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16 Jan 2007 : Column 209WH—continued
Mr. Stuart: The hon. Gentleman is right to raise those issues on behalf of his constituents, and many other hon. Members could tell us similar stories from across the country. That is why I am so glad to have the opportunity today to hear from the Minister, who will be able to address some of our concerns and perhaps announce a policy U-turn on some issues—we can but hope.
We currently have a large gap between ministerial rhetoric and the reality on the ground. For several years, the Government have recognised the important role that community hospitals can play. In 2000, the NHS plan, for those who can remember it, was to be the salvation of community hospitals. It committed the Government to introducing 5,000 extra intermediate care beds and said that there was
“near universal support for development of ‘care close to home’”.
In my area, care close to home is still used as the watchword, but care is being moved away and is now four-hours’ return drive from my constituents. “Keeping the NHS local: a new direction of travel”, which was published in 2003, stated:
“Community hospitals can provide a rich variety of local health and community services...One common theme for this type of hospital is a key role in the provision of intermediate care”.
The Labour party’s 2005 general election manifesto pledged to
“help create an even greater range of provision and further improve convenience”—
I would be interested to have that explained to my constituents. It continued:
“we will over the next five years develop a new generation of modern NHS community hospitals.”
Nobody could have predicted last year’s health White Paper, “Our health, our care, our say”, which was positively glowing about the merits of community hospitals. Normal users of English assumed that, when the Government said “community hospitals”, they meant community hospitals as commonly understood—in other words, as existing in 326 or 327 places across England. The document said that community hospitals provided better recuperative care than district general hospitals. In that respect, in my first debate, I mentioned an elderly man I met in Hornsea cottage hospital, but I mention him again because he helped to cement my commitment to community hospitals. When I first visited the hospital, I asked him, “What’s it like in here?” He screwed his face right up and said, “What’s it like in here? I had eight weeks in Hull Royal infirmary. When I woke up in here, I thought I were in bloody heaven.” That is how people feel in community hospitals and community hospital beds. When asked, patients say that they want more care provided in community settings. The White Paper said that intermediate care was
“good for the patient—it is often closer to relatives—and evidence has shown that care standards are higher.”
If the evidence shows that, it could have come only from the community hospitals that existed at that time, but they were not some new model of community hospitals—they were the existing ones. The document was everything that we could have hoped for, but as
things stand, Ministers are heading in the opposite direction. Policy announcements are not being followed through.
Up and down the country, the very community facilities needed to make the change from acute hospital-centred care to care provided much closer to home—either in the community or, where appropriate, in the home—are being closed down. Thousands of beds have been closed in community hospitals at the same time that the Government have espoused the need for care closer to home. That is the current conflict between stated Government policy and the reality on the ground—a conflict that must be resolved, and quickly.
I shall leave the Minister with a couple of questions and I should be grateful if he could answer them now; indeed, he could intervene if he wishes. First, may we have a definition of a community hospital? I fear that the Government have perhaps quietly redefined what a community hospital is without telling anyone. Perhaps the definition of a rural community hospital as being one that serves a catchment area of 12,000 or 20,000 no longer fits some national model for community hospitals. Without a definition or an explanation, it is hard to see what invisible hand is driving closures.
My second and most important question, to which I hope that the Minister will give greatest thought, is whether the Government are serious about listening to the patient voice. They have boasted, perhaps fairly, that they have insisted on formal, proper consultation to give local people a say over any changes in the health service; they have said that that is unprecedented, that the position is better than it was under the previous Conservative Government and so on. If they mean that, and if they meant it when they said that changes should be made only with people, not for them, let me ask the Minister one question. In Beverley and Holderness, and beyond into east Yorkshire, every GP surgery, every district nurse, every elected member of the Labour party, the Conservative party, the Liberal Democrats and the independent parties, every parish council, every community group and every school—literally everybody in the community—believes that the beds should remain. That position is unanimous, and not one person takes a different view. Indeed, we had two public meetings in Hornsea last year about a different matter, and I asked the chief executive about this issue at the first meeting. He did not answer, so at the second meeting, I asked “Has a single person agreed with your clinical argument that the proposals are an improvement?” He said no, and I certainly felt at that point that he surely could not carry on with the proposals. If the local communities in my area are utterly united, must the primary care trust listen? Is there anything that Ministers will do to make PCTs listen if they want to carry on and ignore the views of local people?
