Community Hospitals (Oxfordshire) (Hansard, 23 April 2004)

§ Dr. Evan Harris (Oxford, West and Abingdon)
I am pleased to have the opportunity to debate the important topic of community hospitals in south Oxfordshire, and I am grateful to the House for giving me the opportunity as a relatively late substitution for the original business set out on the Order Paper before the recess. I am particularly pleased to see that the Minister of State, Department of Health, the hon. Member for Doncaster, Central (Ms Winterton), will respond to the debate. It makes a change for us to be discussing community hospitals on this occasion, rather than aspects, gruesome or otherwise, of human organs, which we have been dealing with in the Committee considering the Human Tissue Bill.
I draw the attention of the House to proposals from the South East Oxfordshire and South West Oxfordshire primary care trusts in a pre-consultation to reduce beds and close community hospitals in the south of Oxfordshire. The proposal could affect beds in six hospitals—Witney in the west, Henley in the east, Didcot, Wantage and Wallingford hospitals towards the south and, in my constituency, Abingdon community hospital in the middle of the south of Oxfordshire.
There is strong support for the stance that I have taken in a cross-party campaign in which people from all parties have been represented, as well as people with no strong political views. I express my gratitude for the support that the campaign has had from the hon. Members for Henley (Mr. Johnson), for Witney (Mr. Cameron) and for Wantage (Mr. Jackson). The hon. Member for Wantage has three hospitals that could be closed under the proposals and is therefore particularly badly affected.
In the debate, I shall highlight significant flaws in the proposals set out in the pre-consultation document and raise concerns with the Minister about the fact that such a substantial reduction in community hospital beds, with or without an increase in domiciliary care, would not benefit the Oxfordshire health economy as a whole. We must bear it in mind that the Oxfordshire health economy is in deep trouble financially and in terms of meeting the activity targets that the Government set. Many of those targets are inappropriate and distort clinical priorities, but if the Government use them to measure how well the health economy is doing, they will see that they are being met—where they are being met—only at the expense of significant overspends and enormous pressures in the system. Areas not covered by targets and the need to report are left to wither and be starved of resources.
The health economy is facing significant challenges from the cost of implementing the GP contract and, in the acute trusts, the cost of implementing and backdating the consultant contract, because it appears that the costings for that were based on a smaller number of sessions than the average in a large teaching hospital such as the Oxford Radcliffe, where it should have been predicted that the management would find that consultant staff were working harder than management thought their contracts required. In addition, there are significant pressures to meet national service framework targets, which are some of the more rational targets, and the requirements to fund National Institute for Clinical Excellence guidance for new drugs.
611 The Government say that there is significant growth in the budget this year—and there is—and in future years. That is something that I voted for, and which the Liberal Democrats recommended before the election rather than simply coming up with after the election. But despite that, I have been told by all sides of the Oxfordshire health economy that the cost pressures that they face, even restricting themselves to what they call the "mustdos"—the things that they have to do, not things that they want to do—come to more than the growth in the budget. That is why many of us suspect that the move to reduce the number of community hospital beds, and as a consequence of that to close hospitals, is financially driven.
One of the problems with the consultation process has been that it is opaque on whether there is a financial motivation behind it. If there is a financial motivation, so be it, because the priorities of the health economy must be juggled, and it may be felt that it is not a false economy to reduce community hospital beds and to seek to reinvest that money in some of the must-do areas that I have described. But at the public meetings there has been a big inconsistency about whether it is financially driven or whether the idea is to close community hospitals and cut community hospital beds for the benefit of patients. That is hard to understand, but it is defended on the basis that those resources can be switched to providing increased domiciliary care, and I shall come on to the problem with that in a moment.
If we look at the numbers that the primary care trusts in the south-east and south-west use in their south locality plan, there are real problems with even the basic assumptions. First, it is hard to find out what sort of numbers there are overall to start with, because two different figures are given in the document. In the table on page 6, 192 beds are defined as open, and then there is a proposal to reduce that overall to a total of 153, but on page 14 in the table of options at the back, which has a range of 11 options detailing various hospital closures, it suggests that there are 228 beds, of which 24 are closed. That gives a different basic start figure. Whether one includes or excludes the 15 separate beds at Townlands hospital in Henley, they still do not round down. It is worrying to people reading the document that the basis of the research behind it seems so poor that it is not clear that the people proposing this know how many beds there are in total.
