HC Deb 20 March 1986 vol 94 cc510-6

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

10.1 pm

Mr. Jack Aspinwall (Wansdyke)

I am grateful for the opportunity to raise on the Adjournment the issues surrounding the proposal by the Bristol and Weston district health authority to close the Keynsham maternity unit.

I would first like to record my thanks to Doctors Tom Garrett, William House and Simon Lowe. I should also like to thank Michael Quinton, secretary of the Bristol community health council and its members, the Wansdyke district council and the 42 general practitioners in the Keynsham maternity unit catchment area who have given positive support. Thousands of people have signed petitions. I thank Mr. Leslie Baker, chief reporter of the local community campaign newspaper, the Keynsham Weekly Chronicle. Mrs. Pam Rocyn-Jones and Mrs. Andrea Hider have been hard-working in their campaign. I should also like to place on record my thanks to Malcolm and Christine Kempster, whom I met on Monday at their home. I also met baby Ellen, who was born at the Keynsham maternity hospital. The professional medical and administrative staff at Keynsham hospital have worked hard to keep a local, caring service.

It is the aim of Government to provide not only the most effective and cost-efficient system of health care but the most responsible. The Bristol and Weston district health authority's proposal to close Keynsham maternity unit negates all three aims. The closure was first proposed by the Bristol and Weston district health authority in September, 1985. In accordance with the appropriate Health Service circular, the Avon family practitioners' committee should have been invited to comment on such a proposal. It was not.

In view of this legal error, the Minister for Health rightly saw fit to defer consideration until the correct consultation process had been followed. The rectification of the error is now being pursued with the family practitioners committee, which firmly opposes the closure. The case is likely to return to the South-Western regional health authority in April. Due to this error a great deal of cost and loss of staff morale has occurred.

I feel obliged to inform the House of the misguided intentions of the Bristol and Weston district health authority. In 1985 total admissions to the Keynsham maternity unit numbered 667. This figure included 579 obstetric admissions and 88 convalescent cases. Of the 579 obstetric admissions, 434 were transfers in, for postnatal care and 113 were actual deliveries. The unit is used by the patients of the 40 GPs in the area and it is estimated, from the bookings made by 1 January, that there would be approximately 120 deliveries in 1986. This is consistent with the number of deliveries in the past four years, despite the uncertainty about the unit's future. Yet the Bristol and Weston district health authority says that the unit is underused. This is not the case. It can be argued that the unit is not reaching its full economic potential, but this is only because some GPs and consultants refuse to accept the change in medical and public opinion in favour of low technology births. There is also the uncertainty about the unit's future. The cost of the maternity unit has been based on it being an outpost of the Bristol maternity hospital and the cost per delivery has been distorted to some extent by that fact.

The cost per patient day at the Bristol maternity hospital is now about £120, whereas the cost per patient day for the whole of Keynsham hospital, including the maternity hospital is £50. If Keynsham were seen as a whole and regarded as a facility for the whole of Keynsham and the surrounding area, the cost for the maternity unit would appear in an entirely different light.

Keynsham maternity unit has a reputation for quality and progressive maternity care. In recent years, there has been new evidence showing that the GP-midwife team is as good as, if not better than, the specialist units. Although the setting and some of the issues are different, the Wendy Savage case is concentrating public and medical opinion on the issue of interventionist maternity care. This is practised by many consultant units, whether or not it is justified clinically or acceptable to most mothers.

A study of the Keynsham and Bristol maternity units undertaken by Doctors Garrett, House and Lowe showed that, for mothers selected as being of low risk and matched for the number of pregnancies they have had for social class, smoking habits, and so on, the perinatal outcome was the same. Intervention by doctors was significantly less in the Keynsham unit. Such intervention — for example, the augmentation of labour and foetal monitoring — is expensive and risky. Professional bodies, such as the British Medical Association, through the general medical services committee, and the Royal College of General Practitioners, now actively encourage GP obstetrics. I refer the House to the resolution approved at the annual general meeting of the Royal College of General Practitioners, which stated:

That in pursuance of quality, the Royal College of General Practitioners actively encourage those General Practitioners who wish to provide complete maternity services (including intrapartum care) in General Practitioner Units. The Royal College of Obstetricians and Gynaecologists implies an encouragement of GP obstetrics by insisting on the retention of standards and skills amongst practising GPs. Many papers have been published which suggest that, in cases selected at low risk, management is best given in GP units. A typical example is Marjorie Tew's article in the August 1985 edition of the journal of the Royal College of General Practitioners. Marjorie Tew is research statistician at Nottingham medical school. She has argued that, by the time of the 1970 national perinatal survey, the percentage of births taking place in consultant hospitals had increased by a third to 66 per cent., but the disparity between perinatal mortality rate there and in GP units had doubled since 1958 to become fivefold—for example the perinatal mortality rate in hospital was 27.8 per 1,000 compared to 5.4 per 1,000 in GP units.

