§ Mr. Andrew George (St. Ives)
I am delighted to have secured this debate, as I know that it is pertinent to many hon. Members throughout the country, especially those whose constituencies contain acute hospitals in remote areas and peninsulas. Given the welcome and continual improvements in clinical standards, specialist medicine and surgery, the purpose of the debate is to examine how small acute hospitals in areas with specific geographic, demographic and resource challenges can maintain and develop services. In view of the fact that this is a half-hour debate, I shall concentrate on West Cornwall hospital in Penzance.
I should declare an interest because my wife is a staff nurse at that hospital. My oldest brother, Mark, aged 45, who has been living with us for a short time, has had a lifetime of illness with Fallot's tetralogy, and has related medical and surgical problems. He was taken into the hospital as an emergency admission on Sunday, and is currently under observation and treatment. When he was admitted, only two medical beds were available at West Cornwall hospital, and none at Treliske, which is the main site for the Royal Cornwall hospitals NHS trust. That is a story in itself.
West Cornwall is one of three acute hospitals in the Royal Cornwall hospitals NHS trust. It has 81 beds, 56 of which are for medicine, for a population of about 150,000 people, depending on where the eastern boundary between the hospital and Treliske is drawn. Of course, that figure is doubled during the summer months. The main site for the trust is at Treliske, just outside Truro, which has 847 acute beds serving a population of more than 300,000 people. The Royal College of Physicians recommends that 400,000 is an ideal population for a fully staffed and equipped district general hospital. Almost all specialties are covered at Treliske, with the exception of certain conditions—for cardiothoracic surgery and neurosurgery, patients are usually referred to regional centres such as Derriford hospital in Plymouth. The third hospital is St. Michael's at Hayle in my constituency, which is largely for planned, elective surgery. There are also 12 cottage hospitals in the trust.
A small acute hospital such as West Cornwall, which has four consultant physicians, three consultant surgeons and limited facilities, faces several challenges. First, the Royal College of Physicians advises that there should be at least two consultants from each of the four main specialties—cardiology, gastroenterology, diabetes and respiratory medicine—and two geriatricians, so as to achieve 24-hour emergency cover. Secondly, there should be adequate anaesthetic cover, which West Cornwall does not have. In those circumstances, senior medical staff should expect to be on call one night in five. Related services such as radiotherapy and accident and emergency should also be in place, which West Cornwall has but only at night time on a nurse-led basis, with specialist anaesthetists, surgical sub-specialists and so on. Some, but not all, of those services are in place.
213WH The third area of concern is the continual pressure since 1997 of what are undoubtedly welcome improvements in clinical governance. The chief executive of the hospital trust is accountable for risk assessment, and pressure is put on hospitals, especially small hospitals such as West Cornwall, on which the continual risk assessment is focused.
Fourthly, financial considerations must be taken into account. Centralising forces require the use of high-cost investigative equipment and treatment to be maximised to give resident on-duty medical staff the facilities that they require. From my conversations with the Royal College of Physicians and others, I am aware of the nationwide concern that the drive towards increasing centralisation of services as clinical standards change and improve will inevitably result in fewer and fewer acute general hospitals, and that those that remain will be highly centralised.
Fifthly, the training requirements of the hospital are provided by senior house officers. Their training posts are maintained, and the deanery has no objection to them. In fact, the hospital would fold without them. However, doctors' hours will come under much closer scrutiny as a result of the new deal and, possibly, the working time directive. Those measures will put some pressure on the system, as will the fact that only a small range of experience is available at a small acute hospital. In a short period, however, doctors see a greater range than they would if they specialised in a larger hospital. There is also a limitation on the training that West Cornwall hospital can provide for cardio-pulmonary resuscitation.
Further challenges affect the review to which I shall refer in a moment. Treliske was on red alert when my brother went in, as it often is. West Cornwall often receives emergency admissions diverted from Treliske, so it is questionable whether Treliske would be able to cope if emergency admissions were suddenly not dealt with by West Cornwall. In the cold light of day, most people recognise that it could not cope, even though West Cornwall is only a small hospital.
Two weeks ago the Cornwall NHS executive forum, which is the purchaser and provider of services in Cornwall, launched a review of west Cornwall hospital services, which it intends to complete by January 2002. The primary aim is to secure the best possible emergency services for the population of the West of Cornwall primary care group within accepted national standards and costs, and to provide additional services at West Cornwall hospital so as better to serve the needs of the local population.