Then there are other concerns about the calculations that have been made on the need for beds. First, the beds required to cater for population growth are deemed to be an additional five on the basis of a population growth between 2001 and 2005 of 1.26 per cent. Very graciously, the authors of the document round that up to 3 per cent. because of an increase in elderly patients in particular, but we must ask why, in 2004, for a proposal that might happen in 2005, we are basing our bed numbers on a projection up to 2005. If this is really a long-term proposal, surely it is rational to go beyond 2005, even if one accepts the figures—many people recognise that there is, and will be much more significant population growth than that, including among the elderly.
There is a proposal that beds be reduced by five through a transfer of respite care—that is, people who currently receive free NHS care on a respite basis being 612 forced into social services care where they will be means-tested. It says that there will be a separate consultation, and when I saw that I thought, "Quite right, so there should be." Then we find that, despite those words, there is to be no separate consultation. I question whether it is a lawful act to reprovide that service through social services without proper consultation of those involved, when one is proposing permanently to withdraw their care.
An analysis has been done through the Jonah project, which suggests that the length of stay for patients in community hospitals can be reduced through better discharge planning—I certainly accept that—and that beds can be reduced by 25. One would like to see the detail behind that, hut it was not available online. Nevertheless, if one accepts that throughput can be increased in such a way—I do not necessarily deny that that is the case—one must recognise that the same will apply in the acute sector. Increased throughput in the acute sector will mean increased demands on the community hospital sector and other forms of intermediate care. The idea that the health economy should implement faster throughput only in the community hospitals when, if anything, there are greater efficiency gains to be made in the acute sector is wrong, but there is no area in which that is factored in.
There is a question about the findings of the balance of care project, which looked at where people should be at any given time. In its snapshot calculations, it recognised that 21 more beds would be needed, because so many people in the acute trust and the Oxford Radcliffe hospital could be better cared for in the community hospitals and other settings. That is certainly true, but I imagine that, to anyone coming to the matter anew, the two obvious empirical factors in terms of the total number of beds needed would be the occupancy level of the existing beds, which would demonstrate whether there was spare capacity, and the waiting list for those beds.
Those are two reasonable measures of whether current capacity is adequate, and they should be considered before deciding whether it can be slashed by 40 or 50 beds from a total of about 200, but, strangely, the document contains no data on occupancy levels, which prompts the question "Why?". I think that the reason is that such data would show that occupancy is almost 100 per cent. If occupancy were running at 70 per cent. or even 80 per cent., which is not far from the maximum optimal level in terms of ensuring that beds are available—beds are often wanted in surges from the Oxford Radcliffe hospital—one could understand the rationalisation. However, there is not 70 per cent. occupancy. One might understand rationalisation and the need for good use of resources in such circumstances, and I am not arguing in principle against any reprovision of services or cuts. However, a snapshot that I asked for, dated 9 March, shows that, of the total of about 213 beds in the six hospitals that we are talking about, out of the 185 or 190 beds in use—about 24 beds were closed at the time when the information was obtained—only six beds were available. One does not need to be an advanced-level mathematician to recognise that that is near maximum occupancy.
I put it to the Minister that there should be no question of closing beds until it can be demonstrated that there is spare capacity, especially in respect of the 613 waiting lists. The Oxford Radcliffe hospital is under huge pressure, partly because of delayed discharges. Asking the hospital for its figures shows that, despite the fining arrangements that the Government have introduced, which were controversial enough, there were still 140 delays in the week starting 12 February 2004, for example. The figure was 160 for a similar week in January, so I am not simply choosing a particularly high figure.
If one looks at the reasons for delayed discharge—clearly, not all the patients are waiting to go into community hospitals—for the Oxford Radcliffe hospital, which is the main acute hospital in the area, one sees that by far the largest reason for delayed discharge is further non-acute NHS care. Some 62 out of the 141 delayed discharges for the week ending 12 February 2004 were for further non-acute NHS care, which will generally be provided in community hospitals. When we ask the PCTs about the matter, they do not deny that there is a waiting list, and it is clear that the waits are not mainly for community hospitals in the north of the county, where there have historically been fewer community hospital beds. There are still significant numbers from the south-west and south-east areas. Indeed, the smallest number is for the north-east. Arguably, the catchment areas for four of the six hospitals are within the South West Oxfordshire PCT, whose residents have significantly greater waits for community hospitals than for hospitals in the south-east. More figures are available, but I hope that the Minister gets the picture.
