HC Deb 18 November 1998 vol 319 cc1081-90

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

12.22 am
Mr. David Prior (North Norfolk)

I am pleased to have secured this vital debate on the future of intermediate care in north Norfolk. The issues raised will resonate in many other rural areas. I shall focus especially on the services provided by our community and cottage hospitals, which include rehabilitation. The deb0ate builds on my Rural and Community Hospitals Bill, which I presented to the House last May, but which fell because of lack of parliamentary time.

In July 1998, the East Norfolk health authority produced for consultation a draft strategy document on intermediate services. The consultation period finished in October and the final decisions are promised next week, on 25 November. I want to use the debate to highlight my great concern about the effects of the health authority's proposed strategy on my constituency. The strategy implies the closure of several hospitals and I hope to elicit the Government's support in preventing any such closures. I think that the views I express are cross-party views in Norfolk, and I am delighted to see the hon. Member for Norwich, North (Dr. Gibson) present in the Chamber at such a late hour, although I sadly note the absence of any Liberal Democrat Members.

There are four community hospitals in North Norfolk, covered by the shadow primary care group North Norfolk Health. They are Benjamin Court in Cromer, Cranmer House in Fakenham, Kelling hospital outside Holt and the Wells cottage hospital. In total, they provide 95 community beds, but the health authority proposes a staggering reduction in that number, to between 16 and 21 beds—a reduction of 80 per cent. Most incredibly, Benjamin Court is to be reduced from 36 beds to none. Benjamin Court, I should add, is almost brand new. That reduction, if implemented, would undermine the viability of Wells, Cranmer House and Benjamin Court. The most likely survivor is Kelling, for which the health authority suggest a much reduced requirement for 12 to 15 beds. That is ironic, because only two years ago Kelling was the hospital that the health authority was most determined to close. So much for consistency.

Are the health authority's forecasts for bed requirements right? Let us consider in contrast the views of North Norfolk Health, the primary care group. North Norfolk Health comprises 34 general practitioners in eight practices, covering 62,000 patients. Its assessment is that it needs not 16 to 21 beds, as the health authority suggests, but 65 to 75 beds. It believes that the health authority should do all it can to keep the cottage hospitals open in North Norfolk. North Norfolk Health's assessment calls for nearly five times the number of beds proposed by the health authority. In the case of Benjamin Court, North Norfolk Health see a minimum need of at least 23 beds, but the health authority see a demand for none.

Those discrepancies are massive and raise grave questions about the health authority's strategy. It is not good enough for the health authority to state: Further analysis work will be undertaken with local primary care groups at the implementation stage. It will be too late by then.

Because of the discrepancies, the health authority, in October, belatedly and after the end of the consultation exercise, felt obliged to have an independent review of bed requirements by a consultancy firm called RKW. One might feel that that was rather late in the day, rather rushed and somewhat less than satisfactory. Personally, I am wholly underwhelmed by the review, not least because it provided no figures for north Norfolk, only for Norfolk as a whole; yet north Norfolk is a special case and different, because it has more existing community hospitals, more elderly people and, because it is so rural, suffers from public transport problems.

RKW came up with a range of community bed requirements for Norfolk of between 176 and 234. The higher end of the range is some 50 beds more than proposed by the health authority. When RKW announced its findings, it was accompanied by a great flash of intellectual brilliance when a spokesman for the company said, with no obvious irony: We are not able to predict what will happen in the future. Quite. No one knows how many community beds will be needed in the future, and we do not need an expert to tell us that. It would be absurd to make any decisions based on the figures so far presented. If any of those figures are reliable, I would put my money on those from North Norfolk Health, because it is closer to the patients and their clinical requirements.

