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The tools of the trade for any Government are language and it is important to be precise. In July, the Government published a sequel to their White Paper, called Our health, our care, our say. It contains a diagram which defines a community hospital as one which offers multi-use community clinics, intermediate care, integrated health and social care, or is a remodelled general hospital—presumably with or without beds.
PCTs or trusts will argue that after closing all in-patient facilities, minor surgery and minor casualty, but retaining two or three physio sessions, the hospital is still open. That is dishonest and it does not wash with the public. The public do not recognise a multi-use clinic as a hospital. They perceive the closure of in-patient beds as a significant loss of services. So, can we agree that a community hospital is, in essence, a small local hospital with 20 to 30 beds, a range of clinics, rehabilitation, a minor surgical and a minor injuries unit? Anything less is a con. Some community hospitals have other facilities such as hospice care, or birthing centres, but they are in addition to, not instead of.
Using my definition, which is drawn from one used by the Community Hospitals Association, out of 320 community hospitals in England, 107 are under threat and 10 have closed this year alone. This has happened when the Government have explicitly stated that,
- “community facilities should not be lost in response to short-term budgetary pressures that are not related to the viability of the community facility itself”.
Community hospitals rarely exceed their budgets. Their beds cost between a third and a half of an acute bed. They are efficiently run with committed staff. The food is edible, the infection rate low and the quality of care high, because neighbours are looking
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The public value these hospitals and recognise that they are closing to pay off other debts—and the public have taken to the streets. Angry protestors are marching across England—in Gloucestershire, Suffolk, Norfolk, Cumbria, the New Forest, Wiltshire, Shropshire and Oxfordshire. It is sad that these areas do not show up on the Secretary of State’s political heat map. Few are in Labour seats. They are in market towns and rural areas—out-of-the-way places that Labour finds hard to reach. The Minister is quoted in this week’s Health Service Journal as saying that some trusts are pretty inept in the way they go about consultations on service reconfiguration, presenting a fait accompli, rather than involving local people. So, being the fifth most powerful person in the NHS, and clearly concerned, what measures is the Minister going to take to ensure that PCTs listen and involve local people; and, where they have not, what is he going to do about it?
Change requires resources. The sum of £750 million has been allocated over five years for the refurbishment and equipment of community facilities. I do not want to be ungrateful but this smacks of a Treasury initiative—Big Brother providing the wrong solution for the wrong problem. NHS LIFT and other capital schemes involving the private sector are available. It is revenue that is in short supply, not capital.
The original benefactors, like my husband’s great-grandfather, gave their hospitals to the local community. In 1948, with great generosity, they gave again to the new NHS—a health service now owned by the people. Today, that generosity is being denied to the local community. Sites are sold to pay off some remote debt unrelated to the local population. Marvellous Leagues of Friends voluntarily paint wards, make curtains and raise funds for buildings and equipment, but they cannot provide trained staff day in, day out. So, as the fifth most powerful person in the NHS, will the Minister negotiate with the Treasury to ensure that this capital fund can be used flexibly and be converted to revenue, as and when the need arises?
I turn to the subject of birthing centres, maternity and midwife-led units. The issues are very similar. Supermarkets driven by consumer demand have realised that people want convenience, diversity and choice. Tesco and Sainsbury, having invested heavily in large stores, are now diversifying in small convenience stores, locally sited. The NHS, as always, forced into short-term expediency, is working against this social trend. It is centralising and reducing choice.
The defence is that units close because they are not popular—that is not true. What happens is that those intent on the closure say, “We will keep this unit open but only from 9 am to 5.30 pm”. Unsurprisingly, women say, “How can I guarantee my baby will respect working hours and arrive just then? I had
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The Birth Centre Network has worked for three years to further enhance midwife-led units and establish quality standards—an initiative applauded by Stephen Ladyman, then the Minister responsible for maternity services. What progress have the Government made in funding this project?
