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Small Acute Hospitals

1 pm

Andrew George (St. Ives): I am pleased to have secured this important debate. I had hoped that it would be longer, but I am happy with a short debate and I shall try to keep my comments brief.

I raised related matters in connection with the small acute West Cornwall hospital in Penzance in my constituency in a debate in this Chamber on 13 March. Today, I want to deal with developments since then, and to raise questions relevant to small hospitals in general. I may of course refer to West Cornwall hospital in particular, as I know it well.

I should also declare an interest, as my wife works at West Cornwall hospital. If time allows, Mr. Benton, I hope that the hon. Member for Wyre Forest (Dr. Taylor) may make a short contribution.

A number of things have happened since the debate on 13 March. At the beginning of that debate I mentioned that my oldest brother, Mark, had been admitted to West Cornwall hospital. He was seriously ill, and ultimately he was transferred to the Treliske hospital. Before going to hospital, my brother had been staying with me and my wife. I am sad to say that, after returning to our home for a short time, my brother tragically died on 2 May at Treliske.

Since then, I have had meetings with the Under–Secretary of State for Health, the hon. Member for Salford (Ms Blears), at which matters were discussed with local representatives and the district council. The promised risk assessment at West Cornwall was completed at the end of May. Its conclusions, which were not a surprise to anyone, were that the hospital had inadequate anaesthetic cover, and that it needed more investment in its diagnostic facilities—especially in radiology, ultrasound, CT scanner equipment, and so on. It also found limitations in the accident and emergency service, especially at night, when the service is led by nurses. I have asked the trust to address the concerns that have been raised, rather than wait for the end of the review period.

I am pleased that the West Cornwall hospital trust has, with other partners, produced a strategic outline case for investment in the hospital, with remote diagnostic and treatment centres throughout Cornwall. I and other Cornish Members have another meeting with the Under-Secretary tomorrow to discuss that outline bid. I welcome that as an important step forward in the process.

Finally, I draw the Minister's attention to the document published by the Nuffield trust entitled "Local Medical Emergency Units". It recommends a different approach to the opportunities that small acute hospitals provide.

The case for the maintenance and retention of accident and emergency services at small acute hospitals rests on the fact that they are clearly closer to events and therefore to the commencement of the episode. In addition, the lengths of time that people wait to be assessed, and the trolley waits that they have to endure, are generally shorter than in larger district general hospitals. I am not criticising the staff in DGHs, who I consider to be as dedicated and committed to the health

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service as staff in smaller hospitals. It is simply a fact of life that trolley waits are longer in the larger DGHs. That is certainly true in my constituency.

However, patient confidence remains high, as is shown in campaigns that have been held across the country. In west Cornwall, 8,000 people have signed letters expressing support for the retention and expansion of services at West Cornwall hospital. In general, communities do not campaign to prop up bad services. If people perceive services to be good, they want to keep them and thus are moved to campaign on their behalf.

The pressures on small hospitals must be recognised. It is harder to provide 24-hour cover when junior doctors' hours are under pressure. As was mentioned in the debate on 13 March, that will be increasingly the case from August 2003. The fact that consultants are increasingly unwilling to work rotas that affect their family lives must be taken into account. Specialisation in medicine is creating fewer general physicians and doctors who are good at managing medical emergencies. Emergency admissions are rising, and it is sometimes difficult to appoint additional staff in smaller hospitals, where there is a sense that the environment is in decline.

Those difficulties must be seen against a background of rising expectations, the increasing incidence of litigation by patients, and the commitment to changes in clinical governance. The favoured model for dealing with the problems faced by small hospitals is to create large, central hospitals. As a result, local hospitals become the focus for discharge treatment and outpatient services in general.

The problem with that model is that it creates logjams in the service. As the Nuffield report to which I referred earlier noted, there is a lack of shared care between the central and the smaller hospitals. As a result, there is a weakening in people's appreciation of the systems of nursing care in the smaller hospitals.

The report contains a model proposed by the former chief executive of Middlesex general hospital, Andy Black, who is now a health consultant. He suggests that that whole approach be turned on its head, and that local hospitals should become the front doors of the district general hospitals. Moreover, local hospitals would provide assessment and rapid consultation using modern systems of digital transmission. They would also use telemedicine, a matter about which my questions to the Department have received useful replies. In that way, the model suggests that medical and nursing staff would be part of the same team, working in rotation between the main site and the local site or sites.

Crucially, Andy Black's model proposes that the local hospital would have imaging and laboratory support, and high-quality electronic links. That is another matter about which I have asked questions, and I am pleased that over the past two years the Department has been looking into the availability of the technology. A report will be published next year on the results of that investigation and on the recommendations that flow from it. Finally, it is clear that a critical transfer team will be needed in the structure that I have described.

