HC Deb 30 November 2001 vol 375 cc1289-96

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

2.30 pm
Dr. Andrew Murrison (Westbury)

I am pleased to have secured the Adjournment debate on an important subject. I begin by declaring an interest. One of the salient features of my constituency is the presence of four excellent cottage hospitals, in Bradford-on-Avon, Trowbridge, Warminster and Westbury. I pay tribute to the vision of the people who built them and to those who work in them, staff and volunteers, past and present.

I look forward to many more fun-packed days with the Minister in Standing Committee A as we dissect the NHS Reform and Health Care Professions Bill. Whatever emerges, it will without doubt bring a profound realignment of health care institutions. I hope that primary care trusts, in so far as they are local and primary care driven, will embrace community hospitals, both in their traditional GP role and as ectopic derivatives of acute units.

In 1974 the Welsh Office produced a paper entitled "Community hospitals, their role and development in the NHS". Although written in a Welsh context, it was more widely applicable and it was the last structured examination of the place of community hospitals on record. I hope that the Minister might consider updating it.

The hon. Member for St. Ives (Andrew George) secured an Adjournment debate last week on what he described as small acute hospitals, but, with the lack of precision typical of his party, he failed to define his subject. From reading through Hansard, I think that he meant small district general hospitals. To avoid any confusion, I should say that I am using the working definition given by the Community Hospitals Association, 'which tells us that a community hospital provides medical care that is usually led by a GP. However, I am fond of the more evocative term "cottage hospital", and will use it interchangeably.

Overall, the number of community hospitals has probably not fallen greatly over the past 25 years, even if two out of three in Warminster have shut, and part of the remaining one is threatened with demolition in order to provide a car park. The surprising thing is that cottage hospitals have not yet truly blossomed. GPs like them, as do patients and carers, but the inherent centralising tendency of the health service has worked against them. The general public perceive that and are quick to mount a defence at the first indication of a threat.

The number of beds has reduced. Taken with the reduction in nursing home places—almost 50,000 since the peak of 1996, according to Lang and Buisson—that has led to bed blocking in acute units, a situation that is so bad in Wiltshire that my right hon. and hon. Friends in neighbouring constituencies were obliged to secure a debate on the subject earlier in the year.

I should emphasise that the obsession should not be with hospital beds or with indices of health care per se, but with health care itself—with clinical outcomes. Hospital beds, hospital facilities and hospitals themselves, however much cherished, are simply a means to an end. They stand or fall on their ability to provide health outcomes that are satisfactory to patients. If community hospitals have not flourished, have alternative means of delivering health care? I regret that that has not happened. The hospital-at-home scheme that many of my constituents were promised has not materialised. That and similar failings have been highlighted by community health councils—hard-working and generally effective bodies that will disappear under the NHS Reform and Health Care Professions Bill.

In my constituency in recent years, we have seen 24 elderly mentally infirm beds lost in the closure of ward 2 in Warminster. We have also seen a reduction in the number of GP beds in Westbury, a question mark put over the maternity unit in Trowbridge and the closure of the minor casualty department in Bradford-on-Avon. However, it is important to celebrate some positive developments: in particular, the advent of cataract surgery and the stroke rehabilitation unit at Westbury. I should like to give credit to the Minister for those developments, but I am sure that he would he the first to acknowledge that the driver has been the energy and enthusiasm of local health service managers and clinicians, supported by the local voluntary effort that is so important in the context of local hospitals.

Logically, that leads me to one of the salient features of community hospitals: local ownership. In a few cases, such ownership can be literal, as it is in the pioneering example of Odiham hospital in Hampshire. However, the bulk of community hospitals are within the NHS, charitable trusts, the voluntary sector or a mixture of all three. All of them tap rich seams of good will, not to mention money and the Trojan efforts of volunteers. While health economists struggle to put a price on those things, it is unlikely that the full extent of their worth is recognised.

