.

My hon. Friend's third point was that the cost-benefit analysis is not credible. In fact, he used terms such as "pseudo-scientific", "highly tendentious" and "subjective"—all of which may well be true, but we are not in a position to criticise the methodology of the exercise. It is for the district and regional health authorities to satisfy themselves about that. The options appraisal was carried out with oversight by the regional planning department. As I said, at a meeting on Wednesday, the authority asked the officers concerned to look again in depth at, among other matters, the revenue feasibility of the option.

My hon. Friend's fourth point was that policy seems to be to centralise acute services as far as the region and the DHSS are concerned but the district health authority is planning to disperse services on three sites. I mentioned that the district health authority is operating on five sites, so reducing them to three is a version of centralisation. It is worth pointing out that the Queen Mary's site is on green belt land. There might be some difficulty in abandoning its use entirely, simply because the site would not be of much capital value to the authority. I understand that it is not intended that all services should move from Queen Mary's.

The fifth point was about the duplication of paediatric services in adjoining districts. My hon. Friend suggested that we should have discouraged developments elsewhere—for example, at Mayday and Epsom general hospitals—to take advantage of Queen Mary's facilities. The trouble is that those district health authorities want their services and feel that it is in everyone's interest to have local paediatric services on their district general hospital sites. Croydon plans to provide all its paediatric services by 1 April. If we said that it should not open those facilities in order to maintain the service at Queen Mary's, I am sure that it would be outraged, and we would have another Adjournment debate on the subject. Queen Mary's hospital now has 199 beds. The occupancy of those beds, even now, is not much above 50 per cent. There is already a sign that perhaps some of the beds, even while the districts elsewhere are using them, are under less pressure than they might be. The problem, therefore, will get worse and the result will not be the one suggested.

My hon. Friend's sixth point was about feasibility and timing. That is under consideration. The feasibility of the district's option is now being considered in detail, and the availability of land, timing, revenue and planning permission, and so on form part of that discussion. As I understand it, there can be no question of Queen Mary's hospital being closed before alternative services are provided.

The district must now go back and discuss with the local planning authority whether it can obtain the land to rebuild St. Mary's on the St. Helier site. The borough of Sutton has specifically resisted extending the hospital into the borough's open space. It seems that there is a long way to go before the matter is resolved. If, or when, the site is made available, the health authority will have some detailed and time-consuming work to do on planning and preparing for the building work needed. The regional health authority has to find the cash to finance the scheme. In today's climate, with such a large-scale capital building programme in the NHS, I would not expect the plan for Queen Mary's hospital in Carshalton to come to fruition for many years. In case there is any question that the facilities at Queen Mary's would not be available, I must say that they will not be withdrawn unless and until better alternatives are available to the children of my hon. Friend's constituents. I am glad to make that statement categorically.

While I am glad to have had the opportunity to discuss the future of Queen Mary's hospital and to pay tribute to all concerned, I believe that we are jumping the gun by some time. If and when a proposal to close the buildings which at present house Queen Mary's hospital, goes ahead, the district health authority will have to carry out the normal consultation procedures, which are lengthy, specific and written into law. If the community health council objects to the plan, the proposal must come to the Secretary of State for a decision.

I can comment as freely as I have done because it is unlikely that I shall still be standing at the Dispatch Box in 1993. That is way in the future. The closure may happen in this current strategic period, that is by 1994, and it may not. Nevertheless, I know that my hon. Friend will find it helpful, in years to come, to have raised the question now and to have taken the chance to express to the House the depth of local views on the planned changes.

Question put and agreed to.

Adjourned accordingly at five minutes to Three o'clock.