Mr. Win Griffiths: Earlier, I pointed out that 220,000 homes in Wales are eligible for help with fuel efficiency, of which more than half117,000are households with at least one person over 60; 40,000 house lone parent families and 32,000 house long-term sick or disabled people.
Ms Keeble: Indeed. From our constituency case loads, we are all aware that the people who are most likely to suffer from fuel poverty are those who spend the longest time at home, particularly the elderly, people with disabilities and people with young children. That is obviously why the most vulnerable people are the key target group that we hope to help with the Bill. The Government and the devolved Administrations believe that vulnerable households should receive priority assistance.
In bringing hon. Members on both sides of the House together in support of the Bill, I hope that we deal not just with problems in the south and those in the constituency of my hon. Friend the Member for Brighton, Kemptown, where there are many students, but with important management issues in the north of England to make sure that, throughout the country, everyone has the benefit of good property. The Government recognise the merits of the Bill and I am pleased to advise my hon. Friend that we are happy to support it.
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 placesalmost 50,000 since the peak of 1996, according to Lang and Buissonthat 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 itselfwith 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
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 be 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:
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:
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.
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 ground- breaking 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.