Today’s PCTs, in turmoil, broke and pressurised to break even, see a line in their budgets and think, “Cut the birthing centre and save £0.25 million”. But they fail to think of the additional costs in the high-tech maternity unit—the additional unneeded, unwanted, highly expensive interventions, not only in cash but also in health terms. Will the Minister, the fifth most powerful person in the NHS, honour the undertaking given by his colleague, Stephen Ladyman, to undertake an economic appraisal of the costs and benefits of birthing centres?
According to the Office for National Statistics, the birth rate has been increasing for the past five years. The Government Actuary’s Department predicts further increases over the 2003 birth rate. Today, 18 birth centres or midwife-led units are under threat, nine have closed temporarily and three have permanently closed. In addition, other maternity units in district general hospitals are under threat. With units closing, where are these women to give birth?
There have been shameful incidents where women in labour have been rushed from one hospital to another searching for a maternity unit—this at a time when in July Ivan Lewis, the Minister now in charge, emphasised that maternity services are a priority and that the Government will meet their manifesto commitments.
So to my final question. The Government extol choice, which is very popular. They believe that more care should be provided closer to home, which is also popular. Therefore, can the Minister—after all, the fifth most powerful person in the NHS—explain how the Government’s policies will be implemented when decisions are devolved and locally ignored?
7.55 pm
Baroness Murphy: My Lords, I thank the noble Baroness, Lady Cumberlege, for bringing forward this debate today, although, unusually, I find myself in disagreement with some of what she said.
I came here today hotfoot from a hospital closure party. We were all given pens with which to write graffiti on the hospital walls, which was an extremely popular event. The Poplar and Stepney District Sick Asylum, which opened with great splendour in 1871, closed today at St Andrew’s Hospital, Bow. Not a single person was there to protest. The people in the local community are extremely pleased to lose their out-of-time, inadequate hospital and, instead, to be provided with splendid new facilities in other areas around the district and, in particular, at Newham General Hospital. It is a very popular hospital closure
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I declare my interest as a member of the board of Monitor, the NHS foundation trust regulator, which is examining with interest and some excitement the possibility that some community hospitals and wider community health services could be delivered via foundation trust status. That would be a practical means of injecting improved local accountability and bringing better financial and managerial rigour and service innovation into the community services sector. This is a £7.5 billion industry and perhaps it needs a little more rigour to be brought to it. To justify effective governance and financial expertise in such trusts, sufficient size is important—perhaps less than £30 million would be unwise—but I urge the Minister not to get too hung up on this or on the current geography of services. It may be better to let some specialist services thrive across larger areas, rather than leave existing generic services as they are.
In this brief debate tonight, I want to highlight three other matters: first, the need to increase the diversity of providers of community health; secondly, the importance of better commissioning of those services; and, thirdly, how crucial it is to understand the detailed costs if we are to make an impact on service delivery.
I have lived through numerous decisions and revisions relating to the role of community hospitals. There are still 450 of them, in spite of the alarms about closure, all the way through from the traditional cottage hospital at one end of the spectrum to, at the other end, a modern, almost bedless site for outpatients, diagnostic tests, minor operations and day treatments. I believe it is possible to have community hospitals without beds. However, we need to ensure that the next generation of community hospitals is the second sort, rather than the latter, traditional sort, where many of the services can be provided rather better by independent sector nursing homes and the spot-purchasing of beds of different sorts. The recent White Paper set out clearly what needs to be delivered, but the infrastructure to deliver that vision is not in place.