Cottage hospitals are, like no other institutions, owned by the communities in which they exist. Several have been revitalised by new models of ownership following threats to close them down. The Memorial Care centre in Rye and Tetbury hospital in Gloucestershire are examples. Community hospitals offer potential for diversity and co-funding. Their closeness to the largely non-publicly funded hospice movement is clear. Yesterday evening, the Minister of State, Department of Health, the hon. Member for Redditch (Jacqui Smith), lauded the hospice movement as one of the great successes of the country's health services, but its success has, of course, largely been achieved in the voluntary sector and not the state sector. There are lessons to be learned from that.

Owing to difficulties in assimilating case mix, comparative costing in the NHS is a notoriously fraught science. However, studies suggest that about 20 per cent. of bed days could be provided more cost-effectively in community hospitals or community settings. We know that it costs £2,500 a week to keep somebody in an acute unit and about £;900 a week to keep somebody in a cottage hospital. One finds that the financial case is even stronger if one accepts the premise that, while acute units must operate as close to full occupancy as possible, there is still a need for give in the system. GP beds can provide a low-cost alternative, provided that occupancy is not, at its low level, deemed to be inefficient. More persuasive still is principle 3 in the NHS plan, which states: The NHS will shape its services around the needs and preferences of individual patients, their families and their carers. If that is not a ringing endorsement for community hospitals, I do not know what is.

Last year, the Community Hospitals Association and NHS Estates began work on a joint publication called "Models of Ownership for Community Hospitals". I am informed that Ministers shelved the publication before completion. I invite the Minister's comments on why that happened. Given the Government's stated desire for a pragmatic approach to the independent and voluntary sectors and the success of community hospital models that lie both inside and outside the NHS, I would have thought that the document was a most worthwhile exercise.

I welcome the emphasis placed on intermediate care in the NHS plan. I also welcome the notion of primary care networks that are supported by the NHS Confederation and others. Cottage hospitals would have a strong part to play in them. However, the position of community hospitals in the NHS plan is opaque, as is the destiny of the Government's £900 million for intermediate care for elderly people and the more recent £300 million for intermediate and social care.

Clarity would be welcome. We are told that the extra money will fund 6,700 intermediate care places. Where will they be located? I searched in vain in the NHS plan and the national service framework for elderly people for any specific mention of community hospitals. When they have cropped up, in debate or in parliamentary answers to written questions, including mine, the ministerial response has been lukewarm. It is not all the Minister's fault.

Community hospitals and small hospitals in general have not been helped by the centralising instincts of the medical royal colleges. The medical establishment has been good at dictating models of health care that are not necessarily the first choice of consumers. It is a classic case of the tail wagging the dog. A good example is the strange death of general practitioner surgery, partly due to the unhelpful attitude of the Royal College of Anaesthetists. Yet given the correct case mix, outcomes from GP surgery are at least as good as in acute units. Perhaps that was in the minds of those who drafted principle 8 of the NHS plan, which rightly demands: The health and social care system must be shaped around the needs of patients, not the other way round. That should be axiomatic.

Although the needs of patients and carers are paramount, we must be mindful of the attitudes and aspirations of staff who work in the health care system. Anecdotes suggest that community hospitals have less difficulty in recruiting than other parts of the NHS. When the maternity unit at Trowbridge hospital appeared to be under threat earlier this year, I pointed out that planners could not assume that staff would happily relocate to Bath. As we struggle to recruit and retain, we should bear it in mind that people choose to work in smaller units for a reason. They are often happy to work close to home, but would not be interested if they had to travel miles to work in a district general hospital.

Last week, the hon. Member for St. Ives spoke about small district general hospitals. The arguments for rationalising some of them are compelling. We cannot be blind to the need to secure cost-effectiveness, clinical standards, specialisation and postgraduate skills. Indeed, the logical extension of my argument is that a community hospital might be more appropriate in some areas than a small or sub-district general hospital.