The advantage of the model is that patients would arrive at hospital sooner after an incident, and that they would be seen more quickly. Moreover, the structure would ensure a good link with primary care.

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When my constituents in west Cornwall—from Land's End, the Lizard and the Isles of Scilly, for instance—go to a central hospital, it is much more difficult to discharge them back home. That results in bed blocking and the clogging of services in the central hospital. The model proposed by Andy Black would lead to the quicker discharge of patients.

Moreover, many patients would not need to go to the central DGH once they had been assessed, diagnosed and treated locally. Those who had to go to the DGH would not need to be assessed and diagnosed again, as a lot of that work would have been undertaken by the local hospital. The transfer team—and there would also be a team capable of dealing with the transfer of critical cases—would take people to the DGH, where the process would continue rather than start again.

I have a series of questions for the Minister on these matters. No doubt he will say that small hospitals are a good thing and that we should keep them, but the moot point is what facilities are retained at them. I have had meetings with the president of the Royal College of Physicians and I detect that the college is changing its approach. It does not seem to see itself as the institution that has to pronounce on the future of small hospitals, but as a body that exists to advise and reflect on the professional standards that should apply in them.

As a result, the Government should give a political steer on this matter. The Department needs to make a clear statement about how the configuration of services should be provided, especially in the remoter rural areas.

The report mentions Downpatrick in Northern Ireland, which is already implementing a model of what Andy Black describes as a step-up rather than a step-down approach. In the latter, patients come into the centre and ultimately step down to the local centre. Under a step-up approach, they come in the front door of the small hospital and step up into the district general hospital if required.

That process is being increasingly considered in other places. There are reviews at West Cornwall hospital and no doubt there will be pressure in areas that face similar pressures because of the small size of their hospitals. It would be helpful if the Department of Health, rather than leaving it to the Royal College of Physicians, indicated where it believed the priorities were and in which direction local services should go in this type of delivery. Otherwise, we are moving increasingly towards centralising services rather than creating or using the front doors that already exist.

I am grateful for the opportunity to introduce this subject and look forward to the remainder of the debate.

1.11 pm

Dr. Richard Taylor (Wyre Forest): I am grateful to my hon. Friend the Member for St. Ives (Andrew George) for allowing me to speak briefly on a subject that, as the Minister knows, is close to the interests of my constituents.

To emphasise the importance of the change of view from the Royal College of Physicians, the president told a group of Members of Parliament that there are already

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40 hospitals in the country taking acute medical admissions that do not have full surgical services to back that up. That is a crucial change.

The president also said that hospitals must have a front door for emergencies. That was borne home to me only today after talking to an elderly lady who went to Kidderminster hospital this week for a breast cancer screening report. Her elderly husband went with her but had an epileptic fit in the out-patients department and was taken to the minor injuries unit. He was told that no doctor was available and had to go 18 miles to Worcester. The knock-on effects on the larger hospitals make this a very important issue.

Other patients have invited the Secretary of State to spend 24 hours on a trolley in the medical assessment unit at Worcester to see what it is like. Many small hospitals that are close to larger ones have not been mentioned. I refer in particular to Pontefract, which is close to Wakefield, and to Macclesfield, Runcorn and Ashington. They could all be under threat from the sort of moves that have taken services away from some hospitals.

Let me conclude by paraphrasing the words of the Under–Secretary of State for Health, the hon. Member for Salford (Ms Blears), at the end of an Adjournment debate that I was lucky enough to secure. Can we go forward in partnership, because if we do, we can avoid conflict and come to a resolution that will be more satisfactory to the large numbers of patients who have, until now, relied on small acute hospitals?

1.14 pm

The Minister of State, Department of Health (Mr. John Hutton): First, may I say how sorry I was to hear about the brother of the hon. Member for St. Ives (Andrew George)? I genuinely did not know that that had happened, and I send him and his family my sincere condolences. It must have been a terrible time for them.

The hon. Gentleman has raised what most people in the House would rightly regard as very important issues that not only affect the future of the West Cornwall hospital but address the wider question of change in the national health service and the balance that needs to be struck between ensuring that services are fully accessible and of the highest possible quality. The hon. Member for Wyre Forest (Dr. Taylor) also alluded to those concerns.

The provision of comprehensive and accessible services of the highest quality, free at the point of use, lies at the heart of the NHS and its rationale, ethos and purpose. The Government remain strongly committed to the values that underpin the NHS. The NHS plan offers what I believe to be a good and strong framework for ensuring that those values can be reflected in a modern setting in which technology is changing quickly, advances in science occur almost daily and public expectations have risen substantially. To meet those needs, we need a broad range of provision—local and regional as well as national—that guarantees the best possible access to the full spectrum of care services.