The shambles over community bed numbers is matched by that over rehabilitation bed numbers. The health authority proposes 124 rehabilitation beds for Norfolk, excluding Great Yarmouth. By contrast, the department for medicine for the elderly based at the Norfolk and Norwich hospital believes that 180 beds will be needed—some 56 more. Moreover, RKW has produced another set of numbers which is nearly 50 per cent. higher than the health authority's number, and much closer to the number suggested by the department of medicine for the elderly. The same uncertainty that surrounds community beds also surrounds rehabilitation beds. Which figures are right? Evidently, no real science is involved.

RKW believes that, overall for Norfolk, as many as 416 community and rehabilitation beds may be needed, whereas the health authority thinks that only 316 beds are needed. Decisions about the future of our hospitals must not be taken on the basis of such uncertainty, not least because such decisions are irreversible.

Moreover, a number of other hugely significant factors, some of which are peculiar to Norfolk, also militate against taking any major decision on the basis of the health authority's strategy. First, North Norfolk Health will cease to be a shadow primary care group on 1 April next year when it will come into real existence with real powers. As stated in the Government's 1997 White Paper, the primary care groups understand patient needs and they deliver local services. That is why they will be in the driving seat in shaping local services. North Norfolk Health has made it clear that it wants to retain the community hospitals, and to use their beds. It cannot be right that the health authority should, only four months before the PCG starts, pre-empt that view on such a critical issue. Secondly, the Minister will be aware that a new hospital is currently under construction to replace the Norfolk and Norwich hospital and the West Norwich hospital. The number of beds in the acute hospital will reduce from 1,037 to 809, a reduction of 228. There is already much local concern about that reduction, and it is aggravated by the suspicion that there is already pressure on the Norfolk and Norwich to discharge patients early to cut waiting lists. Many general practitioners in Norfolk talk openly about a revolving door syndrome, by which, to reduce waiting lists, patients are discharged from the acute Norfolk and Norwich hospital too early, only to be readmitted later.

With fewer beds in the new hospital, there will be added dangers of bed blocking and of rising waiting lists if there are too few community and rehabilitation beds. That concern has been highlighted both by Dr. Coni, a retired geriatrician from Addenbrooke's hospital, who has conducted independent clinical research on the health authority's behalf, and by the department of medicine for the elderly. In its submission to the health authority, that department said: The proposed reduction in rehab and community beds will lead to a large number of patients waiting in the acute hospital for intermediate care, which will in turn seriously affect the acute hospital's ability to meet its waiting list targets for elective surgery … Without adequate intermediate services the ability of the acute hospital to function effectively will be seriously compromised … Quite clearly the access to intermediate services in community hospitals is of crucial importance to the acute hospital. Too great a reduction in community hospital beds could undermine the effectiveness of the new hospital and increase waiting lists. That risk cannot be worth taking. We must have some insurance in the system.

Dr. Ian Gibson (Norwich, North)

Will the hon. Gentleman say something about alternative suggestions, and about the report into travel times from his constituency to the new facilities? Will there be a major problem with the travel facilities? Will he comment on the conditions in the new facilities?

Mr. Prior

Perhaps I can return to those points a little later.

The third factor I want to mention is the direct relationship between intermediate care and social services. Despite the eligibility criteria, it is right for patients to stay longer in hospital if there are no proper and adequate social services back-ups in the community. This year, Norfolk county council has had to reduce social service spending by more than £4 million, and a similar saving has been identified for next year. Until the Government are prepared to recognise the extra costs of delivering social services in rural areas and to an elderly population, the squeeze will continue.

The independent RKW research assumes that increased social service provision will reduce the need for 21 beds in Norfolk, and that a further 58 beds could be dispensed with because the length of stay in a bed will decrease. Both assumptions are highly suspect. My gut feeling is that, far from there being a reduction in the demand for beds, we may need to increase their number simply to compensate for fewer resources being available from social services.

The fourth factor is that the Secretary of State announced on 30 September a national inquiry into hospital beds because, as he said: It became clear last winter that in some parts of the country the scale of closures had gone too far. That inquiry is due to report next spring. It may produce useful methodology, guidelines, evidence and ideas. It should not be pre-empted.