Revenue follows capital investment in the NHS, so the Government’s announcement of £850 million capital investment in such schemes is very welcome. But we must pause and consider why NHS LIFT, which, as the National Audit Office pointed out recently, has been relatively successful in getting new private money invested in GP premises, has not on the whole stimulated the new-style community services or the new kind of community hospitals which the Government support. The answer lies in the poor commissioning of services. Unless we strengthen the commissioning and detailed procurement of services, acute hospitals will continue to dominate. We have seen how difficult it has been for United Healthcare to make inroads into primary health and community health services in the teeth of reactionary opposition. Can the Minister tell us what steps the Government
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I was very encouraged to see in the Health Service Journal of 19 October a commitment from the Minister to unbundling the tariff for rehabilitation services—to encourage community-based options—and for diagnostics, too. This is crucial if we are to understand what money is being spent on community health and how we can begin to spend it better. When is some definite news expected on that unbundling work, which is so crucial to delivering the services that we need?
8 pm
Baroness Emerton: My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for raising this debate. I shall speak about maternity units.
Maternity services should be safe and of the highest quality, because, for more than 100 years, the midwifery profession has been regulated. Midwives are regulated by a set of midwives’ rules and a code of conduct. Formal supervision of midwives takes place, with supervisors of midwives accountable for ensuring that all the rules are followed.
There have been many changes in policy on who leads in the practice of childbirth, not least as a result of the input of the noble Baroness, Lady Cumberlege, into the Changing Childbirth report of 1993. However, whether hospital delivery or home delivery is the fashion, the priorities are a safe pregnancy, safe delivery of a healthy baby and a healthy mother. However, despite the regulations and supervision, all has not been well and we need to ask why.
The United Kingdom is renowned for a very low level of maternal deaths. The national average is 11.4 per 100,000 births, but, between 2002 and 2005, this figure rose dramatically, when, in Northwick Park hospital, 10 maternal deaths were recorded. This led to an investigation of maternity services by the Healthcare Commission. It identified common factors in nine of the 10 cases. They included: insufficient input from the consultant or a senior midwife, with difficult decisions often left to junior staff; failure in a number of cases to respond quickly where a woman’s condition changed unexpectedly; inadequate resources; agency and locum staff; the lack of a dedicated high dependency unit; a working culture which led to poor working practices, resulting in a poor quality of care; failure to learn lessons in the unit—the trust took action following the deaths, but the working environment was such that mistakes were repeated—and failure by the trust board to appreciate the seriousness of the situation. The board was aware of the high number of deaths and should have acted sooner to rectify the problems.
Sir Ian Kennedy, the chairman of the Healthcare Commission, said that the root cause of poor performance is often weak managerial or clinical leadership, which can leave problems unidentified or unresolved; in other words, the unit has become dysfunctional. As a result of the Healthcare Commission's report, an outside team was brought in to assist in rectifying the problems. It was led
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Sadly, this is not an isolated case of performance management of clinical care not being exercised. Commissioned by the Burdett Trust for Nursing, a report was recently published by the Office for Public Management entitled, Who Cares Wins: Leadership and the Business of Caring. A companion study was produced to back the OPM report’s findings, with evidence based on research by Plymouth University. Having studied a random sample of healthcare trust board minutes, researchers found that only 14 per cent mentioned direct clinical care.
The OPM report demonstrates that the business of caring is a whole-board issue and it argues that, if a more market-driven health system is going to deliver a new NHS, patient satisfaction and customer care need equal ranking with finance, targets and outputs on board agendas. However, it also makes it very clear that critical organisational factors need to be addressed so that the business of caring is led and managed in a way which is clearly accountable and which seeks, and acts on, patients’ opinions.
The unanswered question that emerges from the work which the Burdett Trust for Nursing commissioned is: how will NHS trust boards be encouraged to balance finance, targets and outputs on their agendas with patient care? Who will be accountable and have the authority at board level for the performance management of clinical care?
We surely cannot wait for units to become dysfunctional, whether they are maternity units, as in Northwick Park, or acute or mental health trusts. Patients surely deserve the highest-quality care delivered in the most cost-effective way. The strategy to introduce a dedicated person at executive board level who is accountable for the performance management of patient care is complicated, involving trust board executives and non-executives, as well as healthcare professionals.
