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Peter Luff (Mid-Worcestershire) (Con): For the second time in two weeks I am extremely grateful to Mr. Speaker for the opportunity to stand in this Chamber and defend a vital local service. Two weeks ago the issue was the impact of the Licensing Act 2003 on a range of institutions and organisations, especially village halls. At first sight that was a national issue with local implications, whereas today's debate appears to be a strictly local affair that has implications that go no further than Evesham. However, that assessment would be wrong for three reasons, which is why it is right that the Minister should have the opportunity to explain.
The first reason is shown by the presence of the hon. Members for Worcester (Mr. Foster) and for Wyre Forest (Dr. Taylor). The proposal virtually to halve the size of Evesham community hospital by closing two wards, removing general practitioners from caring for patients in another ward and transferring orthopaedic services to Kidderminster has serious implications for the whole county of Worcestershire and its surrounding areas.
The second reason is that the proposals fly in the face of one of the Government's key national policy objectives for the national health service: local service delivery and accountability. In 2003, "Keeping the NHS local: a new direction of travel" challenged the perceived wisdom that biggest is best, and committed to the delivery of as local a provision of services as possible. It also strengthened the commitment for the NHS to work with and not for local people in developing options for the delivery of services.
In 2000, "The NHS Plan: a plan for investment, a plan for reform" and in 2004, "The NHS Improvement Plan: Putting people at the heart of public services" again committed to a major investment in services closer to home, particularly the management of patients with long-term conditions. South Worcestershire primary care trust is doing the exact opposite. It is reducing local primary care services in order to support the costs of a large acute hospital sector that provides a range of services that could, and should, be provided close to patients' homes and in primary care settings.
The third reason is that the drivers of the outrageous proposals are all national. The cuts being considered by South Worcestershire PCT, of which the proposals for Evesham community hospital are just a part, are its response to national policies imposed on it, often against its will. Its experience is far from unique. The proposals for Evesham were developed not on clinical grounds, but simply because it is the largest part of the PCT's budget over which it has any discretion. This would be the second round of damaging cuts at the hospital in three years and has four equally unacceptable parts.
The first is the proposal to close the enormously successful and essential rehabilitation ward, Bredon ward, which offers a vital service to support the county's acute hospitals and was developed only two years ago with the current PCT. Closing the ward will mean many things: patients being stuck in an acute hospital where the focus is on primary treatment not rehabilitation; increased pressure on an already seriously overstretched
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acute sector; patients not being able to return near to home for post-operative care and rehabilitation; more travelling for families to see and to support relatives; and less locally co-ordinated discharge planning and so more chance of problems on discharge.
The second part is the closure of the immensely well regarded Willows stroke unit. The letters I have received about that proposal would melt even the stoniest heart. I have many of them here and if time permitted I would quote from them extensively. The stories they tell of hope reborn and of outstanding nursing care show how much the service achieves and how precious it is. The ward is widely recognised as a centre of excellence. It was opened only a few years ago by the late Sir Harry Secombe, and the PCT itself has invested in it significantly. Early discharge of the kind of people treated on the ward would be to betray their best clinical interests. It would lead to huge pressure on families, and would severely compromise treatment and rehabilitation and, crucially, jeopardise successful outcomes.
The closure of those two wards would undermine the viability of the staff grade doctors' role at the hospital. That would probably lead to the closure of the one ward, the William Astley ward, otherwise unaffected by this package. The attempt to keep that role viable probably explains the third proposal, to remove GPs from Izod ward, which would mean a reckless loss of continuity of care from local GPs who know their patients' circumstances and full medical history. The quoted saving for ending the role of GPs seems remarkable, because the current total Izod ward bed-fund payments for all the GPs put together amounts only to little more than a third of the quoted saving, and there would probably be redundancy payments to make as well.
The fourth proposal is the transfer of orthopaedic services to the independent sector treatment centre at Kidderminster. The only reason for that is that the Department of Health has forced the primary care trust into a contract that it, the local GPs and the patients do not want. On a case by case basis, Evesham community hospital is cheaper than the treatment centre. The Kidderminster centre is a 55-mile round trip from Evesham; therefore, the journeys that would have to be made there for an initial consultation, surgery and a single follow-up visit would amount to a combined trip of 165 miles. That assumes that patients have easy access to cars, which many do not. By public transport, the journey is a nightmare, especially from the villages of south Worcestershire.
