§ Motion made, and Question proposed, That this House do now adjourn—[Mr. Alan Howarth.]
§ 2.3 am
§ Mr. Roger Knapman (Stroud)My interest in the subject of community hospitals has been stimulated by the proposals of the Gloucester health authority, which seeks to close the Berkeley and Tetbury hospitals in my constituency. Those are hospitals that are greatly valued by the communities which they serve. The communities have responded generously, both to the modernisation and the upkeep of those hospitals, largely through the sterling efforts of the leagues of friends. Moreover, the communities were originally given these hospitals by local benefactors in the last century, although it would seem that, with a piece of Socialist spite, the property was confiscated from them in 1948.
The level of public concern for these hospitals is shown by the fact that at recent public meetings protesting against their closure about 1,000 people attended the Tetbury and over 600 turned up at Berkeley. The purpose of this debate is not to criticise the Gloucester health authority, which is one of the best in the country, but rather to challenge the basis on which the assessments of the working party which was set up by that health authority were made.
I appreciate that if I dwell solely on constituency matters I shall receive virtually the standard response from the Minister, which is that small community hospitals make an important contribution to the NHS but that it is for individual health authorities to determine the appropriate pattern of district services. In doing so, they will balance the benefits of community alongside those of larger district hospitals in the light of changing circumstances so as to secure from the available resources the best possible value and level of service provision for all the local communities that they serve.
I have seen that answer on a number of occasions, but I hope tonight to hear a little more, and I respectfully suggest to the Minister that the Government should have a policy towards community hospitals beyond the bland statement that they make an important contribution to the NHS, because some are under the threat of closure or have closed for reasons which give cause for concern.
The role of community hospitals was perhaps best defined by Dr. Rou in the Health Service Journal dated 26 February 1987, when he said that
patients suitable for admission to the community hospital may broadly be described as patients who, while requiring hospital care because they cannot be managed at home, do not require the facilities of a district general hospital or the services of a specialist team.Indeed, the working party of the Gloucester health authority paid a generous tribute to the work of the community hospitals before proposing their closure. Can anybody suggest that there is any reduced demand for their services? Elderly people should not have to travel upwards of 20 miles for treatment that they could receive locally. In particular, the terminally ill must prefer to spend their final months or weeks in their own localities where their friends and families, and the vicar, can visit them and the doctor they know can treat them.Can the Minister confirm that the NHS reforms that are currently being instituted—and should be pursued—include the belief that the NHS should be more 1065 consumer-orientated? If so, the protection of community hospitals should have top priority, for the reasons I have outlined.
But it is not just in Gloucestershire that such concerns exist. The Association of General Practitioner Hospitals considers that there are about 400 general practitioner hospitals in Britain but would like to see that number increased to between 1,000 and 1,500. Yet fears have been expressed about the closure of such hospitals. They are indeed tempting targets, likely to be thought of as peripheral to those who believe that they can spend the money in a more effective way.
We are realistic enough to realise that the roles of community hospitals are not set in tablets of stone and that many operations are exceedingly complicated and can be carried out only at the district general hospitals with, among other things, modern anaesthetic equipment. So, seen from the eyes of a health authority, such proposals can make sense; it is much easier for it to conduct its business under one roof and centralise its activities in one district general hospital.
It was reported in the General Practitioner dated 5 February 1988:
In hospitals which use nurses to work in theatre, in casualty and on the wards, a drop in operations can quickly make it easy for the district to cut staff, argue the theatre is not viable and ultimately the whole hospital is not cost-effective.I would say that that summary entirely fits the pattern that has occurred in my constituency. Such proposals are directly contradictory to the views expressed in the DHSS report "The Way Forward", admittedly now some 11 years old, and more recently "Towards good practices in small hospitals" by Dr. Charles Shaw. The reason for this is best illustrated by the background paper "Community Care", which is available in the House of Commons Library. On page 3 of this paper it is shown that the principal agencies involved in community care are social security, health, social services, housing, the voluntary sector and the private sector.Does my hon. Friend agree that all those parties are concerned with health provision, including the care of the elderly? The reality is that if the health authorities are able to close community hospitals many of their elderly or geriatric patients will then be looked after and paid for by other services, and this is the crux of the matter. Health authorities have a duty to manage their budgets in the most efficient manner, but do they take into account the effect on other agencies, such as the Department of Social Security? The inescapable truth is that they do not. Therefore, the right answer for the health authority is often the wrong one for others affected—wrong for the taxpayer, wrong for other providers of health care and, above all, wrong for the people in the locality concerned.
Community care and community hospitals are inextricably linked. In most areas we have an aging population, some of whom require regular treatment, and they should not be required to travel long distances to obtain that treatment.
