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Their workload is considerable. Without them that workload would land at the door of community hospitals and the NHS. Across the UK there were more than 58,000 admissions, of whom 42,000 were new in-patients; there were 30,000 deaths and 160,000 patients were visited by home-care teams. So hospices are an important resource in the communities they serve; they provide care that evaluates well and they relieve pressure on the NHS; but they cannot and should not operate in isolation. An example of integrated care is being led in the hospice world by Marie Curie’s Delivering Choice programme, which is keen to work with providers at every level. Local hospice services can provide in-reach services into

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community hospitals to ensure networked care. Community hospitals are not only a step down from hospitals and a step towards home, but they also provide a higher-tech environment than the hospice unit for some diagnostic and therapeutic admissions that do not need to go to a specialist or acute centre and for some drug monitoring.

However, many in their last illness are not imminently dying and they need services and support near their homes where a local hospice does not exist. No one should forget the social cost of caring. There are more than 6 million carers throughout the UK, about 12 per cent of the adult population. The number providing support for 20 hours or more every week has increased steadily and is probably over 2 million now. The number of heavy-end carers—those providing more than 50 hours of care a week—has increased at a proportionately greater rate. No one should forget that those providing this heavy-end care are twice as likely not to be in good health as those who are not carers. Those under 25 are three times more likely not to be in good health. It is also clear that mental and physical health deteriorates the longer carers continue to care, particularly when they do not get a break. I know that a third of those who have not had a break have mental health problems.

So community hospitals need to work with their local hospice services and with other community services to relieve the pressure on carers at home. With all the powers that were highlighted by the noble Baroness, Lady Cumberlege, in her opening speech, does the Minister recognise the huge resource that hospices provide? Can he assure us that the Government see integration across all sectors—home, hospice, community hospital and on to acute and specialist trusts—as a priority in the new NHS so that resources are best utilised, patients receive the most appropriate care to match their needs and carers are not worn to the ground by caring at home, nor by travelling great distances to visit someone they love in an in-patient unit?

8.16 pm

Baroness Masham of Ilton: My Lords, just before the Summer Recess, on a very hot day, a large lobby from the West Country and the New Forest campaigned for community hospitals. I was impressed by how the communities had come together. The lobby consisted of patients and their supporters, hospital staff and fund raisers. They wanted Parliament and their Members of Parliament to know how strongly they felt. All through the Summer Recess, in north Yorkshire, where I live, there has been a running campaign for the local community hospital in Ripon to stop cutting beds and for two units for elderly people with mental health problems to be retained. They also provide much needed respite care. Members of the public who know how important those facilities are have been organising petitions. The local councillors and the PCT members have been walking out of meetings and disagreeing with each other and the public have become more

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concerned as the Ripon community hospital has now cut its 20 beds by half, two of which are hospice care beds.

The Government keep saying that more healthcare has to be provided by primary healthcare, but the overspend led to the shortfall in other services, including the fast response teams and nursing, causing a shortage of district nurses in the Ripon area. The out of hours doctor service at the weekends and after 7pm seems to come from Harrogate, which is 26 miles away from Masham, where I live. The local surgery operates only from 9am to 7pm with a lunch break from 12.30 to 2pm, Monday to Friday, with a half day on Thursday. The local vet service also has an out of hours service, but the vets answer emergency calls quicker than the doctors. It is not surprising that the local population in rural areas feel threatened when they see their local services diminishing and they know that people are living longer and the Government have stated that there are more people with Alzheimer’s and dementias. Many of the local rural surgeries are not equipped to deal with many procedures that the Government are now saying could be undertaken in them. That is why the community hospitals have a role to play.

The Government have given a great deal of extra money but now the question is being asked, where has all the money gone? The maternity units up and down the country seem to be patchy. I have heard high praise from two people I am involved with: first, my secretary, who had a caesarean in a County Durham hospital; and secondly, a nephew and his wife, who enjoyed a natural birth in a birthing pool in east Yorkshire. Both families had successful births and praised the attention of the midwives, but there are other units that seem to be under a great deal of pressure and I am told that there is a baby boom at the present time.