The PCT must know that the loss of orthopaedics would also lead to physiotherapy and X-ray at Evesham becoming less viable. What makes this proposal truly bizarre is that, under the Government's policies, most local people will choose to be referred to the much closer Cheltenham general hospital, where the cost will be even greater than at Evesham.
In summary, these cuts are as unacceptable to the people of Evesham and the surrounding community as the downgrading of Kidderminster hospital was to the people of Wyre Forest. The hon. Member for Wyre Forest is present, and I am grateful to him for the support he has given us.
Dr. Richard Taylor (Wyre Forest) (Ind): I just want to put on the record that the Kidderminster treatment
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centre was provided, following a Government inquiry, to perform elective surgery to relieve the pressure on the acute hospitals in the county, at Redditch and Worcester. It was not provided to rob other community hospitals of services that are being performed locally and that already take the load off the acute hospitals.
Peter Luff : I entirely agree, and I am most grateful for that very helpful clarification. The hon. Gentleman understands the role of community hospitals, and I hope that by the end of the debate the Minister will understand it, too. I feel sure that I will be encouraged in that respect.
There is anger of unprecedented proportions in the vale of Evesham, and I am deeply grateful to two local institutions for their magnificent support for our campaign; the fine local paper, the Evesham Journal, and Evesham Technology, the local computer manufacturer and retailer. They have helped to give focus and expression to that anger.
To understand the depth of that anger, it is necessary to understand the history of Evesham's hospital; or, rather, hospitals, because Evesham used to have two, Briar Close, built in 1879, and Avonside, built in 1930. I understand that there was also a third isolation hospital in the town, but this debate has its origins in the story of Briar Close and Avonside.
In 1986, Worcester and district health authority announced plans to deal with an overspend of £1.8 million by, among other things, transferring services from Briar Close to Avonside, although, to be fair, the plans also included the building of a new theatre. Seventy health workers lost their jobs when Briar Close closed down in 1988 and the land was sold for housing development. Evesham was now down to having one hospital, in which, when it was taken over by the NHS in 1948, there had been 287 beds, many for long-stay elderly care, so it was a significant hospital.
Some extensive ward upgrading took place at Avonside in 1986, but in the same year the maternity unit moved to Worcester, despite widespread public opposition. That loss of service marked the beginning of a tale of the gradual erosion of the hospital, with some bright and encouraging exceptions. In 1990, ward six closed, and Bartholomew ward went the same way in 1998. On a brighter note, a public appeal launched in 1993 led to the establishment of the Macmillan palliative care unit. However, 2003 saw further trauma as another round of cost cutting by the PCT led to a reduction in staffing at the minor injuries unit, and in 2004 the physiotherapy unit suffered reduced staff numbers. We now come to 2005 and the latest cuts, which would reduce the hospital to just 42 beds, including the five Macmillan beds, all of which is designed to contribute to a £4 million cost saving exercise by the PCT.
Over the years, Evesham people have always been told that their hospital was secure, and over those same years it has been slowly chipped away at by an NHS looking to make savings to make good problems elsewhere in the county. Evesham has been the sacrificial lamb once too often, and it must not happen again.
Evesham people felt very closely attached to both hospitals, and they continue to make generous donations to the remaining hospital. All the wards undertake continual fundraising to provide extra
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facilities. The friends of the hospital receive frequent bequests and numerous donations from clubs, groups, organisations and businesses from Evesham and the surrounding area. Over many years, the friends have supplied equipment; for example, they kitted out a young disabled person's room with a shower and hand basin with equipment specially designed for disabled use. These cuts are the reward for their loyalty.