It is clear that the trend of both medical and public opinion is back to "low technology" childbirth wherever possible. The Paulton maternity unit in the Bath district health authority is flourishing, with demand rising. The Keynsham maternity unit mothers' support group has made it clear that more women do not want "high technology" births, and, furthermore, do not want to go to the Bristol maternity unit. To close Keynsham would be to reduce the choice for expectant mothers. Moreover, it will reduce obstetric skills for GPs and once these have been removed, it is doubtful whether they will be recovered. Above all, in the light of new research and demands by mothers, it will be closing the door on what must be regarded as the way forward for maternity care. This is not the act of a responsible Health Service.

Financially, the Bristol and Weston district health authority hopes to save £68,400 with a net saving of about 11 staff. It is on this saving on which the Bristol and Weston district health authority and subsequently the South-Western regional health authority rests its case. That saving is unrealistic. The sum of £68,400 would be counterbalanced by additional expenditure at the Bristol maternity unit to which patients would be directed. In addition, supposed savings would be further lost on extra services to cover the hole left by the closure of Keynsham—for example, community midwives have to visit newly discharged mothers for the first 10 days. The Keynsham area consists of numerous outlying villages with a high mileage to travel for the midwife and further consequent expenditure. Moreover, given the initial delay with regard to the faulty consultation procedure, the hopes of the Bristol and Weston district health authority to be able to release £68,400 in the next financial year by closing the Keynsham maternity unit have already disappeared.

Although originally the Bristol and Weston district health authority made no proposals for the re-use of the space vacated by the maternity unit, which it should have done in the original consultation if the procedure had been properly followed, there is now a definite proposal for its re-use. That proposal is to move in the unit for the younger chronically sick—long-term physically handicapped—who are now accommodated in the inadequate Clara Jeffries unit in the hospital. That would be a short term measure until better long-term accommodation is created away from a hospital site in conjunction with specialist housing. Certainly, the Clara Jeffries unit is inadequate and new accommodation is needed, but the use of the maternity unit is not the answer. Another solution for the short term problem is the use of the Bristol General hospital, suggested by its managers, as a better short term solution.

Finally, to close Keynsham would not be practical. One has only to look at the geography of the area. If the Keynsham unit were to close expectant mothers would be forced to go to either Weston-super-Mare or central Bristol. The other nearest hospital the Royal United at Bath, is not in the Bristol and Weston district health authority region. Mr. Bamford, consultant gynaecologist at the Royal United hospital has said: the Obstetric services based at the Princess Anne Wing, Bath, have serious problems due to pressure on beds, Midwives and Medical Staff, these difficulties being more severe than in any other Maternity Unit in the Wessex Region. Inevitably, if the GP Maternity Unit at Keynsham is closed, some patients will look to Bath for intra-partum care and this will just not be possible. Quite apart from this consideration, it can be argued that it is positively detrimental to confine low-risk patients in high-technology units. I would, therefore, strongly support the campaign for retention of intra-partum facilities at Keynsham for low-risk patients. The sheer difficulty of travel to and from other hospitals, not only by expectant mothers but by husbands, friends and relations, would be costly and extremely inconvenient. It is precisely at such a time that a new mother needs the support, care and close contact of a family. With increasing pressure on Bristol, new mothers would surely be discharged too soon without the support structure they would get at Keynsham.

I have already pointed out the Keynsham area contains a number of outlying villages and districts. For those communities and the surrounding areas of Longwell Green, Bitton, Hanham Abbotts, Oldland and Brislington, maintenance of the Keynsham maternity unit is even more crucial.

The alternatives to closing Keynsham are plainly unrealistic. Expectant mothers have to go somewhere. Currently, it is the practice of the Bath district to discharge patients from the Royal United to Keynsham after 48 hours. The Bath district has indicated that if the Keynsham maternity unit were to close it would not be prepared to accept patients from Keynsham. Still further, patients from Bath would not have the opportunity to receive the support of post natal care provided by Keynsham. The Bristol maternity unit would have the problem of combining high throughput with a high technology practice required by high risk patients.