Can my hon. Friend confirm that the cost of care in community hospitals is about 60 per cent. of that in district general hospitals? That seems to be the experience in Finland, where I believe a study has been made. It is also estimated that 40 per cent. of all operations could be undertaken at community hospitals. Do the health 1066 authorities have the flexibility to analyse these matters and use the community hospitals more frequently, thereby taking pressure off the district general hospitals? What is our policy towards community care? Surely our response to the Griffiths report should be known before any more community hospitals are closed.
Towns with community hospitals are often treated like a pampered minority. But I suggest that in rural areas community hospitals are a natural and necessary focal point for medical care and community care in that district. Of course, economies can be made. In too many towns we have the doctors' surgeries in one street, provision for elderly people in another and the community hospital elsewhere—in other words, scattered all round the town and all the premises requiring staff round the clock. Sheer common sense dictates that huge savings could be made by concentrating these on one site wherever possible.
In conclusion, can my hon. Friend confirm two main points? The first is that no more closures of community health hospitals will be made before our response to the Griffiths report is known—I gather this may be known soon. The second, and perhaps most important, is that when health authorities justify such closures by savings —I suggest often illusory savings—these figures will be considered only in the context of overall health provision and the financial effects on other providers of health care will be considered.
A former permanent secretary remarked:
If you are not confused about community care and community hospitals it shows you are not thinking clearly.I feel confident that my hon. Friend will help to lift the fog.
§ Mr. Christopher Gill (Ludlow)I rise to support my hon. Friend the Member for Stroud (Mr. Knapman) because I have similar constituency interests. I have small hospitals in my constituency. I wish to take this opportunity to remind the Minister of the enormous fund of goodwill that exists in rural areas for these small hospitals. My hon. Friend has drawn attention to the fact that, in the main, they are generously supported by leagues of hospital friends. In an earlier debate this week we were reminded that this nation is very charitable and the hospitals in our community have, on many occasions, been the beneficiaries of the charity for which the British people are renowned.
In my constituency—I am sure that this also applies in other constituencies—small hospitals are a focal point of community life and we should not underestimate their importance. In the countryside there is a sense of community and belonging which has long since been lost in many of our towns and cities and will not easily be regained.
I endorse all that my hon. Friend has said about the low cost of these hospitals. He suggested that they may be up to 40 per cent. cheaper than the bigger ones. They are certainly more homely, which is an important feature for their patients, and they are also more compassionate. They are capable of dealing with minor accidents, convalescent cases, patients needing respite care and—as my hon. Friend has mentioned—the terminally ill. They play an important and vital role in our community.
If these hospitals are allowed to close they will never be replaced and their demise would be the loss of an 1067 inestimable asset. We should consider this matter carefully and not leave any stone unturned in our efforts to keep them open.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)I congratulate my hon. Friend the Member for Stroud (Mr. Knapman) on securing time for a debate on the future of community hospitals. I also listened with great interest to the contribution of my hon. Friend the Member for Ludlow (Mr. Gill). I know of his strong constituency interests in community hospitals. I also noted the interest of my right hon. Friend the Member for Northavon (Mr. Cope), in whose constituency Berkeley hospital fell prior to the last boundary changes.
In opening the debate, my hon. Friend the Member for Stroud asked me to spell out Government policy on community hospitals and this is an excellent opportunity to do so. He will not expect me to make a specific statement about the two hospitals in his constituency, for reasons which I will outline later. Not only for the record, but for the purposes of this brief debate, I shall outline Government thinking on the role and importance of these hospitals.
Ministers have said on a number of occasions that small, non-specialised hospitals have a valuable role to play in providing a limited range of services, if that is what is needed locally. Local needs and wishes, the health authorities' assessment of them, and their own priorities will decide the future for each community hospital. Health authorities must ask themselves: is the hospital popular with the local community? Is its current function appropriate to today's circumstances? Is it cost-effective? Before any decisions are made the pros and cons of small community hospitals must be considered.
The advantages, as I see them, are as follows. First, relationships with local people and primary care services are easier where the hospital is seen as part of the local community being served. If it is serving geriatric patients, that means that they are able to stay in their local community. Secondly, recruitment of some categories of non-medical staff may be easier. They do not usually have to travel far to work and they soon become familiar with the hospital, the services it provides and staff already working there. Thirdly, not all in-patients will need the full range of investigation and treatment available in larger hospitals. Fourthly, journeys and access will be easier for relatives and friends as well as for patients. Fifthly, such hospitals encourage local voluntary support—and I very much agree with what both my hon. Friends have said on that score. Sixthly, communications between management and staff are less complex. Finally, GP beds can provide continuity of care directly from the GP's surgery to the hospital. I should explain that a GP bed is not under the control of a consultant, and that the GP usually provides the medical care.