The key objectives are to carry out a clinical risk assessment, which is happening at the moment, and devise and complete a full option appraisal to identify the full costs and consequences of three options. The first option is to develop and invest in West Cornwall hospital to meet national standards for an unspecified emergency take. The second is to have a selected emergency take, and the third to transfer all emergency admissions to Royal Cornwall hospital at Treliske.
It is timely that I raise this debate now, in view of that review, which has political and resource dimensions. Its considerations have implications, on which I look forward to the Minister's comments.
214WH West Cornwall Healthwatch produced a document that I sent to the Minister's Department entitled "The People's Option on the Future of West Cornwall Hospital". I hope that she has received it by now. The document shows that the issue was keenly contested and debated in west Cornwall, and describes a different approach in north Devon. Barnstaple hospital, which serves a population only slightly larger than that of west Cornwall, has 423 beds rather than the 81 in West Cornwall hospital. Past investment in services at Barnstaple hospital must have been significantly different from that in Treliske.
In the wider community, much concern has been expressed about what has been going on and the likely outcome of the review. Paediatric and obstetric cover at West Cornwall hospital has been removed, and accident and emergency services are nurse-led at night. Although the hospital has a good record, I accept that there is no room for sentimentality when assessing such services—otherwise the grim reaper would have a field day.
Formula funding does not take account of the geographical challenges of areas such as Cornwall. We would hit water if w e went to Land's End, the Lizard and the Isles of Scilly—the north, the west and the south of my constituency Appeals for emergency services cannot be made from any of those places. That is not taken into account in the funding formula: nor is the fact that we have a significantly older population than elsewhere, and our population doubles in the summer because of tourism. Such factors need to be taken into account if we are to have the resources to fund the hospital properly.
As for bed blocking, a consultant told me that an emergency admission to the hospital does not require a financial decision, but such a decision is often needed and difficult to obtain when a patient wants to leave hospital and go into a nursing home bed. Many nursing home proprietors have drawn to my attention significant problems in that regard.
The relationship between West Cornwall hospital and Treliske hospital is not as co-operative or mutually supportive as it could be. Sometimes, medical staff at Treliske are professionally dismissive of the work undertaken at West Cornwall hospital in difficult circumstances. The implication is that some consultants do not want to come to West Cornwall hospital from Treliske because it will take them too far away from their private patients at a neighbouring hospital. Relations are not good. In 1998, the Royal College of Physicians, the British Medical Association and the Royal College of Surgeons in their report entitled "Provision of Acute General Hospital Services" said:District General Hospitals situated in areas of the country where it is not practical to amalgamate with others, will need to continue for the foreseeable future. The smaller the acute unit, the greater should be the co-operation with adjacent acute hospital units, both professionally and contractually, in order to provide sustainable high quality specialist care for patients.In a press release in 1999, the Association of Community Health Councils stated:Patients in rural areas may die because hospitals are too far to reach in an emergency… Many small acute general hospitals are currently under threat because of the strict interpretation of Royal College guidelines which specify the number of acute hospital services required to meet the needs of a certain number of people.215WH The Government said in the rural White Paper:We are committed to the provision of comprehensive, high quality health care for all those who need it, regardless of ability to pay or where they live, and to ensuring greater consistency of access across the country.In reply to my written question about the assessment of ability of health services to meet national clinical standards in remote areas, the Minister said:Advances in healthcare and changes to the practice of medicine, particularly the increasing sub specialisation of doctors, results in changes to the way healthcare is delivered to patients. The Government are keen to see that patients have access to services at as local a level as possible but against this desire must be balanced the need to ensure that patients receive the highest levels of clinical care, wherever that care is provided." —[Official Report, 21 November 2000: Vol. 357, c. 160W.]The Minister said that it is up to local providers to make that balanced choice. That choice will depend on funding. Resources will have an effect on the current review of hospital services in west Cornwall. My questions for the Minister concern her Department's review of the current funding formula for local health authorities. I believe that the formula does not adequately represent areas such as mine, as I said as long ago as November 1997, when I introduced a private Member's Bill. At that stage, I heard no contrary arguments, and I understood that the Department would examine the issue. Bed blocking will have implications for the future configur ation of services.
In areas with demographic and geographic challenges, such as west Cornwall and the Isles of Scilly, what is the minimum level of acute emergency support that a local population should expect? Given the welcome improvements in national clinical standards, what assistance or advice would the Minister offer if the range and level of consultant cover did not match the advice and guidance of the royal colleges? In hospitals such as West Cornwall, where senior house officers cannot do their jobs and meet the requirement of the new deal on working time by August, can training posts be protected?