The hon. Member for St. Ives was right about anticipating what I was going to say—he must have seen a copy of my speech. In this context, local hospitals such as West Cornwall have a very important role to play. There is, by the same token, one obvious pitfall to try to

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avoid. When we think of modernising medical care, it is easy to think of sophisticated, high-tech treatments provided in large, specialised hospitals. It is true that certain complex services and high-risk conditions require a critical mass that can be found only in larger centres, but that tells only part of the story. In determining care for a new century, it is vital that, wherever possible, we place at the centre of our thinking the views of the people and patients that the NHS is here to serve.

The public place a high value on locally available acute care; so do we. That means providing treatment as close to where people live as is practical, in hospitals that serve local communities and that are focused on meeting their needs.

When the hon. Gentleman raised the subject of acute hospital services in remote areas in March, he acknowledged the need to strike an appropriate balance between the convenience of local services and the requirement to concentrate expertise for reasons of safety and quality. He was right to do it then and right to emphasise the point again today. However, 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 and utilising the latest advances in telemedicine, to which he referred. It is a strategy based on local solutions that sets standards and quality measurements. That is what we must remain focused on.

The hon. Gentleman expressed his continuing concerns about the future of the West Cornwall hospital in his constituency. The local primary care trust, in conjunction with the acute trust—the Royal Cornwall Hospitals NHS Trust—is reviewing the services provided at that hospital. He is aware, as I am, that one of the main reasons for the review has been concern to ensure that patients at the hospital receive the best possible clinical care.

There is a clear commitment on the part of the Royal Cornwall Hospitals NHS Trust to develop the West Cornwall hospital. In August, a major scheme to expand the day case surgery and out-patients departments was opened. I understand that the hon. Gentleman was there for that. That will mean that more patients will be seen and treated closer to home; there are extra staff and more beds than ever before. A new treatment room for endoscopies has also been created, with the ability to reduce waiting times—an important objective—by increasing the number of weekly sessions from three to five. Three years ago, capital investment of more than £250,000 saw the renal unit's capacity double. Altogether, I think that that constitutes a clear commitment to the future of the hospital. However, let me repeat again the assurances that have been given to him before. There is no intention whatever to close the West Cornwall hospital or its casualty service. Indeed, the review is looking at proposals that would increase the number of services provided and patients treated at the hospital.

Since the hon. Gentleman raised the subject in March, the review process has largely been completed. A range of models of service provision at West Cornwall hospital have been developed by local clinicians and are being tested against criteria drawn up by local people. The Royal College of Physicians has been asked to comment

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on the suitability of the models, and it is the intention of the local primary care trust that formal consultation on the proposals will commence in February.

The review of services at the West Cornwall hospital is feeding into work on service and capital developments to modernise health services across the county. It is being undertaken by the entire Cornwall health community, led by the Royal Cornwall Hospitals NHS Trust. The emphasis in this work to modernise health services is on achieving the closer integration of acute, community and primary care, and providing acute care as close to patients' homes as possible. Of course, the public have a right to be consulted on matters of this importance.

The review process in West Cornwall is, I understand, being carried out in as open and transparent a manner as possible, with heavy public involvement. I hope that the hon. Gentleman is satisfied with the way in which the process is being conducted. There have been numerous local meetings, including with all the local councils and the community health councils. If he has any concerns about the detail of that process, I hope that he will raise them with me and I will pursue them on his behalf.

I shall say a few more general words about the future of acute care, which was the subject of most of the hon. Gentleman's remarks today. As I said at the start, I fully understand the desire of people to receive care as close to home as possible. It is clear in that regard that small hospitals have an important role to play, provided that safety and quality are not compromised. I hope that both hon. Members who have spoken in the debate would agree with that observation. However, there is no one model to fit all local scenarios. It is properly a matter for local consultation, taking into account as fully as possible the views of local people.

Historically, there has been a gap between care provided in hospitals and care provided in the community. The need for efficient, effective and joined-up care requires that those separate parts of the system should work more closely together. For example, cancer networks have been developed to improve linkages across hospitals and between acute and primary care. Through those networks, services can be planned across the care pathway for cancer patients, with resources targeted where they are most needed to serve the needs of the local population. Such networks have already proved very effective in many areas. The Devon and Cornwall network, for example, is participating in a national programme to educate and support district and community nurses in the general principles and practices of palliative care. That will allow more patients to be cared for at home, if that is their wish—and that is probably true of most people—and avoid unnecessary hospital admissions. I hope that the hon. Member for St. Ives agrees that that is the right direction to take.