However, some disadvantages should be borne in mind. First, small hospitals will not have the full range of diagnostic equipment and specialised treatment that may be required if complications develop, meaning that patients may have to be moved elsewhere. That is particularly true of maternity, in which regard I have a continuing responsibility to reduce the level of infant post-natal mortality. It is undeniable that the larger 1068 district general hospitals have a better range of facilities to resuscitate infants born with complications than some of the smaller community hospitals.
Secondly, there may be uneconomic duplications of services and specialised staff on a number of different sites. Thirdly, they may not provide all the experience and variety of training that nursing staff require. Fourthly, they may not provide all the experience that junior medical staff require as part of their training, leading to the royal college's withdrawal of training recognition of posts and consequent medical staff shortages. Junior doctors may also be required to work very long hours to provide cover because they do not have the benefit of the size of staff of a large acute hospital.
Staff costs are higher where there is travel between two or more sites because medical and other specialised staff are on site only part-time. That could result in a reduction of quality in clinical services. Finally, there is the risk that staff may become professionally isolated and inward-looking.
Of course, not all those factors will apply in any particular case: each proposed new community hospital or proposed closure of an existing hospital must be considered on its merits. It therefore seems to me that the trend, which undeniably exists, away from small hospitals for acute in-patient care—I stress the word "acute"—will continue, except for the following clinical purposes. My hon. Friends may agree with this.
First—I am now referring to categories of care that it is appropriate to provide in smaller community hospitals —there is minor surgical and medical treatment not requiring sophisticated supporting services, which can often take place under GP supervision. Secondly, there are day surgery facilities—although again day surgery is not for the inexperienced, and difficulties may be caused by the lack of sophisticated back-up facilities. Thirdly, there is the possibility of some long-stay geriatric provision. In general, however, geriatric acute care should be based at the district general hospital, although I agree with my hon. Friend that for non-acute geriatric care there is an almost overwhelming case for including the local community hospital. Fourthly, there is recuperation and rehabilitation nearer home following major surgery at the district hospital, thus releasing beds in the hospital and reducing lengths of in-patient stay there.
Small hospitals may contribute to the health care of the elderly in three ways: through rehabilitation, continuing care and "respite" care. For patients who do not need the full range of medical services, small hospitals away from the district general hospital site may offer a quieter, less formalised environment and easier travelling for both patient and visitors—who may themselves be elderly. For rehabilitation units, small hospitals can provide a base for the various remedial therapy services.
Many patients in long-stay care essentially need nursing but not specialist medical care. Given that their long-stay bed effectively becomes their home until they die, health authorities are urged to provide this service in a homely setting rather than within the rigidities of a hospital ward. The beds may be provided in a private nursing home under a contractual arrangement, in a nursing home within the National Health Service or in a small hospital, depending on what is appropriate to meet the needs of the patient, and the relative cost advantages.
Small local hospitals no longer needed for other services may be suitable for adaptation to services for the 1069 elderly. I very much agree with my hon. Friend the Member for Stroud that small hospitals can provide those services. I also agree that we should not isolate expenditure on community hospitals from that on primary care—that is care provided by the doctor—social services or social security payments.
Indeed, the essence of good care for elderly people is frequently a continuation of support from all those services. The Griffiths report is, of course, mainly concerned with care in the community rather than in hospital. My hon. Friend is well aware that we are actively engaged in working up our own proposals and hope to be in a position to bring forward our plans in the near future. I cannot give my hon. Friend the assurance he seeks that there should be a moratorium on closures of any community hospital, but I can say that we shall take into account the wider aspects of community care in any decision on an appeal against closure which comes to Ministers and I hope that my hon. Friend will be satisfied with that assurance.
Turning to the procedures that are normally followed in any proposed hospital closure, district health authorities should consult widely where changes are being proposed to the local pattern of hospital provision and services. GPs, other health interests and professionals, the community health council, local authorities and voluntary bodies should be included. They will need to take into 1070 account not only the age and suitability of the buildings concerned, but also costs of repair and adaptation, future running costs, local patterns of travel and employment, likely availability of suitable trained staff, including medical and nursing recognition for training by the royal colleges, and existing links between the hospital and its local community, including links with local voluntary bodies. Any proposals for closure or significant changes in services provided which have been objected to by a community health council must be decided upon by Ministers.
Earlier in my remarks, I set out the criteria that we believe are relevant in considering the value of local community hospitals, and I hope that district health authorities will bear them in mind during the consultation process.
In the south-west, the regional health authority sees a vital role for its community hospitals which are so important, especially in rural areas. The regional health authority has, however, asked districts to review the effectiveness of their smaller hospitals, and that is a perfectly appropriate request. As my hon. Friend knows, I cannot comment on individual closure plans unless and until they are appealed to Ministers. However, in conclusion, I can say that we shall always treat any appeal carefully and after proper regard for all representations made.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-eight minutes past Two o'clock.