Finally, in 1999, the royal commission on the long-term care of the elderly will report. It will have something to say about the eligibility criteria for NHS beds and about the overlap between the NHS and the private sector. It may even suggest ways—I hope it does—of attracting private money into supporting community hospitals. The royal commission's terms of reference specifically include considering the options for funding long-term care for elderly people in their own homes and other settings. That review, which will have taken two years of exhaustive research, also should not be pre-empted.

The confusion and uncertainty over bed numbers, the impossibility of seeing clearly into the future and the particular uncertainties facing Norfolk at this time argue strongly for no precipitate, radical change now; yet the health authority's strategy reveals that its goal is clearly revolutionary change. I shall quote a few extracts from that document, which will give a flavour of it. It says: This is a plan for change. It is a far-reaching plan … Change is needed … Older style community hospitals will close. The most hackneyed and meaningless soundbite of all says: We need to make some fundamental changes if we are to develop health services fit for the next millennium. That is cool Britannia-speak, not a cool, clinical assessment.

A further, overpowering reason against radical change is the public's overwhelming support for our community hospitals. Their support is based on their personal experience of the quality of care received by patients, relatives and friends and the fact that it is delivered locally, and it is manifested by massive voluntary financial support and a huge number of volunteer visitors.

The community hospitals are part of our local fabric in North Norfolk. We are not starting with a clean piece of paper, however much the health authority would like that. We are starting with a number of institutions that have attracted a great deal of good will over generations, perform a vital public service and have a committed, dedicated and professional staff. As Dr. Coni from Addenbrookes has said: Now is not the time to pull down the edifice; it is time to build on what is there. Dr. Coni is the clinician appointed by the health authority to give his clinical views after a lifetime in geriatrics.

That is also the view of the North Norfolk GPs and the department for medicine for the elderly at the Norfolk and Norwich hospital. There is no clinical case to support the closure of the community hospitals, quite the reverse. Now is absolutely the worst time to try to make any such decision. It would be a travesty if any such plans were approved.

Dr. Gibson

Did not Dr. Coni also say that the do-nothing option was not on?

Mr. Prior

I am not for one minute saying that we should do nothing—far from it. There is a strong case for specialist rehabilitation centres. I am particularly in favour of the rehabilitation centre at Cromer, and all the traffic analysis by the university of East Anglia, to which the hon. Gentleman referred earlier, suggests that Cromer is the right location. We should not rule out options for the future and we should not decide now to close community hospitals when the facts do not support those decisions. If the health authority comes to any such decision, I would ask the Secretary of State to review the decision and take evidence from the clinical experts, including the GPs, the experts in geriatrics at the Norfolk and Norwich, and Dr. Coni, and to give weight to the common sense of all those who use, work for and support our community hospitals. The health authority's plans for intermediate care in North Norfolk are not acceptable.

12.39 am
The Parliamentary Under-Secretary of State for Health (Mr. John Hutton)

I congratulate the hon. Member for North Norfolk (Mr. Prior) on securing time for this important debate. The hon. Gentleman has, quite properly, expressed his concerns about the future of intermediate health services in Norfolk. I shall respond to the specific issues that he has raised, but first I shall set out the current position.

East Norfolk health authority, as the hon. Gentleman said, is in the process of preparing its intermediate care strategy. There has been extensive consultation, but no decision will be made until 25 November, when the health authority meets in public. The final strategy will then be decided.

The first stage of the consultation finished on 13 October, and the health authority is now considering its outcome. There will need to be a further period of full consultation if there is to be any significant variation in services which might be necessary to implement the agreed strategy. No decision can or will be taken behind closed doors. The health authority has been particularly open in its debate on the draft strategy "Facing the Future". Indeed, I am aware that the hon. Gentleman congratulated the health authority on its open approach.