Will the Minister give his support to the concept of having a designated person at board level accountable for performance management of clinical care and consider making resources available for the training that will be required for executive and non-executive board members? A designated performance manager of clinical care would be in the interest of ensuring that care and compassion become part of the agenda and a high quality of care for patients.
8.06 pm
Lord Fowler: My Lords, I congratulate my noble friend on securing this debate and on the way in which she posed the Question. One of the great mysteries about this Government’s health policy is
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The Government use the remarkably ugly word “reconfiguration” of services to explain what they are doing. Basically, that means closing some facilities to develop others. They are never entirely frank in public about the implications and, particularly, the closures. On 5 July, an announcement from the Department of Health trumpeted a,
without the press release quite making it clear that the promised £750 million was capital spending and not revenue, which is where the problems were.
However, the department knows as well as everybody else that the general policy that it is following involves hospital closures. They are difficult decisions for any Government to take, where, at the very least, the public should be able to expect that decisions are taken absolutely objectively. This is the one point that I want to make in this short debate.
On 3 July, two days before the “huge cash boost for community hospitals” press release, a meeting took place which involved not just health Ministers, but party political representatives of the Labour Party, including the party chairman, Hazel Blears, and political advisers from Number 10. I quote from the Times of 15 September, reporting on a number of e-mails which had come to it. The e-mails stated that Patricia Hewitt, the Secretary of State, called for those at the meeting to be provided with “heat maps”, showing public opposition and the potential political implication of any closures. Another e-mail from Patricia Hewitt’s private secretary asked for a political meeting to discuss the implications of the Civil Service submission on how services should be changed. The e-mails in the Times report went on to state that the Health Secretary wanted a political meeting to discuss the submission and that she wanted the health Ministers, the noble Lord, Lord Warner, and Andrew Burnham, to attend with their advisers, as well as Ms Blears with her two advisers and two advisers from Number 10. A further e-mail from Miss Hewitt’s diary secretary stated that Ms Blears had asked for a party representative to be included at the Department of Health meeting. Later, a spokesman for Ms Blears confirmed that the meeting had taken place, but said that, because it was political, there was no record of who was present. He said:
This is a serious matter which goes to the heart of how the Government are run.
For six years, I was Secretary of State for Social Services and I had one special adviser. My Ministers of State—unknown people like John Major and Ken Clarke—had a no special advisers whatever. At this meeting there appear to have been six or seven special advisers. However, I find it utterly extraordinary that
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There is one man who can answer those questions: the noble Lord, Lord Warner, who was at the meeting. Will he confirm that such a meeting took place? Will he explain what he understands by “heat maps”? Will he confirm the membership of that meeting and confirm that no note was ever taken of it? Above all, how can such a clearly party-political meeting be justified to consider an official submission on such issues of health policy? Should not any policy involving closures be fair and clearly seen to be fair? Is there not a danger at the moment of the whole process appearing tainted?
8.11 pm
Baroness Finlay of Llandaff: My Lords, I too thank the noble Baroness, Lady Cumberlege, for instigating this debate and for the way in which she opened it. I declare my interest in palliative care. I wish to address hospice services as a community resource, the way in which they integrate with community hospitals, and the fact that I believe that they should be more integrated than they are.
The in-patient beds in the community are an important resource. At the moment, in England there are 176 units, providing 2,624 hospice beds. This patient-focused community resource is effectively subsidising the NHS provision to a great extent. Last year, English adult independent voluntary hospices spent £326 million on providing services. It has been estimated that if the NHS were to provide a similar service to that provided by the voluntary hospices, it would incur expenditure of around £415 million, unless it also benefited from the equivalent volunteer input that the local community services attract and are able to motivate and maintain. But the hospices, despite the £415 million that the NHS would have incurred, received only £119 million of NHS funding, leaving about £208 million as non-NHS funded expenditure. It is worrying that over a quarter of hospices recorded a deficit last year.
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