Mr. Michael Cocks (Bristol, South)

Will the hon. Gentleman press the Minister in his reply to answer the point that his constituents are simply the latest in a long line to suffer from the gross distortion in hospital services which has occurred in the Bristol area through the over concentration on the wholly unsuitable St. Michael's hill site, condemned in the Zachary Cope report in 1945 but rebuilt at the insistence of the university and the private consultants in Clifton? Will he stress to the Minister the importance of answering that point in the interests of everybody in the area?

Mr. Aspinwall

I am grateful for the intervention of the right hon. Gentleman. That is a vital point in my representations to the Secretary of State.

I feel very strongly that the problems of inadequae general practitioner cover for home confinement, the demand for which would inevitably increase if Keynsham were to close, and the proposal to close the Keynsham hospital maternity unit, would condemn my constituents to ineffective, inefficient and irresponsible health care. Local general practitioners, the family practitioners committee, the Bristol community health council, the mothers support group at Keynsham and I are fervently opposed to the Bristol and Weston district health authority's decision. To maintain the Keynsham maternity unit would meet the growing demand by mothers for choice and provide the general practitioner-midwife team with a location for obstetrics practice. It represents what must be the future and it would provide an integrated system of health care for the Bristol maternity unit. Moreover, it could give possibly the best cost-effective and efficient structure of health service.

I urge the Minister to ask the Secretary of State to withhold his consent for the proposals of the Bristol and Weston district health authority and the South-Western regional health authority in order to ensure that the excellent service that is provided by the Keynsham hospital maternity unit and its caring staff and local general practitioners remains.

10.16 pm
The Parliamentary Under-Secretary of State for Health and Social Security (Mr. Ray Whitney)

I congratulate my hon. Friend the Member for Wansdyke (Mr. Aspinwall) on his good fortune in securing this Adjournment debate. He is well known and recognised as a doughty fighter for all the services in his community. He has strongly and clearly represented to the House the very strong views that he holds about the future of the Keynsham hospital maternity unit. They are shared by the organisations to which he referred. The Government have very much welcomed the opportunity to hear my hon. Friend's views. The regional and district health authorities will take note of them, as will my right hon. Friend the Secretary of State for Social Services and I.

I shall address not only the Keynsham issue but also the wider context in which health authorities are having to plan the future pattern of their health services. I am particularly grateful and pleased that my hon. Friends the Members for Bristol, East (Mr. Sayeed) and for Westonsuper-Mare (Mr. Wiggin) and the right hon. Member for Bristol, South (Mr. Cocks) are in the Chamber this evening.

As my hon. Friend has said, the proposal by Bristol and Weston health authority is that deliveries and post-natal care at Keynsham should come to an end. My hon. Friend quoted a number of statistics. Perhaps I might in return be permitted to refer to a few myself, because undoubtedly there has been a continuing decline in the number of births at the unit: from 356 in 1976 to 188 in 1979, to 160 in 1980 and 1981 and to 116 in 1982, with a slight rise in 1983 to 123. Of these I understand that only 61 in 1983 were delivered to residents of Keynsham and the neighbouring district of Saltford. Indeed, of the 190 deliveries in 1983 to residents of these communities, 129 took place at other locations, including 60 at the Bristol maternity hospital and 11 at Southmead hospital. On average in 1983, occupancy of the 12 maternity beds was just under 50 per cent. In 1982, it was as low as 35 per cent.

These were trends which the district health authority felt it could not ignore. It was naturally concerned at the declining use of Keynsham, especially by local people. It was rightly concerned that the resources at its disposal should be used to the best possible effect. This is what we expect health authorities to do. The demand for health care and methods of delivering services are not static. There are demographic pressures and improved methods of treatment, including the development of care in the community. This means change and we expect health authorities to balance carefully all these aspects in determining the pattern of care that they wish to provide.

Since 1978–79 this Government have provided an extra 20 per cent. in real terms for hospital and community health services. In the coming year we expect to provide a further £650 million—or 6.7 per cent.—against an inflation forecast which is significantly lower than that, as my right hon. Friend the Chancellor of the Exchequer was able to underline when he spoke to the House on Tuesday. This represents a very significant increase in resources. This, together with the cash savings of £150 million which health authorities are planning to generate in the coming year, will enable all health authorities to implement a substantial expansion of services, but this will not absolve any health authority from the need to deliver services in the most effective manner.