I want to consider outcomes briefly. Care of the elderly in cottage hospitals must never be a means of denying appropriate access to acute units. Ageism should have no place in our health care system. People should be in cottage hospitals only in accordance with strict clinical protocols that are as rigorous as those that exist elsewhere. However, high quality should not be confused with high-tech. There is more than a grain of truth in the maxim that the greater the complexity and cost of an intervention, the less likely it is to add to the sum of human happiness. The outcomes of community hospitals will continue to be procured using relatively low-tech means, but that does not mean that they will have less value. The reverse is true.

A vision of community hospitals based solely on GP beds would be impoverished and outdated. A myriad services, therapeutic and diagnostic, can be as well provided in community hospitals as in large, remote and often inaccessible units. I happily cite the groundbreaking ophthalmic, stroke and maternity services in my constituency as evidence.

I should be grateful if the Minister provided an insight into the Department's vision for community hospitals, their outputs and how the voluntary and independent sectors might help in their development. I should be grateful if he would deal particularly with the care of the elderly and the elderly mentally infirm, especially those in rural areas, where there is a pressing need.

I gave the Minister advance notice, and he is aware of and will not be surprised by my special interest in the four community hospitals in my constituency.

2.44 pm
The Minister of State, Department of Health (Mr. John Hutton)

I welcome the opportunity to discuss these issues with the hon. Member for Westbury (Dr. Murrison), who has displayed his usual knowledge and grasp of all the subjects he raised.

I hope that the hon. Gentleman will agree with me on two issues. First, the community hospitals in his constituency perform a valuable role and enjoy strong local support. I join him in expressing my appreciation and thanks to the people who work in them, for the care and support that they provide to their patients. The hon. Gentleman raised the issue of investment, and the change that has taken place in community hospitals, saying that we should recognise the contribution that local staff had made to some service developments and improvements. Of course, it is important to give credit where it is due. In relation to the examples that the hon. Gentleman gave, it is the hard work and energy of local staff that always make a difference in the national health service, both in planning changes and in seeing them through. I pay tribute to the work and energy of local staff in securing those developments.

The job of the Government is to set the overall standards and framework in which those service enhancements and developments can take place, and, most importantly, to provide the additional resources that the NHS needs to facilitate those changes, which cannot happen unless the resources are made available, and they are now being made available at a level that the NHS has never witnessed in the 50 years since it was established in 1948.

The second point on which I hope the hon. Gentleman will agree is that no part of the NHS can ever stand still. It is right that we always ensure that the services we provide are of the highest quality and are capable of meeting the health care needs of the local population safely and in the most accessible way possible. That discipline applies, of course, to the future of community hospitals, cottage hospitals and smaller district general and acute hospitals—whatever terminology we use.

That is why I should make it clear that there are no plans to close any of the community hospitals in the hon. Gentleman's constituency, in Westbury, Bradford-on-Avon, Melksham, Trowbridge and Warminster.

Dr. Murrison

Melksham is not in my constituency.

Mr. Hutton

I am grateful to the hon. Gentleman for pointing that out. It must be very close to his constituency, but I was not trying to mislead him or other hon. Members.

The hon. Gentleman suggested that Warminster hospital was threatened with demolition to make way for a car park. My understanding is that there are no plans whatsoever to do so.

Dr. Murrison

My point was that part of the hospital is threatened with demolition to make way for a car park.

Mr. Hutton

I thank the hon. Gentleman for clarifying that. Perhaps it is a matter to which we can return.

There are no plans to close the hospitals that I have mentioned. They have served the hon. Gentleman's constituents well for many years and are a valuable local component of the NHS in west Wiltshire. On the contrary, the local West Wiltshire primary care trust, which is now responsible for the running of the hospitals, is strongly committed to their future, and is seeking further to develop the services that the hospitals provide. In a number of important areas, extra investment is being made in those hospitals.

Last year, a new nurse liaison service was introduced at Trowbridge hospital, to work across the other community hospitals to facilitate the discharge of patients from the Royal United hospital in Bath. As the hon. Gentleman mentioned, cataract surgery has been introduced within the last year at Westbury hospital—an important and welcome development—and this year the primary care trust will be spending nearly £;250,000 additional expenditure on day surgery at the hospital. Across the hospitals, staff numbers have increased over the last four years.