May I ask the Minister a question particularly associated with London? It seems that there is an upsurge in births by caesarean. Is the reason for this that maternity units have become overstretched with midwives having to care for more than one woman in labour at a time and women being worried that complications will not be spotted in time and their baby will be placed at risk? As there have been some disturbing cases the risk of litigation may also be a factor. Are pregnant women told of the risks of caesarean births such as breathing difficulties and the need for specialist treatment for the babies? It also takes mothers longer to recover after the birth and they may be at a serious risk of infection. Whatever the procedure, does the Minister agree that the safety of the mother and the baby should be paramount and the safest procedure should be worked out before birth so that crisis situations do not arise?

I was invited to visit a GP’s surgery south of the river a short time ago and was told that health visitors are going to be cut. It seems worrying with a high amount of deprivation in that area. I thank the noble Baroness for airing this important topic and I look forward to the Minister’s reply.

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8.21 pm

Baroness Neuberger: My Lords, I too would like to thank the noble Baroness, Lady Cumberlege, for asking this Question and in this short speech I want to address maternity services. Women of my generation believed that the hugely successful campaigns for choice in childbirth had changed things. The Good Birth Guide generation would be able to give birth where and how they wished. Some wanted to give birth in warm water, some went for natural childbirth and others for home births. Some wanted an epidural; others, despite medical advice at the time, wanted a caesarean, and so on. It seemed as though things had truly changed, but towards the end of the 1990s that perception began to shift. Reform, the think tank, showed in December 2005 that women giving birth in NHS hospitals received less care from their midwives than 10 years earlier.

To support the question of the noble Baroness, Lady Masham, the number of hours worked by midwives in NHS hospitals fell 14 per cent between 1994 and 2004. In 1994 60 per cent of midwives worked full time. By 2004 that figure had fallen to 39 per cent. In addition, the Council of Deans of the nursing and health professions representing nursing and health faculties at UK universities voiced its fears in May this year that the NHS would by 2009 be stuck with a chronic under supply of nurses, midwives and other allied health professionals because of cuts. But, as of last month, we are being told by David Nicholson that there may be as many as 60 reconfigurations of NHS services, some—perhaps all—of which will affect maternity services. That runs alongside a government policy, as stated in, Our Health, Our Care, Our Community, of expanding community provision for expectant mothers. It stated:

That acknowledged that women were not being able to choose where their baby was born.

However, in, Our Health, Our Care, Our Say: making it happen, published on 18 October, there is no explicit mention of maternity services—at least, I could not find one. The Minister in another place, Andy Burnham, said that decision-making is a matter for PCTs and strategic health authorities in consultation with the local population. That may be right. Nevertheless, something strange seems to be going on here. Part of that may concern a real difficulty.

In Stroud, a renowned local midwife maternity unit was given a last-minute reprieve last month after strong local objections to its projected closure because of local health service debts. Near where we live, in Leamington Spa, people in Banbury are up in arms about the Horton Hospital—not to mention Kidderminster, not very far away. At the same time, there are clear clinical reasons for shifting some services to specialist centres or to newer configurations, as the noble Baroness, Lady Murphy, said. That needs to be much better explained or consulted on. The case of Stroud is not alone. Nor is

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its future assured for the long term, unless the Minister can give us those assurances this evening.

David Nicholson said that the NHS had to tackle the “wicked” issue of maternity services. He said

For whom is that true? For all pregnant women? The noble Baroness, Lady Emerton, has already pointed out some difficulties that have occurred in some of those acute hospitals. How can the Secretary of State for Health announce £750 million for local people to set up and develop local community services, as she did, if David Nicholson wants to cut community maternity services, which are hugely popular—and, for women without complications, often preferable?