The hospital must be saved, and the long-promised new hospital must be built. That must happen not just because local people are upset and angry; indeed, it is not just local people who are upset. Evesham provides a service to the whole county, and its wonderful staff are held in deep affection the length and breadth of Worcestershire. I accept that the Minister may not have a detailed grasp of Worcestershire's geography, but it is significant that the Kidderminster Times this week has a letter of protest from Bewdley, and my first telephone call of outrage came from Hartlebury. Evesham must be saved because it provides essential services to the whole county, because closing these wards will endanger patients, and because the proposed cuts will not generate the savings claimed.
Mr. Michael Foster (Worcester) (Lab): I am most grateful to the hon. Member for Mid-Worcestershire (Peter Luff) for giving way. The issue that he raises of the capacity of the health economy in Worcestershire concerns us all. Does he agree that if the Government are seriously considering building new community hospitals, an ideal base for one such building would serve my constituents in Worcester and his on the Droitwich side of his constituency? That would be the ideal place for a new community hospital.
Put simply, and perhaps more controversially, the financial pressures on the South Worcestershire primary care trust are the direct result of the enforced implementation of national Government policy. That is why it is right that the Minister should be here. The Government imposed on the NHS well-meaning but expensive commitmentssuch as the waiting time initiatives and the new GP contractbut did not provide sufficient extra funding to pay for them fully.
They forced acute hospital trusts and primary care trusts to find every creative device to balance the books in the year before an election. Then, incredibly, they ordered those same trusts to achieve balance again in the current financial year. That last instruction, which no trust manager dare ignore, precipitated the crisis for Evesham. The tricks of election year cannot be repeated, but the Government have made the cynical calculation that howls of outrage the year after one election will be forgotten by the next one. However, if those cuts are allowed to proceed, the people of Worcestershire will
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not forget it. We do not even know what the acute hospital is going to do to find the £20 million it needs to balance its books.
Two specific local problems, imposed on the county by central Government, lie at the heart of our difficulties. First, the Government built a major acute hospital under the PFI that was too small and had a contract that was too inflexible. All the risk is borne by the NHS, and when the Worcestershire Royal hospital operates well beyond the sensible and contractually agreed level of 85 per cent. of capacityas it has to most of the time; sometimes it operates at more than 100 per cent.the contractor receives massive penalty payments to compensate for those excessive activity levels.
Secondly, the Government imposed on the countyfor reasons rightly set out by the hon. Member for Wyre Forestan orthopaedic independent sector treatment centre at Kidderminster, where the profit making contractor gets paid the full contractual sum, irrespective of how many procedures are performed there. It is not full; no wonder the PCT is trying to bully Evesham patients into making the impossible journey to Kidderminster.
The Government are imposing high and unavoidable costs on the local NHS to meet contractual obligations to profit-making private sector operators, and that has led directly to cuts in local services. Evesham hospital is being sacrificed to meet the bills of two private sector contractors; that is what makes the story truly remarkable. The only matter for local decision making now in Worcestershire's NHS is which local services should be cut to meet the obligations imposed on it by Whitehall. What makes this matter additionally disturbing is that the South Worcestershire primary care trust appears to be one of the worst funded in England.
In 200304, the latest year for which I have figures, the trust was funded at about £100 per head below the English average. Given that there is a population of roughly 250,000, that means we were short-changed by at least £25 million. I am trying to get more up-to-date figures from the Government, but the figures that I have mentioned, taken from an article in Pulse magazine, appear to show that the South Worcestershire primary care trust should not be seeking £4 million in cuts, but be looking for ways to spend an extra £21 million.
As it is, the PCTs have said that saving around £2 million from the cuts at Evesham is unrealistic. Additional costs flowing from the proposalsthe costs of longer stays at Cheltenham General and Worcestershire Royal hospitals, of additional nursing and day rehabilitation services and of spending more on hospital care outside the PCTwould further reduce savings.
The campaigners have some positive suggestions to address the financial situation. The merger of the county's three PCTsSouth Worcestershire, Wyre Forest and Bromsgrove and Redditchwould cut central costs a bit and significantly improve the efficiency of commissioning. Equitable funding for Worcestershire's NHS would give us enough resources to abandon the cuts, and the redevelopment of Evesham community hospitala new hospitalcould reduce capital and maintenance charges, improve efficiency and expand services, repatriating work to the county and costs back into the PCT.