It is important for local health planners to try to strike the appropriate balance between the convenience of local services and the requirement to concentrate expertise for reasons of safety and quality. The hon. Gentleman referred to those problems as they apply right across the NHS in all parts of England, not just in his constituency. He made the important point—with which I strongly agree—that many needs can and should be met locally, close to home, by delivering care through networks of skilled providers working together, rather than in isolation. We must remain focused on that. I believe strongly that community hospitals have a positive contribution to make in that area. The hon. Gentleman suggested that the Government did not believe that community hospitals have a positive role to play in the future, so I certainly want to set the record straight on that.

The provision of comprehensive and accessible services of the highest quality free at the point of use lies at the heart of the national health service, its purpose, its ethos and its rationale. The Government remain strongly committed to the values that underpin the NHS. The NHS plan, from which the hon. Gentleman quoted, offers what I believe—I do not know whether he does—is a good, strong framework for ensuring that those values can be reflected in a modem setting. Medical technology is changing very quickly, advances in science occur almost daily and, crucially, public expectations have risen substantially in recent years.

If we are to succeed in meeting those needs, we will need a broad range of local, regional and national provision that guarantees the best possible access to the full spectrum of care services. If, in turn, we are to do that, we will need to make maximum use of community hospitals and primary care organisations for delivering and co-ordinating a local population's care.

At the same time, we recognise that certain complex services and staffing requirements need the scale found only in larger centres. I am sure that the hon. Gentleman accepts that, given his expertise and knowledge. Numerous international studies—I am sure he is aware of them and may have contributed to many of them—have shown that patients fare much better when their care providers have more experience and the support of specialised teams and equipment, which is usually concentrated in the larger medical centres.

Primary care trusts will play an increasingly important role in the national health service. The decisions, thinking and strategy that the hon. Gentleman was calling for will need to focus on the work of primary care trusts. They will have a much greater influence in developing local services, and will be better able to tailor those services to local needs. If that is to be achieved successfully, they will need to engage front-line staff, local communities and partners in the independent and the voluntary sectors—to which the hon. Gentleman quite properly referred and with which we are keen to develop further and stronger links—in their plans for improving health services. In their role as primarily local organisations, PCTs will bring about improvements in local services by engaging and involving local people, patients and staff.

I understand that Wiltshire health authority has drawn up a strategic framework within which all the primary care organisations are currently working and to which they are committed. One of the most important elements of the framework is that care should, when practical, be provided at home or as close to home as possible.

The hon. Gentleman quite properly referred to the work being done in Westbury hospital and the new dedicated stroke unit. I think, as I hope he does, that that provides tangible evidence that our approach is working in practice. Patients from west Wiltshire who suffer a stroke are taken to the Royal United hospital at Bath, but are then quickly visited by the stroke co-ordinator from Westbury, who assesses them. Patients are transferred to Westbury hospital when they are ready, where they receive an intensive course of rehabilitation. I am glad to say that, in the vast majority of cases, that enables them to return to their own homes as soon as possible, where they want to be and where they will continue to receive support as necessary from the multidisciplinary community support teams. That is a good and successful model.

The PCT is now considering how to make best use of the skills of staff and the facilities of the other community hospitals and the two clinics in the area to see how other specialist services can be organised to provide local care in west Wiltshire.

The hon. Gentleman referred to the need for a vision behind this work. I am glad to say that the vision that the PCT has for its local community is positive. It is to support and promote independence; to reduce social exclusion and provide services with equitable access; to provide better care and higher standards; to provide choice for people using services and their carers—I believe that choice is increasingly important as we consider the future of the NHS—to provide care at or closer to home; to provide a wide spectrum of care options; and to deliver services through integrated working unimpeded by organisational boundaries and supported by shared or joint budgets.