If the promise is that all women will have choice over where and how to have their babies by 2009, how will what seems to be happening now with community services help; and how will the Government monitor whether it will be possible for women to choose? We seem to have two conflicting policy objectives. Since we have the fifth most important person in the NHS here—the Minister—perhaps he can explain how the Government will make that possible.

8.26 pm

Lord McColl of Dulwich: My Lords, I, too, thank my noble friend Lady Cumberlege for securing this debate about these vital services.

As the custom of this House is to talk only about subjects that one thinks one knows something about, I shall confine my remarks to community hospitals, because, for 15 years, I had the privilege and enjoyment of working in one such hospital one day a week—in Edenbridge, in Kent. It is run by five first-class GPs and is a great morale booster for the local population and staff. They have a rather revolutionary practice: they keep the place spotlessly clean. Not only were there no complaints about cleanliness; there were no complaints about catering or patient care. That hospital is now threatened with closure, through no fault of its own.

Community hospitals play an important role, as has been said, in the local healthcare system, contributing general medical care and rehabilitation after strokes and operations. It is estimated that there are 4,000 GPs working in community hospitals. On average, they are called into their hospital five times a week and carry clinical responsibility for resident patients. Community hospitals almost always stay within the constraints of their budgets set by the PCTs, but the new Department of Health system of payment by results, which pays acute trusts for the work that they do, makes no provision for the in-patient care provided by community hospitals. Acute hospitals have not been willing to share their income with the very hospitals which take their patients for rehabilitation. In the case of elderly patients, that may require an extended period.

Indeed, community hospitals have also been very helpful to the NHS in taking patients who could not be discharged and who were therefore blocking beds.

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Bed blocking does three things: it prevents the admission of patients for elective operations; it diverts acute admissions to other hospitals; or it causes excessive delays in accident and emergency departments.

Despite appeals to the Secretary of State to set a tariff for community hospitals and establish a fairer financial system between acute hospital trusts and community hospitals, the Secretary of State has stated to my friend in another place, Sir John Stanley, that community health services are outside the scope of payment by results and that funding must be negotiated locally. This proves very difficult when many acute hospital trusts and PCTs are already overspending their budgets.

In the light of the Government’s clear wish that community hospitals are not closed for short-term budgetary pressures and their wish to see community services take on more work, why can the Government not ensure that the PCTs are given the financial support to keep open the very community hospitals which fulfil their criteria? We must not let the present crisis of funding in the NHS sweep away an extremely valuable and treasured resource which will be irreplaceable.

Many community hospitals were created by voluntary contributions and efforts and continue to be supported by their local communities. Their demise would mean this support would be lost. They have very strong and loyal support from the communities they serve and this support has been earned by many years of dedicated service. The public’s strong support is quite easy to understand. The opportunity for continuity of care from the patient’s own GP team, the friendlier surrounding and the proximity to the patient’s home and family make them an excellent environment for recovery and rehabilitation.

With these convincing arguments, acknowledged by the Government’s 2005 election manifesto and again by their White Paper in January, can the Minister explain to the House why community hospitals are still closing and why many more still remain under threat of closure, especially considering the Government’s wish to provide more healthcare closer to people’s homes?

8.32 pm

The Minister of State, Department of Health (Lord Warner): My Lords, I am sure we are all grateful to the noble Baroness, Lady Cumberlege, for the opportunity to have this debate this evening on this important topic. I am extremely flattered by the power that she and a number of other noble Lords have invested in me. I have to disappoint her a little by saying that I am going to resist this overwhelming power that the Health Service Journal seems to have invested in me by not succumbing to telling large parts of the NHS how to plan their local services in great detail.

I have to say that I was mildly surprised by one or two of the speeches from the Benches opposite. I know it is a long time since they have been in government, but they were in government from time

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to time, and I thought they were now also in favour of giving a fair amount of independence to people locally. That is the principle on which I am operating.