Primary care trusts will play an increasingly important role. Shifting the balance of power in the NHS means that local PCTs will have much greater influence in developing local services and will be better able to tailor services to local needs. If that is to be achieved successfully, they will need to engage front-line staff and local communities and partners in their plans for improving health services. In their role as primarily local organisations, PCTs will bring about improvements in local services, by engaging with and empowering local people, patients and staff.

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Small hospitals are working hard to develop their role and to embrace new ways of working. The challenge is to deliver the right care in the right place at the right time—as the hon. Gentleman said, and I agree with him—across the system. Internal organisation of hospital services can be substantially improved through a redesign process, such as that of the booked admissions programme. Some 5 million patients are expected to benefit from the national booked admissions programme by 2005.

Andrew George: I am grateful to the Minister for giving way and for his response thus far. My points were mainly about acute emergency admissions to local hospitals. While I appreciate that local hospitals make a significant contribution to primary care, and will continue to do so, I would appreciate it if he would address emergency admissions to small hospitals before the end of the debate.

Mr. Hutton: I certainly intend to do so, and this might be an appropriate point. One often runs out of time in these short Adjournment debates. The hon. Gentleman mentioned the Nuffield report and the work of Andy Black, which are both important. We need to consider their wider implications carefully, and we are doing so. The Nuffield report considered routine emergency medical cases and how they could be treated, as opposed to traumatic cases that require a full range of surgical and intensive care procedures, which are very different. The only useful point that I can add to the ground that the hon. Gentleman and I covered earlier is that it is a difficult balancing act.

Local hospitals have huge amounts of expertise available and we will not fritter that away. That would be stupid. However, we need to strike a balance between quality and good patient outcomes on the one hand and the natural desire for people to receive critical care as close to their communities as possible on the other. It is difficult to get that right, but we have had the opportunity to consider what has already been done. The Nuffield work has been piloted in several different areas, including Scotland, east Kent and Witney, so that we can look, listen and learn about the safest and best way to adapt and modernise emergency care services.

I lived in Hexham for many years, and the hon. Member for Wyre Forest often mentions that area. We need to try to ensure that services are appropriate to local needs and geography. The constituency of the hon. Member for St. Ives is probably one of the most remote in the country. I know it well, because my father lived in Cornwall for many years, and he also died there. The needs of people in Cornwall differ from those of people in the north-east, in terms of geography and the spread of services.

Shifting the balance of power and moving decision making in the NHS much closer to the front line—of staff and of local communities—offers us an

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opportunity to consider the issues in a different way so that the right judgments can be made. We have to make difficult judgment calls and if the hon. Gentleman ever has the chance to sit in my place, he will learn just how difficult it is. It is not possible to ensure that everyone is 100 per cent. happy with all the decisions that have to be made, but we work hard to try to ensure that the proposals are fully consulted on. We take care to ensure that we have the best clinical advice available to us to inform the decisions made locally and—if necessary—for the benefit of Ministers who make such decisions. We certainly do not take decisions on the provision of emergency medical care lightly.

Andrew George: Before the Minister returns to his prescriptive notes and while he is speaking ad lib, will he comment on the fact that the Royal College of Physicians, in its report on West Cornwall hospital, identified the need to establish one clinical community, rather than the artificial divide between the district general hospital and the small hospital as two separate clinical communities? The work done by Andy Black suggests the possibility of rotating staff. If a Minister were to welcome an environment in which rotation happened, between sites and within trusts, it would help to enable further progress to be made.

Mr. Hutton: I accept that point and I will draw the hon. Gentleman's remarks to the attention of the Under–Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), who has responsibility for the development of emergency care services. At the risk of stating the obvious, the NHS is a service based around science. Unfortunately, medical science is not an exact science, but it is a science and our decisions are informed, first and foremost, by the science and what we understand about advances in technology and what they mean for the patients and services of the NHS. That will continue to be the case, and we always listen carefully to the professional advice given to the Department from different quarters about the best way to proceed.

The advice is not always one way. Sometimes, there are two or three different schools of thought and Ministers are then expected to exercise the judgment of Solomon. However, I wish to assure the hon. Gentleman that our judgments are informed by the best clinical information that we have and that will remain the case.

The hon. Gentleman politely and charmingly described me as ad libbing so I had better return to my text, to reassure my officials and before any further policy is developed in a somewhat unannounced way. He talked extensively about telemedicine, which will be an exciting opportunity for us to work more collaboratively and make better use of resources in the NHS. It is one way to tackle what he described as the divide between local hospitals, trauma centres and district general hospitals—

Mr. Joe Benton (in the Chair): Order.

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