9.58 am
Mr. David Drew (Stroud) (Lab/Co-op):
I congratulate the hon. Member for Beverley and Holderness (Mr. Stuart), who has again chosen an important topic, on securing the debate. I also congratulate him on setting up CHANT, which is an all-party group. We have many common issues, as well as some differences, but those are locality based, rather
than party political. I also welcome the topic that he has chosen because it allows me to go wider and talk about what I deem to be community services, which have a community focus, but which may or may not come within the definition of a community hospital. In that respect, one problem—the Minister heard the hon. Gentleman’s question—is what we now mean by a community hospital, and it would help to clarify the debate if we had some response to explain exactly what we mean by the term.
I take issue with one point. If Conservative and Liberal Democrat Members think that only they are feeling the heat, they should come to Stroud, because we have exactly the same problems. I do not feel victimised and I have a good relationship with my hon. Friend the Minister—[Interruption.] Well, I should not feel victimised. However, the issue transcends party political debate, and our constituents feel strongly about it.
I think part of the problem is that the point at which we enter the debate, and the basis on which we conduct it, is sometimes as important as the outcome. People are concerned, and certainly confused, about where we are going. I have two points to make, beginning with a financial issue.
I have been through the whole process, in Gloucestershire, of a debate that has transcended community hospitals and has gone into maternity and mental health provision. The latter is a very live debate at the moment because of the potential closure of three smaller units for older people with mental health difficulties. An issue to be dealt with is what information is available, and the basis on which the financial decision is taken. Those matters also relate to the second area that I want to discuss: what are the underlying medical priorities or prerogatives? Those, too, are not easy to unpick.
As I have said, the debate is a live one in my constituency, where we face the closure of one community hospital, in Berkeley. One could argue that that makes complete sense, because although we are losing a community hospital we are potentially gaining another in the Cam and Dursley area, which happens to be where the majority of the population in the South Vale live. One could take the view that we are swapping one for another. If things were that simple I should have to say, taking account of the population, and with regard to voting, or whatever, that we should go with the place where most of the population live. Stroud is like many other constituencies, in that it is semi-rural. Parts are very rural, but there are concentrations of population in the market towns. If resources alone are considered, hospital facilities, or even medical facilities, should be where there are the largest populations, and people should be allowed access to those facilities. That is part of the problem: it would be okay if we lived in a world where people could get that access, through good public transport, but things are not as simple as that. If Berkeley is closed, other provision will be made, but I would always start to consider the issue from the other end: why do we not think of other uses that can be made of community hospitals, which may not currently be providing the services we want from them? I hope that that debate will go on.
I begin with the financial picture. Gloucestershire is typical, although, with my hon. Friend the Member for
Bristol, North-West (Dr. Naysmith), I might say that it is somewhat untypical. We in Gloucestershire felt that we had run a reasonably tidy ship with our budget, and because—I have said this before so I will say it again—we were in the strategic health authority from hell, with Avon and Wiltshire, which had significant underlying deficits which continue to this day, we felt a bit put upon when we had to find £40-odd million in savings in a year. As things have transpired, most of that money has been found. Whether it has really been found, or whether changes are still to come, we shall have to find out. When I entered the debate about these matters, I wrote to my then primary care trust, which, in the nature of a small PCT, sent my letter on to another PCT. We always had a strange situation in Gloucestershire—although we had three PCTs, on virtually every issue there was a lead PCT. In the end, therefore, it was not my own PCT that I corresponded with to try to get the information.