The case has not been made for a reduction in bed numbers, and the onus should be on the PCT to demonstrate the need for such a reduction because of spare capacity before it starts to suggest which hospitals should close. I suspect that the table of 11 options for closing different hospitals was an attempt to change the valid question, "Should we reduce community hospital bed numbers?" to "Which hospitals will close?" and to set one hospital against another.
I do not dispute the need to ensure that there is more domiciliary care, and I am sure that I share with the Minister the view that domiciliary care, with assistance, is more appropriate for some patients than residential care and that it is the best option for some patients who do not need to be in a hospital setting of any kind, with the risks that that entails. One can countenance a switch of provision when shown that there would be an alternative increase in domiciliary care provision. The people to whom I have spoken, who populate the committees that have considered issuing a response to this document, share that view—they do not say that we should never close any beds—but they are concerned that the health economy and social services have to demonstrate that staff are available for domiciliary care before they start closing hospitals, which is an irreversible step.
Although it is difficult to recruit nurses, and beds in community hospitals close partly because of that difficulty—although I think that planning blight is also a factor to bear in mind—I am told that it is even more difficult to recruit domiciliary care workers. Their job is more difficult; they receive less support because they are moving around; and of course they are paid even less than nurses in community hospitals. It is incumbent on 614 the health economy to show that it can afford and resource the other option before closing beds in community hospitals.
A number of people from across the parties and of no particular political persuasion have taken a mature look at the proposals, and hospital groups have made responses to the pre-consultation document. I have met the South West Oxfordshire primary care trust, which covers my constituency, and I make no criticism, in general terms, of its leadership. They have been willing to meet me, and they have performed a pre-consultation exercise, which is more than the statutory requirement; I want to put that on the record. It is still not clear to me, however, and I am not convinced that it is clear to the PCT, what are the real reasons for making these proposals at this point, without having done the work that is required.
I have raised the matter with the strategic health authority, asking it to take a view on whether it is appropriate to seek to reduce community hospital capacity when the Oxford John Radcliffe hospital is under enormous strain, as I think it will be for the foreseeable future. I suspect that the hospital is extremely concerned about the change, given the huge number of delayed discharges that occur due to a wait to get into a community hospital. When I worked at the John Radcliffe as a senior house officer in emergency medicine, my colleagues and I found community hospitals to be an extremely valuable source of step-down rehabilitation care, and I know that the staff still find that to be the case.
I am now bringing the argument to a higher level, to this House and the Minister. I hope that she will recognise that this is not an antediluvian opposition to all change, but a serious worry that the change is not thought out, it is not yet justified and, financially and in terms of patient care, it will make matters worse.
I pay tribute to the people working in community hospitals and those trying to balance the books in the health economy, but these proposals will not do, and I believe that my constituents share that view.

§ The Minister of State, Department of Health (Ms Rosie Winterton)
I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on securing this debate on what is obviously a matter of great concern to his constituents. I join him in paying tribute to the staff in his area, including not only those on the front line but those working in the PCT, who are obviously committed to making improvements to the local NHS.
The hon. Gentleman expressed a number of concerns about the situation in his area. As I am sure he is aware, it is our policy, within the framework set out in the NHS plan and the "Shifting the Balance of Power" initiative, to devolve funding decisions to the front line. Oxfordshire PCTs received an extra £41.7 million this year and will receive an extra £134 million over the next three years to 2005–06. With that extra funding, it is for PCTs, in partnership with strategic health authorities and other local stakeholders, to determine how best to use their funds to meet national and local priorities for improving health, tackling health inequality and modernising services. They are obviously best placed to do that because they have specialist knowledge of the local community.
615 As part of the modernisation programme set out in the NHS plan, many NHS economies and organisations are considering, with local stakeholders, changes to the way in which they organise their services. In doing so, they need to take a whole- systems approach that takes account of the contributions of different hospitals and primary, intermediate and social care providers. They need to work in partnership and to have genuine integration and joint planning of services.