What discussions has the Minister had with the royal colleges about the challenges faced by isolated hospitals? Does the Minister accept that cardiologists may have to act as general physicians in order to provide full cardiology cover in remote peninsular settings? What should the commissioning bodies do when purchasing acute services if the main acute hospital at Treliske is unable to cope with changes to emergency admissions?
The choice for West Cornwall hospital is clear—either it receives significant investment to improve clinical standards or it withers on the vine. The local community wants the investment model, but we require the advice of the Minister to take the issue forward.
§ The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)
I should like to thank the hon. Member for St. Ives (Mr. George) for raising this issue and creating an opportunity for this important debate. On a more specific note, I was sorry to hear about his brother's experience. I hope that he is well on the road to recovery.
The hon. Gentleman is right to say that people living in remote rural areas are entitled to the same standard of high-quality care, focused on their needs, as national 216WH health service patients anywhere else in the country. For starters, that means more beds, not fewer, and providing treatment as close to where people live as is practical in hospitals that serve local communities and are focused on their needs.
We must also ensure that people in rural areas, as elsewhere, get care that is safe, appropriate and of the highest standard. As the hon. Gentleman acknowledged, there must be a balance between the convenience of local services and the requirement to concentrate expertise for reasons of safety and quality. That can be achieved by delivering care through networks of skilled providers who work together, not in isolation. The strategy must be based on local solutions within the national framework. Different patient needs call for different responses.
To illustrate the difficulty of the balancing act, I offer an example of a patient with heart disease, because the hon. Gentleman mentioned cardiologists. The NHS must be flexible to service the needs of such patients. Specialist services require a critical mass so that staff can gain experience of a variety of related problems. For example, the Royal College of Surgeons recommends that surgeons should perform 50 bypass operations a year, and cardiac surgical units should perform at least 400 bypasses a year. Having many similar patients means that error rates are reduced and junior staff get the guidance that they need. Specialised equipment such as cardiac ultrasound machines are found only in larger centres, because extra training is required to ensure their safe use and to achieve the best results.
There are two extremes: highly specialised diagnosis and treatment, and close-to-home convenience in the primary care setting. Many other interventions fall between the two. The person who suffers cardiac arrest and collapses in the street obviously needs an immediate response. In such a case, effective arrangements for speedy transfer and the availability of trained ambulance staff are what counts. Clinical evidence proves conclusively that early defibrillation and resuscitation save lives, so we have put defibrillators in public places. We must strike a balance between specialist care and immediate response.
That is one reason why the Government give the highest priority to the public receiving a 999 emergency response as quickly as possible. NHS ambulance services are at the forefront of the Government's modernisation programme. In March 2000, the Government invested an extra £21 million in the ambulance services to support delivery of the 75 per cent. category-A eight-minute target.
§ Mr. George
On thrombolysing myocardial infarctions, does the Minister accept that in stabilising such patients it helps to have at least a basic acute general hospital with emergency admission provision? Even if on-call cardiologists are not available there, at least the hospital can stabilise the patient and transfer him to an acute general hospital elsewhere.
§ Ms Stuart
At first sight, that might seem logical, but digging a bit deeper, what matters is the drugs that paramedics in ambulances are allowed to administer. Stabilisation can safely occur further away. Although I am not happy that the west country ambulance service 217WH has not yet reached the 75 per cent. target that the Government have set, I am delighted that it has made considerable improvements in its response times. Its starting figure was just under 40 per cent., and I understand that, as of February, it achieved more than 50 per cent. That is an increase, although we recognise that the service still has some way to go. I am not suggesting that the circumstances are perfect, but we must strike a balance that is right and can be sustained.
The hon. Gentleman expressed anxiety about the future of the West Cornwall hospital, whose services the local primary care group is reviewing. I am aware of the royal college's discussions and report. I understand that the royal college involved the hon. Gentleman and made the report available to him.
The aim of that review is to achieve the best clinical care for patients. Even if difficulties are experienced in trusts working together, we expect local difficulties to be resolved locally, and we have made it clear that it is for local health economies to make the right decisions. I am assured, however, that the group does not intend to close West Cornwall hospital or its casualty service.
The review is examining the provision of more, albeit different, services locally. I understand that the review is being carried out as openly and transparently as possible, with full public involvement.