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To sum up, here are some specific points for the Minister. He will not be able to answer them all today, but they are the local points that need to be answered. On orthopaedic services, can the Minister confirm that it is NHS policy to encourage and support patients to choose the hospital from which they receive treatment? What makes the Government confident that they will choose Kidderminster hospital rather than Cheltenham General hospital? As the procedures at Cheltenham will be at full tariff price and therefore more expensive than at Evesham hospital, how would that save money?
On the processes of the primary care trust itself, section 11 of the Health and Social Care Act 2001 requires PCTs to involve patients and the public from the very beginning when developing possible service changes, rather than just consulting them on proposals developed by PCT management. Can the Minister explain how patients and the public have been involved in developing those proposed service cuts?
With respect to the closure of wards, can the Minister confirm that patients who need rehabilitation but who are discharged home from the acute hospitals instead of being transferred to Evesham would receive the same level of therapy and nursing? Can he confirm that the closure of the two wards would not lead to more patients being forced to enter care homes to free up acute hospital beds because they are not fit enough yet to return home? Can he confirm that the ward closures would not shift costs of care to social services or to individuals and their families?
With respect to the proposal to remove GPs from Izod ward, can the Minister explain why the PCT wants to do that at Evesham but not at Malvern, Pershore or Tenbury Wells? Can he confirm how much the reduction in quality of service at Evesham will actually save? Will it be easy to recruit good staff-grade doctors in the future? There are doubts about that.
With respect to the capacity of the county's health service, the acute hospitals are regularly on alert and unable to find beds for people requiring emergency admissions. Worcestershire Royal was on black alert only last Friday night, so how will the loss of 38 more beds from the Worcestershire health economy affect the situation? As the hon. Member for Worcester suggested, should not we be developing new community beds rather than cutting existing ones?
Can Evesham still expect the new hospital that it has been promised for so long and that it so urgently needs to provide a broad range of services similar to that currently provided? Can the Minister assure me that the capital sums raised by any sale of the existing site will not be used to plug one year's deficit, but be reinvested in the health service of south Worcestershire in the shape of that new hospital?
I hope that the Minister understands that he cannot shrug off responsibility for the mess and say it is all about local decision making. It is the decisions of the Government that have created the situation, and I hope that it is the Government who will help get us out of it.
The Parliamentary Under-Secretary of State for Health (Mr. Liam Byrne) : Thank you, Mr. Cook. I think that this is the first time I have served under your chairmanship, and it is a pleasure to do so.
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I congratulate the hon. Member for Mid-Worcestershire (Peter Luff) on securing this debate on Evesham community hospital. He has taken a keen interest in health matters in Worcestershire, and I know that his expertise does not extend simply to the borders of his own constituency. During his career, he has had some exposure to health matters in the great city of Worcester, which I am glad to see is also represented in this debate by my hon. Friend the Member for Worcester (Mr. Foster).
I know, too, that the hon. Gentleman has raised the proposals now under discussion by his local primary care trust in a parliamentary question, to which my hon. Friend the Minister of State replied on 9 June. In what was an eloquent dissertation today, he raised a number of detailed issues. I will address as many of those as I can, and I will write to him on those that I am unable to answer satisfactorily.
If the hon. Gentleman will indulge me, I will describe a bit of the backdrop before I turn to address the specifics of the important local issues that he has raised. Perhaps the most prominent feature of that backdrop is the extent to which health care in communities up and down our country, including in places such as Evesham, has changed in the past six or seven years. Massively increased investment has allowed us to hire more staff, build more hospitals, cut waiting times and cut mortality rates, in some cases quite dramatically.
I looked at some of the figures as I prepared for an Adjournment debate on Monday with the hon. Member for Wyre Forest (Dr. Taylor), who also knows a great deal about health care in the area that we are discussing. Some of the figures bear some repetition. Overall, spending is up by a third. Staff numbers are up by 21 per cent., with GP numbers up 13 per cent., consultant numbers up 44 per cent. and nurse numbers up 25 per cent., and 85 new hospitals have already been delivered. That has allowed us to cut in-patient waiting times first to 12 months, then to nine months and now to six months. Indeed, I understand that nobody in the South Worcestershire PCT area is waiting more than nine months for inpatient appointments.