I simply asked for the information that would allow me to make a dispassionate decision, as best I could as a local Member of Parliament, on where the money was currently being spent and whether that was in accordance with health priorities. I wrote a letter last September, when the debate was at its height. It was a few weeks into the period in which we had been asked to send consultation responses. I sent responses about the maternity unit in Stroud and also about older persons’ mental health provision. I also made general comments on community provision. I am still awaiting a reply. I was at one time very critical of PCTs, because I am expected to make decisions on the basis of good-quality information. I asked only four or five questions. I wanted to know what each individual practice spent and how that related to areas’ health needs, because although there has been a debate about unfairness between areas, and the way in which the budget is divvied up, I am fairly certain that there are also instances of unfairness within areas and that the current distribution of spending does not necessarily reflect health needs, whatever we deem them to be. The location of the facilities does not necessarily respond to health priorities. I am still waiting, but I am less critical than I was, because when the figure were completed the new PCT chief executive refused to issue them, saying that they were embarrassingly wrong and that she would not issue them until they were right.
One thing that the current crisis has unearthed, for good or bad, is the dearth of good-quality information on what is being spent and by whom, and whether that spending is being done fairly. I hope that the Government will continue to push primary care trusts so that we receive that information, and so that I can make some proper judgments on the appropriateness of health provision. That really matters for community hospitals, because we need to know the implications as far as who goes to them and whether they receive the right provision.
My second topic is medical priorities. As we are talking about community hospital services, I shall consider mental health. Aspects of some of the decisions that have been taken worry me. There was an underlying pressure to cut with, in Gloucestershire’s case, an attempt to take from the partnership trust
35 per cent. of the budget with regard to older people’s services in mental health. That is a dramatic and indefensible cut. With regard to adults of working age we reallocated the money in question, through closing a centre in Cheltenham and concentrating facilities at Wotton Lawn in Gloucester. We took the money and put it into community and crisis teams, which makes sense. That cannot happen with older people’s health, so a continuing problem arises in that case.
The medical priorities give rise to difficult issues. The arguments that are always used include risk and the idea that there is, increasingly, a greater risk in providing services in very local, small-scale settings. The obverse of that is increased specialisation. Of course there are also many advantages to having consultants all in one place, even though they always seem to like going out to places such as Stroud hospital to do out-patients clinics—and, indeed, to Berkeley hospital. No attempt is being made to get rid of Berkeley in relation to out-patients. Those arguments always confuse me, because of the demand for more centralisation and specialisation.
Besides the fact that I want the Government to explain clearly what we mean by the terms “community hospital” and “community services”, it is important that we should understand that there are non-medical reasons for needing community hospitals. That is certainly true in relation to older persons’ mental health. I should like experimentation with intermediate care to take place. I have a vested interest: some hon. Members know that my father is in intermediate care at the moment. In my view, Berkeley hospital is crying out to be turned into an intermediate care facility, which will transcend health and social care and tackle some of the problems of who pays, and how. Community enterprise models could be examined and alternative streams of money could be sought. There is no big-time alternative to the NHS funded by the state, but there are models to consider. I hope that that debate will be taken forward.
The problem is that we always end up with the question: “Do we close this?” and, if we are lucky, we may get something instead. That is the wrong debate, and it gets a terribly emotional reaction from constituents. That is understandable, because they love their health facilities and hospitals. However, we must move the debate on to consideration of the two issues of fairness that I outlined, and other ways of providing facilities, including GP facilities. We must make sure, in addition, that the debate is not driven purely by medical priorities. There are other reasons why the facilities in question are important.
Miss Anne Begg (in the Chair): I should like to be able to call the Front-Bench spokesmen at 10.30 am. Four hon. Members have indicated that they would like to speak, so I should be grateful if they could keep their remarks to about five minutes.
10.10 am
Mr. Philip Dunne (Ludlow) (Con):
Thank you, Miss Begg. It is a pleasure to have you in the Chair. I start by congratulating my hon. Friend the Member for Beverley and Holderness (Mr. Stuart) on securing the debate. As he said, we have discussed these issues several times in the past 12 months or so. As usual, he
vigorously and vociferously championed his area and the cause of community hospitals in general. I also congratulate him on setting up CHANT, of which I am pleased to be a patron.