Already the health authority has received more than 1,400 responses, and about 3,000 people have attended the 12 public meetings to discuss the strategy. I understand that three public meetings were held in the hon. Gentleman's constituency at Cromer, Fakenham and Holt. Although he was unable to attend any of them, I am well aware of his concerns and his desire to protect the community hospitals in his constituency.

Community hospitals are an established part of the local health service and rightly enjoy a great deal of local support. I join the hon. Gentleman in paying tribute to all the staff in the community hospitals that he mentioned.

Intermediate care is a new way of organising those services that do not require the resources of a general hospital but are beyond the scope of the traditional primary care team. Intermediate care is a flexible concept, and the content of any intermediate care strategy will vary according to local need. It is about better ways of working and providing a seamless service for patients.

One of the factors that we need to consider is the role of intermediate care and other new models of care such as telemedicine in a modern NHS. There is a clear need to explore and evaluate those models of care and to share good practice right across the NHS. In recent years, we have made funds available through the continuing care challenge fund and winter pressures moneys to pilot this type of innovation within the service.

In the work that has been done in east Norfolk, intermediate care is defined as NHS community beds, rehabilitation and day treatment. The health authority's draft strategy for intermediate care identified an approach to determine the equitable provision of intermediate services in the future, and then it identified possible locations where services needed to be provided in order to respond to demand. It has also estimated the number of beds needed in each area.

The hon. Gentleman referred repeatedly to his concerns about those estimates. I know that others have expressed concern about the proposed number of beds. As he said, the health authority has commissioned independent research into that subject. The health authority strategy is now being reviewed in the light of the independent research, and a decision will be taken next week.

As has happened in other parts of the country, services have developed piecemeal over the years. I am sure that the hon. Gentleman would be the first to acknowledge that. The health authority is of the view that the current service provided does not reflect population changes and the immense progress in medicine, which has resulted in shorter stays in hospital. In its view, the present provision does not give fair access to community beds across the county.

As the hon. Gentleman said, there are seven community hospitals in East Norfolk—Kelling, St. Michael's in Aylsham, Wells, North Walsham, Dereham, Wayland in Attleborough and Northgate in Great Yarmouth, which deliver a range of NHS services. Four of those are in north Norfolk—Kelling, North Walsham, Wells and St. Michael's. The health authority considers that that current layout of community hospitals is not equitable and that many people have to travel outside their area for in-patient NHS treatment. My understanding is that the health authority strategy aims to provide a much fairer pattern of NHS community beds across the whole of east Norfolk. Of the 458 beds covered by the review, 207 are in north Norfolk.

Mr. Prior

I am not an expert on hospitals or medicine. I can only repeat the views of the clinicians who have worked in north Norfolk, the general practitioners who will form the new primary care group, the experts in geriatrics at Norfolk and Norwich hospital, and now the independent firm of research consultants. They have come up with requirement levels for north Norfolk that are vastly different from those of the health authority.

Mr. Hutton

I shall come to that issue in a moment. My understanding is that the health authority, having commissioned that independent research, is now reviewing its strategy in the light of it. It would be premature to speculate and try to predict the results of that reconsideration ahead of the meeting on 25 November.

As I have said, 1 understand that 458 beds are covered by the review. Some 207 are in north Norfolk, 173 are in south Norfolk, 48 are in the Great Yarmouth area, but only 30 are in Norwich—the largest centre of population in the county. Only 27 out of 86 GP practices in east Norfolk have direct access to GP beds. I understand that no Norwich-based GP can refer direct to a community bed. That need to provide an equitable, quality service is the driving force behind the health authority's strategy.

The draft strategy will consider a number of new facilities, including an NHS centre with community beds in Norwich, new rehabilitation units for Norwich and Cromer—to which the hon. Gentleman referred—and day treatment and therapy centres for Norwich, Cromer, Great Yarmouth and Diss or Thetford. In considering the future of the community hospitals, occupancy levels were also considered as part of the strategy review. In north Norfolk, they have not been high. Until recently, figures showed that, of those 458 beds, an average of only about 340 were occupied at any one time.