When we look at some of the biggest killers in the country, we can see the results of that investment and improvement. Cancer death rates are down by 12 per cent., and coronary heart disease death rates down by 27 per cent. I was glad when officials told me that that improvement in health outcomes appears to be shared by the residents of Mid-Worcestershire. Indeed, Evesham hospital has benefited from the increased investment. Its budget has increased by more than £1 million, or about 16 or 17 per cent., in the past few years.
The larger question that looms over our debate this morning is where we go from here; where do we go nationally, and where do we go in Mid-Worcestershire? The larger question is, on the basis of the investment and success to date, how can we create an NHS that is truly patient centred; an NHS that we would be happy to use and that we would be happy for our constituents and our own families to use?
The Government's answer is straightforward. First, we believe in more investment, but it must be coupled with a new degree of choice for patients about where and how they would like to be treated. Secondly, we propose national frameworks, or national standards, for how
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that care is provided. Some of those standards have been described variously as the envy of the world and among the world's leading definitions of health care, but they must be coupled with a new freedom for local health care professionals working with their local communities to decide how best those standards are met. It is that new freedom which is the real author of today's debate.
Here we have a situation where local health care professionals have very properly surveyed the health needs of the local population, and have come to a set of recommendations, or provisional conclusions, about how to invest the resources with which they have been entrusted, and their plans have, as we have heard quite graphically this morning, struck a note of discord.
Peter Luff : It is important to understand that the primary care trusts do not want to make these cuts. They are not my enemy. They disagree with what they are having to do; it is not their choice. They have no discretion over the rest of their budget. The only discretion they have concerns small pots of money, as at Evesham community hospital. They are making these cuts not out of choice, but because they have no choice.
The provisional recommendations that the primary care trust has set out are plans that must be drawn up to explain just how the local health economy intends to deliver the standards that people ultimately voted for in the general election a few weeks ago. They are set out according to guidance issued in July 2004 by my Department and snappily entitled "National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/062007/08".
The first point to make, however, is that these are not recommendations or provisional conclusions born of a financial crisis. Far from it. The hon. Gentleman will know this. Revenue allocations are made to primary care trusts on the basis of the relative needs of their populations. It is quite right that, as a country, we invest health resources in areas where there is the greatest health need.
This means that South Worcestershire will receive an allocation of £313.5 million next year, rising to £344 million in 200708. There is a cash increase of £57.1 million, 19.9 per cent. over the next two years. I hope the hon. Gentleman will accept that this is a significant increase in resources.
The hon. Gentleman mentioned two points. First he felt that the local primary care trust has been in some way short-changed. The response to that is that we must invest in areas where there is the greatest health need. Secondly, he felt that the cost of new standards was over and above the resources that have been invested. I want to point out that in 200203, the primary care trust had a budget of something like £200 million. When we look forward to 20078 and we see that the figure is £344 million, I think that an increase of £144 million over a fairly short time is a very significant envelope with which to invest in delivering new standards.
Another pertinent point is that the health professionals of South Worcestershire primary care trust will not and are not making decisions about how
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to spend this very significant amount of money without intensive engagement with the local community. This is a matter of fact and, I might say, a matter of law. The hon. Gentleman mentioned section 11 of the Health and Social Care Act 2001, which is very important. It placed a new duty, from the beginning of 2003, on NHS trusts, primary care trusts and strategic health authorities to involve and consult patients and the public in service planning and in the development of proposals for changes. As the hon. Gentleman points out, that encompasses ongoing service planning, development of proposalsnot just consideration of the final productand decisions about general service delivery, not just major changes.
Furthermore, the Healthcare Commission will regularly assess patient and public involvement as part of its review of clinical governance. The Act, as the hon. Gentleman pointed out, was reinforced by the approach and principles set out in "Keeping the NHS Local", published on Valentine's day 2003. It provided new guidance on service change that builds on the new arrangements for patient and public involvement. It challenged the view that biggest is best, and explored some innovative ways of keeping high quality and locally accessible services within the important bounds of patient safety.