This Government are committed to transforming the NHS. Questions have been asked this evening about where we spent the money. One of the things we have done is invest over £1 billion in new and refurbished GP surgeries and we have opened over 42 LIFT projects with another seven in procurement. These do enable local parts of the NHS to provide a wider range of services in community settings. We have had to spend a lot of this money to improve the pay and the numbers of NHS staff, to deal with the appalling fabric in parts of the hospital service that we inherited, and to tackle the extremely long waiting times that we inherited, which in some cases led to unnecessary deaths.

So we have put a lot of money in and my understanding of many of the patient surveys, including those from the Independent Healthcare Commission, is that people who actually experience the NHS recognise the improvements made, as distinct from those who may be excited by misleading reports in the media. Patients have told us that they want more care closer to home and many professionals support this. We are committed to providing more community services in a range of settings as part of this programme.

I have to say to the noble Baroness, Lady Cumberlege, that I do not resile in any way from the flexible definition of community hospitals that we have used. I do not think we want to go in for the kind of rigid definition that she seemed to be suggesting. That will only fetter the ability of local communities to design services which meet their local needs in a way which is suitable for today’s and tomorrow’s society.

We also have a bold vision of radically improved maternity services, which I will say more about later. By 2009, all women will have a range of choices of where and how they have their baby and what pain relief they use. Every woman will have continuity of care before and after birth, provided by a midwife she knows.

There is a clear synergy between our vision for community services and our vision for maternity services. We expect local commissioners to ensure that the new generation of community hospitals and services include in many cases good-quality maternity services. Nothing that we have said would prevent that.

In January we published a White Paper, Our health, our care, our say, which reiterated our manifesto commitment to develop a new generation of modern community hospitals over the next five years. Listening to some speeches, one could start to assume that all community hospitals as they are today would be fit for purpose for the years to come. Some of them may be so but many need to change. I was much heartened by the fine speech of the noble Baroness, Lady Murphy, who drew attention to the fact that sometimes facilities outlive their usefulness and have

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to be replaced. That is part of having a mature debate about the NHS, instead of ossifying hospital services in a form which no longer meets local needs.

In July we published Our health, our care, our community: investing in the future of community hospitals and services. I am pleased to learn that the noble Lord, Lord Fowler, actually read our press notice, although I am sorry that he did not like it more. The document sets out in detail how we plan to develop new community hospitals. It announced the investment of £750 million capital funding over the next five years and gave detailed guidance to primary care trusts that wish to bid for some of that capital.

The publication told PCTs that we want new community hospitals to be safe, effective and affordable. We want them to span primary and secondary care, a boundary that is sometimes artificial in today’s age. Wherever possible, we want to see social care and other public services brought in to some of these new developments. We want them to use innovative funding models and to be designed in consultation with local residents. We want to see the third sector and the independent sector play a role in the development of these new services so that they are fit for purpose in local communities.

The department has received the first round of bids. Eleven proposals have been submitted from eight of the 10 SHAs. Officials are reviewing the submissions and collecting more information. I hope to be able to advise successful bidders and make an announcement well before the end of this year. We will move speedily to approve the bids and get things moving on the applications.

I make no apologies for standing by the definition I gave of a community hospital.

Some noble Lords chastised us slightly because this is a capital project not a revenue one. But the Treasury has defined capital spending, as did a number of distinguished ex-health Ministers on the Benches opposite. You cannot substitute capital for revenue in such a way. This has always been a capital scheme.

I can tell the noble Baroness, Lady Finlay, that the scope of the new community facilities that we hope to see developed provides opportunities for better support for carers. They can provide opportunities to produce more help with palliative care and to support hospices. It is down to local people to decide what is fit for purpose in their community hospitals. We do not want to fetter them in taking forward those ideas.

In September 2004, we published the maternity standard in the National Service Framework for Children, Young People and Maternity Services. It requires that women can choose from a range of ante-natal, birth and post-birth care services in their local area. We followed this with our manifesto commitment that by 2009 all women will have choice in this particular area. This brought forward the timescale for the implementation of key elements of the maternity standard from 10 to five years. We have outlined a lot of detail since then.

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