As I am sure the hon. Gentleman is aware, the Government are committed to providing the first-class national health service that the nation needs for the next millennium, which will provide the best possible balance and range of services for local people. We set out our plans for modernising the national health service in our White Paper last autumn. It is clear that hospitals will need to develop and evolve to meet the changing needs and expectations of the public and clinical advances. In some cases, that will mean building new hospitals; in others, it may mean closing old ones, changing their use, or using hospital facilities in new and different ways.

Hospitals and trusts will need to work more closely together and replace competition with co-operation and a renewed emphasis on improving quality, including national standards and clinical audit. As part of that modernisation programme, the Government have already approved 31 major hospital developments, worth almost £2.4 billion. That is the biggest renewal and modernisation programme in the history of the national health service. As the hon. Gentleman is no doubt aware, the largest private finance initiative health project yet agreed is the £214 million new hospital on the outskirts of Norwich that will serve much of north Norfolk and the hon. Gentleman's constituency. I am sure that he will want to welcome that major investment in the national health service in Norfolk.

The Government do not intend that hospital services will develop and evolve in a vacuum. New national service frameworks will provide a clear structure within which local hospital services should develop. In addition, as my right hon. Friend the Secretary of State for Health announced recently, we have set up a national beds inquiry to review the needs and best usage of hospital facilities—particularly beds—to provide clear and strategic direction for the NHS locally in planning and developing services.

The Government are committed to the NHS, and have pledged large sums of money, which shows that commitment. Only this week, my right hon. Friend the Minister of State, Department of Health announced £180 million of capital investment for the new Eastern region next year. Last week, we announced a cash increase of £22.9 million for East Norfolk in its allocation for next year—a real-terms increase of nearly 4 per cent.

I am surprised that the hon. Member for North Norfolk failed to refer to that, but he did mention what he thought were pressures on social services budgets. It may be of interest to him that, under the terms of the comprehensive spending review, we were also able to announce significant increases for social services over the next three years, amounting to £3 billion. In addition to all that extra cash, for this year £3.2 million has been pledged to help East Norfolk to tackle waiting lists and winter pressures.

On the role of community hospitals, our White Paper recognised that community hospitals have been sidelined too often in the past. Our aim is to provide a service which offers swift advice and treatment, as close to where people live as possible. Community hospitals will be an important part of delivering such services and may, in many cases, provide an appropriate setting for intermediate care services. They will, however, have to fit into plans for the wider health and social care systems—and meet the same quality standards and fairness and efficiency tests—as other parts of the health care system.

There is no single national blueprint which will suit different localities. That is why it is the job of health authorities to ensure that local services are matched to local needs. There is no doubt that community hospitals, in some form, will have a key role to play—where they are appropriate and can provide a safe, clinically effective and efficient service for their locality. It is right that the future of community hospitals in Norfolk, as elsewhere, should be decided on that basis.

Under our White Paper proposals, primary care groups and trusts will be a focus for better integrating primary and community care services. Clearly, they will have a role in delivering intermediate care services, but the health authority has a strategic role in examining the overall pattern and range of services.

We must take into account whether any change in local health services will improve care for patients, and that applies to community hospitals just as much as to any other part of health service provision. No part of health care stands alone: it is an interconnected system—between primary, community and acute services. How that is delivered will differ from one area to another.

Ministers can become involved only if a local community health council objects to any of the proposals. Until such time, we must remain objective and impartial. In its draft strategy, the health authority states that the quality of patient care matters most. It is also a matter of equity. Those are both tenets to which the Government clearly subscribe, and the Anglia and Oxford regional office—and, subsequently, the Eastern regional office—will be monitoring the situation to ensure that those considerations prevail.

If the matter is to come before Ministers—

The motion having been made after Ten o'clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at eight minutes to One o'clock.