To help the NHS to build those local solutions, in February 2003 the Department published guidance that set out the principles and approach that should be applied to all proposals for service change, as well as the various stages of the consultation process. The initial stage should commence with the local health economy engaging stakeholders—staff, patients and the public—and, ideally, the process should end with the local health economy moving on to implementation once a preferred option is agreed: of course, that is what Ministers would prefer. There may be instances where, for example, an overview and scrutiny committee of a local council refers decisions to the Secretary of State for Health, who can then call on an independent reconfiguration panel to investigate the situation and to offer advice.
As regards intermediate care, our policy aim is to maximise choice, control and independence for individuals, whether they live at home, in supported housing or in a care home. We know that most older people wish to live in their own homes for as long as possible, but that requires a wide range of high-quality support services and, again, good partnership between service providers.
I am aware that a great deal of excellent work is being carried out by PCTs and social services in Oxfordshire to improve intermediate care in the county by developing services for older people that are easy to access and are provided, where possible, in people's homes, whether it be their own home or a nursing home. In Oxfordshire, primary care trusts and social services operate a pooled budget of approximately £45 million. The aim is to ensure that resources are used in the best possible way to meet the needs of older people and people with physical disabilities.
As I said, health services will wish to respond to the changing needs of local people. I understand that that is why PCTs in the south of Oxfordshire decided to review the provision of community hospital services and intermediate care. The informal consultation paper, "South Locality Plan—The way forward for community hospital and intermediate care services", proposed options for improving levels of care, providing support to other parts of the NHS and providing sustainable services within allocated resources.
The south Oxfordshire primary care trusts took the view that the south of the county has traditionally offered a more bed-based service, given the number of community hospitals. There are established intermediate care support services teams in the PCTs but the service is not available to all areas. I understand that the PCTs' preferred option has been to develop equitable domiciliary care services in partnership with local authorities and in line with progress in north Oxfordshire. The services have jointly developed access to care and rehabilitation, which brings together NHS 616 intermediate care support services arid the rapid response, re-enablement and community rehabilitation services that social services provide. The idea was to offer rapid assessment of individuals followed by intensive home support.
In May 2003, before the informal consultation, the Oxfordshire health care system commissioned "Balance of Care", a survey of the health needs of more than 1,000 patients. Several issues were highlighted in the report that followed, including work force medical cover, emergency care, out-of-hours services and delayed discharges, which the hon. Gentleman mentioned.
I appreciate the concerns that the hon. Gentleman expressed about the validity of the survey and its subsequent contribution to the south locality plan. However, I understand that the aim of the informal consultation was to gather stakeholders' views. The hon. Gentleman may know that the strategic health authority currently recommends that PCTs do not proceed to formal consultation on existing options. The work is continuing with PCTs, in conjunction with the strategic health authority and local communities, including the local authority, to consider other care options for people in south Oxfordshire in the context of local community services.

§ Dr. Harris
Will the Minister confirm that that means that the immediate threat to cut the number of community hospital beds and close hospitals is effectively withdrawn and that she is referring to an instruction or recommendation to the strategic health authority not simply not to consult on the matter but not to go down that path?

§ Ms Winterton
Yes. The strategic health authority has recommended not to proceed with those options and to consider other options of care for people in the area. I understand that work is in progress to deal with some of the local issues that the hon. Gentleman raised.
I am advised that the strategic health authority is leading on supporting trusts in implementing the European working time directive. Trusts are promoting the "improving working lives" initiative, which encourages flexible working and the provision of opportunities for training and development. Significant effort is also being made to recruit staff to the community hospitals with a series of joint recruitment open days in some hospitals.
As I said earlier, it is our policy that PCTs, in partnership with other local NHS trusts and the strategic health authority, decide the priorities for the NHS locally. That is where specific local knowledge and expertise lie. It is not appropriate for Ministers to decide on the direction of travel and exactly how services should be reconfigured—we have made that clear. The NHS locally should do that. I hope that the hon. Gentleman, who introduced a debate that is so important to his constituents, will be reassured by the points that I have made, not only about the reconfiguration of services but the action that is being taken to deal with the genuine issues that he raised.