I participated in a similar debate a year ago when all three community hospitals in my constituency of 600 square miles were threatened with closure. I am pleased to say that the reaction in the community was so strong and vigorous that one of those hospitals is now secure and has managed to reopen the maternity unit, which was then closed, and has completed a redevelopment allowing additional services to be provided in Bridgnorth. The future of the other two remains highly uncertain, however, so I want to concentrate on them today.
In Ludlow community hospital, which is at least 25 miles from the nearest district general hospital, we suffered the loss of the mental health ward six weeks ago. That has meant a loss of jobs, closure of beds and disruption for patients. There are now no in-patient beds for acute elderly mentally infirm patients in my constituency. The only provision available is in a hospital in Shrewsbury that was built in 1843. I believe that it is the last Victorian asylum in the country that is still being used for mental health patients. The closure was against the preference of the responsible clinicians and happened solely because of the financial straits in which the primary care trust found itself.
We are also threatened with the closure of one of the two rehabilitation wards in Ludlow community hospital. That has been staved off entirely as a result of the vigorous community response: the PCT has agreed to a consultation period to allow the community time to come up with an alternative solution. Also, the minor injuries unit in Ludlow has been saved although the hours of operation have been reduced.
The other community hospital with an uncertain future is in Bishop’s Castle. The PCT board is meeting a week today to consider what to do with it. The board had a plan for its reconfiguration which would have involved a nursing home operator taking over management responsibility for the hospital and redeveloping the site. While that plan was seen as controversial in the town, it was at least a plan that the PCT had put forward, consulted on and was keen to progress with, but the plan appears to be doomed to fail almost entirely because of arcane accounting practices in the NHS.
The problem for the PCT is that the community hospital is too small. It sits in the NHS books at an accounting value below the threshold at which opportunities are available for larger hospitals to deal with the problem of impairment, with which the Minister will be familiar. The community hospital is leased from the county council so there is no freehold asset value available. The buildings are in the books at £704,000, which is below the £2 million threshold at which much more flexibility is provided by the NHS. Will the Minister address this issue in his remarks? Where is the logic for that arbitrary threshold? It is entirely within the power of the NHS to relax the threshold at which the NHS bank can be used to provide loans to PCTs to overcome impairment problems.
The PCT has approached Ministers, the finance director of the NHS, the strategic health authority, the
Department of Health bank and the county council—the freeholder and the nursing home operator. It has spent 11 months trying to come up with a solution to a £704,000 impairment problem. If it cannot find a solution by next Tuesday, there are no alternatives. All this is to save £150,000 of operating costs. A small-scale problem poses a threat of there being no hospital provision for a large number of my constituents in a remote area.
I deal now with what is happening in Ludlow and a potential way forward for Ludlow community hospital and others. The prospect of salami slicing into the size of activity and the services offered in Ludlow is so worrying to our community that we have been galvanised into trying to find a solution because the PCT is clearly incapable of doing so. At the initiative of the League of Friends, we are working with the local council and the PCT to find a social enterprise solution in which the commissioner-provider role is split and the community takes social responsibility for the provision of health care in the community.
Consultants were appointed last week to prepare a business case over the next three months to establish the viability of an independent Ludlow community hospital managed by the community, through a structure yet to be determined, that would fall outwith the PCT’s management. The idea is to release the management of the hospital from the shackle of the PCT’s financial constraints. Services would continue to be provided by the NHS under contract with the PCT and with nearby acute hospitals, which would provide some rehabilitation cover. The new mental health trust would take responsibility for mental health in Shropshire from 1 April and try to restore some of the provision that the PCT has ended. That is an imaginative way forward. We hope that it might be a pathfinder, certainly for our area within the SHA, which was very positive about the development, and might be suitable for other community hospitals. I urge the Minister to do what he can to ensure that that idea succeeds.
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