In the south-western region the position is even brighter than in the country as a whole. A revenue increase in the coming year of 7 per cent. comes on top of above-average increases in every year since 1979. The fact that the Bristol and Weston district is relatively well provided for already means that under the region's RAWP formula—the process of Health Service resource allocation—it has received proportionately less than other authorities in the south-west. However, it too has received regular increases year by year which have enabled a number of important developments to take place. These include the brand new general hospital at Weston-super-Mare and the expansion of cardiac surgery at the Bristol Royal infirmary.

Mr. Jonathan Sayeed (Bristol, East)

I trust that my hon. Friend realises that under RAWP, because Bristol is a teaching area, it is losing out as the cost of equipment had increased faster than the provisions under RAWP. Secondly, it seems to me sad that births in Bristol should be concentrated on areas with high technology which is at the convenience of the consultants rather than lower technology which is in the interests of those giving birth.

Mr. Whitney

I recognise the point about the teaching areas. I hope that my hon. Friend will agree that there are pros and cons in having a teaching hospital in the area. I should not like to be drawn at present on the clinical merits on one form of treatment or another. I think that the Health Service is flexible enough to cater for all.

All that I have been saying in terms of the expansion of the services has to be set in the context of what the south-western region hopes to achieve in the next 10 years. The region has established a very praiseworthy objective of achieving a relative shift in resources from hospital-based provision to community care for priority groups such as the elderly, the mentally ill and the mentally handicapped. These developments should, as a whole, greatly improve health care in the south-west, but they cannot be brought about without some alterations to existing provision nor by avoiding the fact that resources which may be used none too effectively at present will need to be put to better use in the future. As part of this exercise, the region is currently reviewing its entire acute hospital provision to ensure it can meet changing demands in the most cost effective manner.

It was against this general background that the Bristol and Weston health authority made its proposal for the future use of Keynsham. As my hon. Friend has said, a change of use at this hospital would have consequences for services other than just maternity. The health authority intends to improve accommodation for physically disabled patients at Keynsham. Community clinic services, including ante-natal services, would be transferred into the main hospital and the separate clinic building would be used as a base for mental handicap support teams. There will also be an eight-place day hospital for the elderly. Therefore, whatever view one takes about the future of the maternity unit, or the way in which the health authority has presented it, it would be wholly wrong to think of the proposal as an entirely negative step.

We shall have to look very carefully at the arguments put forward by my hon. Friend about the particular type of maternity care that Keynsham provides, and to which my hon. Friend the Member for Bristol, East (Mr. Sayeed) referred, and also the social implications of any change, such as transport points and general accessibility to services. I understand that all the deliveries that currently take place at Keynsham could, if necessary, be accommodated at the Bristol maternity unit and that the proposal is not in fact dependent on any agreement by Bath health authority to take on some of the case load. There is also the community midwifery service. But obviously we shall want to examine the alternatives, and I shall bear in mind what my hon. Friend the Member for Wansdyke has said.

My hon. Friend will realise that I cannot comment formally on the arguments for or against retaining the maternity unit. Through the consultation process, the Bristol community health council has opposed the change of use an this means automatically that the final decision will rest with my right hon. Friend the Secretary of State for Social Services. At this point I must not pre-empt his decision.

As for the present position, my hon. Friend knows that the south-western regional health authority endorsed the Keynsham plans last September and forwarded them to my Department. My officials examined them carefully and were not satisfied that the consultation process had been followed to the letter. In particular, as my hon. Friend has said, the Avon family practitioner committee, which is now a statutory body, responsible to the Secretary of State, had not been consulted formally, although an attempt had been made to consult general practitioners through the local medical committee. This omission has been rectified and the family practitioner committee has now given its views. The district health authority is likely to consider its position at a meeting next month. If the authority still approves the change of use, the regional health authority intends to look at it again, probably in May, before it could come finally to the Secretary of State.

I should like to thank again my hon. Friend for expressing his views so clearly and forcefully. I assure him that my right hon. Friend will consider carefully the points made by him and by my hon. Friend the Member for Bristol, East before reaching a final decision.

Question put and agreed to.

Adjourned accordingly at twenty-five minutes past Ten o' clock.