As the hon. Gentleman might know, one of the core principles of that guidance is to take a whole systems view of the local health economy, encompassing the different contributions of hospitals, primary care settings, intermediate care settings and social care providers.
What does that mean for Evesham hospital? I understand that, as a result of the dialogue around the primary care trust's local delivery plan, three basic proposals were discussed at the primary care trust board meeting on 8 June, and will be part of the debate with local stakeholders prior to the public consultation which will follow. It goes without saying that these proposals are at a very early stage.
As the hon. Gentleman pointed out, I understand that the proposals encompass the possible closure of two wards at Evesham hospital, in the context of the development of community matrons and an increased district nursing service; the reduction of orthopaedic activity at Evesham hospital, with the treatment being undertaken at the new Kidderminster independent sector treatment centre; and changes to the arrangements for medical cover.
I am advised that the PCT has been open in its handling of this matter and I am pleased about that. That is in no small part down to the hon. Gentleman's long-standing engagement with local health care professionals. The PCT is discussing the proposals with a wide range of stakeholders, including staff, patients, the local council, social services and the public. Those discussions are ongoing and I expect the PCT carefully to consider all the representations that it receives.
It might help the House to weigh up what the proposals mean in practice if I explain that Evesham hospital conducted around 32,260 cases last year, spanning minor injuries, day hospital cases, and outpatient, inpatient and day cases. The combined total of discharges on Willows ward and Bredon ward was about 256. Of course, it is not very fair to set one figure
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against another but were I pressed to do that, I would point out that the total number of discharges from the two wards represents about 1.75 per cent. of total activity in 200405.
The hon. Gentleman challenged the idea of chipping away at the service. It is probably fair to consider exactly where the local PCT is talking about investing the money that it is being given. It proposes that there will be £700,000 for new NHS dentistry, £700,000 for new mental health services, £2 million to be directly invested in access to acute services and the move to a maximum 18-week waiting time, £700,000 for community services, including four new community matrons, an intravenous therapy team, a community rehabilitation team, a muscular sclerosis nurse specialist, a Parkinson's disease nurse, community health trainers for the prevention of obesity and three heart failure community nurse specialists. So the proposals that the PCT is weighing up do not relate solely to the issue of closing one ward; there is also the serious issue of what other investments will be made.
The hon. Gentleman mentioned the issue of Kidderminster independent treatment centre. My understanding is that the contract for that independent treatment centre was agreed on the basis of 100 per cent. new orthopaedic activity, as required by the local health community. South Worcestershire PCT was a signatory to the final business case and raised no concerns at that time. That was the basis on which that was put forward.
There are important choices ahead for the local community. I am reliably informed that the intention is to discuss the matter further at the PCT's board meeting on 3 August. Ultimately, decisions about the local configuration of services are not made from Whitehall. I think that there is a degree of consensus about these issues. Among some of the extremely interesting reading that I was ploughing through last week I came across an interesting quote, which thundered
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The hon. Member for Mid-Worcestershire made a number of constructive suggestions and I congratulate him on his engagement with local health professionals in structuring some of these proposals, which will be a valuable input to the board meeting on 3 August. However, I underline that the role of Health Ministers and the Department of Health is to secure adequate resources for funding the NHS and to set out the strategic framework for the NHS to work within. My hon. Friend the Member for Worcester mentioned the possibility and indeed the opportunity of provision for greater community capacity in and around Worcester. The Government will undertake an important public consultation on out-of-hospital care later this year. I encourage both my hon. Friend and the hon. Gentleman to be active players in that consultation, because as the future of health care changes, it is important to change the shape and nature of local health care provision.
Our policy structure allows decisions about local NHS services to be taken at a local level. It cannot be right for Health Ministers to stand in Westminster and write a prescription for what health services should look like in every community up and down the country. We have increased the funding for PCTs significantly. We have set the standards. It is now down to local PCTs to decide their local priorities. I look forward to hearing further news from South Worcestershire PCT as these plans are developed together with the local community, as it goes through the consultation procedures that have been set out over the weeks and months ahead.
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