The hon. Gentleman asked about the minimum level of acute emergency support that a local population can expect. Everyone should expect to receive the best possible treatment in the most appropriate clinical setting. Local health authorities, working in partnership with primary care groups and trusts and other local stakeholders, are responsible for determining how best to use their funds to achieve that.
The hon. Gentleman asked about health authority allocation. Allocation is based on relative needs, and the matter is currently under review. However, an interim measure has been introduced. As a first step, for 200102, we have introduced an interim health inequalities adjustment of £130 million. Some rural health authorities qualified for that, including Cornwall, which received £3.585 million.
The hon. Gentleman also mentioned bed blocking. His area has not experienced the severe problems experienced in some other areas. The money allocated this winter to deal with the problem in his area was about £125,000. We made it clear that health and social services must pool their funding so that patients are discharged.
The hon. Gentleman suggested that consultant cover in his area was insufficient. That is one reason why the NHS plan set a target for major expansion in the number of consultants. We are investing more in specialist registrars, which is the main feeder grade for consultants. The intention is to invest in new trainees and to target the specialties that are key to delivering the NHS plan and the national service framework targets, which include cardiology and cardiothoracic surgery. We will closely monitor the application of the plan and the placing of new consultants.
The hon. Gentleman was right to be concerned about the implications of certain measures for a reduction in the working hours of junior doctors and the effect on 218WH training posts in west Cornwall hospitals. Currently, junior doctors are excluded from the Working Time Regulations 1998, although such regulations apply to all career-grade doctors However, by August 2003, junior doctors should not contractually be working more than 56 hours a week. We were involved in negotiations about how much time the European Union would give us to implement that directive. It is right to reduce junior doctors' working hours because it is not safe for a person to be on duty for 80-odd hours. The phasing process will create a safe working environment for doctors and patients. The working time directive is due to come into effect in 2004, and discussions will be held with the British Medical Association, the royal colleges and other NHS employees to make the transition possible.
Local health sere ices face many challenges to provide acute medical and surgical cover in isolated hospitals. The NHS plan mentions the possibility of ending single-handed working by consultants by raising staff numbers over the next three ) ears. I emphasise that working in isolation is not good for consultants' professional development, and is often not good for patients. We should not underestimate the opportunities afforded by information technology, which enables the exchange of patient records. Telemedicine allows highly specialised consultation to take place over large areas. That is not a cheap option. Often there may only be a few consultants who can deal with specialist conditions. We are pursuing such technology with great urgency.
We are committed to what used to be called community hospitals or cottage hospitals. They have a right and proper role, and the previous Secretary of State, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), stopped the closure of many such hospitals. They are vital service providers, and allow local health care to be delivered, extend intermediate care, and give patients a choice between home and hospital. Such services are more important in rural areas and require careful thought. However, they are also important in urban areas, although I accept that solutions reached by local health authorities will be different in each case.
§ Mr. George
Does the Minister think that it is acceptable for areas with a low population, such as west Cornwall and other peninsulas around the UK, to have a relatively high pro-rata number of consultants available to provide such a level of service?
§ Ms Stuart
The royal colleges and others suggest that smaller hospitals should reconfigure to provide a selection of services for the community, such as elective surgery, maternity provisions, paediatric cover and major out-patient services. Proper consultant staffing should be decided when the services have been decided. The number of consultants should not determine local service provision. Which services should be provided should be decided first, and then a determination should be made of what constitutes safe cover.
The review indicates that there is local good will and a consensus to find a solution. The royal colleges want to be as supportive as possible in finding a solution. We should not underestimate the importance of networks, such as cancer networks. I know that benefits are being gained in some areas near the hon. Gentleman's 219WH constituency. For example, the Devon and Cornwall cancer network has decided to install at least one linear accelerator in Truro, which will reduce by 100 miles the distance that a patient from Penzance must travel for radiotherapy. Elsewhere, the Royal Devon and Exeter trust and Barnstaple district general hospital have joint appointments for oncologists.
It is important to recognise that there is no single model of service. I take the hon. Gentleman's point about there being isolated areas with limited support, but I hope that I have reassured him that we are doing everything possible to provide a framework for good local health service delivery that will serve his constituents as effectively as it serves people living in more urban areas.
§ Mr. Mike Hancock (in the Chair)
I join the Minister in wishing the brother of the hon. Member for St. Ives (Mr. George) a speedy recovery, and hope that he is home with him soon.