I meet people in my surgeries—perhaps the hon. Gentleman does, too—who feel frustrated when they come into contact with public services in this important area of the welfare society. They are bounced between social care and health care organisations, and we need to improve on that. It should be our job, in the context of public services—in this instance, care services—to make navigation of the system much easier than it is now.

I consider the "vision" aims of the local PCT laudable. I understand that the PCT has already conducted a review of services provided at community hospitals, and that during the coming year it will work with local organisations, patients and carers to develop services that meet the health needs of the people of west Wiltshire. That is right, because it is its primary responsibility.

I know that there are worries about possible changes in services, especially in rural areas, where travelling can present difficulties. Careful consideration must always be given to such concerns. I understand that the PCT already provides some transport, both between local hospitals and to the Royal United hospital in Bath. I am told that it will work closely with the county and district councils to improve the service.

I said at the outset that the right strategy for all these issues should be based on local solutions. It must be for the trusts concerned, working with all local agencies, to consider how that can best be achieved—with, of course, the involvement of local people: that should be at the forefront. The public have a right to be consulted on matters of this importance, as, after all, it is their national health service.

We are fundamentally committed to a system of patient and public involvement providing not only more support and representation for patients, but rigorous scrutiny powers for local government. The hon. Gentleman mentioned the abolition of community health councils in the NHS Reform and Health Care Professions Bill. We believe—we have engaged in these conversations before—that the present arrangements do not meet the exacting standards required, which is why we are strengthening the arrangements for patient and public involvement.

West Wiltshire PCT will engage fully with local people and other agencies in discussions on how services are provided. If the hon. Gentleman has any concerns about the process in future, he should bring them to my attention.

The hon. Gentleman mentioned intermediate care—the important standards that we have set in the national service framework, and our wish to expand that part of the national health service. I agree with him that community hospitals can make an important contribution to intermediate care. All too often older people, in particular—through no fault of their own—find themselves in accident and emergency departments or busy hospital wards and stay there much longer than they need to, because there is no real alternative. Alternatively, they are admitted to residential or nursing homes prematurely because of that lack of real alternatives. Intermediate care means providing such alternatives.

In the development of an intermediate care service, the need for different organisations to work together in partnership with the older person involved to maximise that person's health and well-being is paramount. We are making a substantial investment in resources for such care and in related services: an extra £405 million of NHS money will be earmarked by 2003–04. That has already allowed us to commission an additional 2,500 intermediate care beds this year, as a contribution to meeting the total requirement mentioned by the hon. Gentleman.

The hon. Gentleman referred to residential care homes. They give cause for concern, and the Government have been discussing the issues with the care home sector for some time. We are trying to make progress, and I think that the extra money for local authorities this winter, and next year as well—£300 million—will make a substantial contribution. Moreover, Wiltshire county council will receive more than £700,000 this year to enable it to speed up the handling of problems relating to discharge.

Dr. Murrison

I asked specifically where the 6,700 intermediate care places would be located.

Mr. Hutton

We made that clear in the plan, but I can send the hon. Gentleman details of where the additional beds are. They will be in a variety of locations: some will be provided by the NHS, while others will be commissioned in a process of collaboration with the private independent and voluntary sector. Such services have historically been commissioned in that way, certainly when local authorities have been involved: the bulk of the expertise has come from the independent and voluntary sector.

As we have always made clear, we feel that identifying precisely where the extra intermediate care beds will be provided—whether they will be in the NHS sector, or in the independent and voluntary sector—would be a mistake. The process will involve a commissioning exercise, and flexibility is needed. The location of spare capacity, and the speed with which it can be used, will depend on local circumstances.

As always on these occasions, time does not permit me to say all I would like to say. Let me end on what I hope is a positive note. I share the hon. Gentleman's enthusiasm for, and commitment to, community hospitals, as he described them. As I have tried to convey to the House, the Government believe that they will play an important role in a number of key areas affecting the future of the NHS, and I hope that that will benefit the hon. Gentleman's constituents.

Question put and agreed to.

Adjourned accordingly at Three o'clock.