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Bromley Hospitals NHS Trust

Volume 475: debated on Tuesday 29 April 2008

I raised the issue of Bromley Hospitals NHS Trust in a debate last July, and I want, through the Minister, to thank the Secretary of State—it is the same Secretary of State—for his written response to the points that I made. I make no apology, however, for returning to the subject today, because the issue is of great importance to my constituents, as the Minister will appreciate. The situation remains extremely unsatisfactory, and important decisions will be taken soon, so it is vital that the Government make the right decisions and have the appropriate input. What I have to say, however, is no reflection on the trust’s clinical staff, who do a heroic job of keeping the ship afloat. I continuously hear that much good medicine is being practised in the trust, but the situation in which staff have to work is very difficult.

The trust consists of two hospitals, both of which, as it happens, are in my constituency. The Princess Royal university hospital at Farnborough is a district general hospital with full accident and emergency facilities. It was built under the private finance initiative and is now seven years old. Orpington hospital is an older and smaller hospital, but it, too, received an infusion of capital five years ago, with £8.8 million being spent on new theatres and wards for elective surgery—hips, knees and that kind of thing. As hon. Members will understand, Bromley residents thought themselves lucky to have such excellent new facilities available to them, but serious problems have emerged.

The first problem is financial. The trust has operated at a loss every year. It now has debts totalling £100 million and it will lose more than £18 million in this financial year—2007-08—despite a cost-cutting regime. The interim chief executive forecasts that the trust will break even next year, but that is extremely unlikely given the present lack of progress, so the debt will continue to mount. Under the PFI scheme, payments of about £25 million a year are made to the owners of facilities, and that includes not only interest on private finance initiative borrowings, but payments for building maintenance and supply and support services. The trust’s financial performance is among the worst in the whole of England and Wales. The other day, the local newspaper—the News Shopper—quoted the interim chief executive as saying that repaying the debt would take between 50 and 100 years, which is quite an astonishing admission.

There are also problems on the medical side. The Healthcare Commission served the Princess Royal university hospital with an improvement notice after an inspection found blood stains on the walls and dust on the surfaces. According to the commission, the hospital is now off the sick list, but these events were a warning. Infection rates for methicillin-resistant Staphylococcus aureus and clostridium difficile are also a problem. Recent figures show an improvement, but the fact is that we are talking about a new hospital where there are still problems with cleanliness and infection.

The performance with audiology is among the worst in the country. I have had a succession of agonised letters from constituents over many years complaining of their inability to get a digital hearing aid in less than two, three and often four years, which is quite astonishing. Many of these people are in their 70s. In addition, the hospital’s maternity ward came out badly in a recent survey, and the hospital has had problems meeting its waiting time targets—both the four-hour accident and emergency target and the 18-week referral-to-treatment target.

The Minister might also be aware of the disgraceful treatment of local fundraisers, who, led by Mrs. Mary Spinks, have collected £500,000 for the Primrose centre for breast cancer care. I shall write to him shortly about that separate issue.

Another important point is that the management at the top level seems always to be interim, acting or short term. The present CEO is there for only six months and will leave in June. His predecessor was there for a year, while his predecessor’s predecessor was there for only a few weeks, which is ridiculous. Needless to say, all these people are on vast salaries.

In addition, there has been a positive frenzy of reorganisations, reports and consultations. The previous chief executive, who was there for only a year, has been taken away to head an interim executive team for the four local hospitals in outer south-east London. The team has been set up to see whether co-operation between the four hospitals could achieve economies of scale. Many people suspect—indeed, this has been talked about officially and privately—that this is a precursor to a merger between all four hospitals or between two or three of them.

The trust’s chief executive is heading a reorganisation exercise in south-east London called “A picture of health”—the Minister may be familiar with the consultation document. It is not easy to consult on such difficult issues, and anyone would have difficulty drawing up such a document. None the less, many of the options were pretty banally stated, with no real attempt to define the costs or alternatives. In the case of Bromley, it was almost pointless to answer the consultation, because all the options related to the hospital in Lewisham, not to the Princess Royal university hospital or the Orpington hospital in Bromley, where the options seemed to be taken as given. On top of that, of course, we have “Healthcare for London”, the document produced by Lord Darzi, who is now a Minister at the Department of Health, which has had a big impact in London. The situation is therefore not only bad financially, but dizzyingly complex, which makes it far more difficult for the trust’s management to make decisions. As a result, confusion is widespread and morale is low. The suspicion throughout is that decisions are financially, not medically driven.

What should be done? First, the primary and overall driving objective should be to put the medical staff in a position where they can deliver the quality of health care that I am sure they can. Secondly, a management team should be put in place that is committed to the trust and which can at least take a five-year view. I appreciate that it is difficult to attract people to management in the trust because of the uncertainties surrounding the positive plethora of consultations and rumours about mergers. However, the Government have helped to create the situation with their endless plans and should assist in resolving the issues so that committed, longer-term managers can be put in place. In that respect, we should also say no to mergers. In my experience as a former business man, mergers are often a distraction for management. It would be much more sensible for managers to focus on putting right what is wrong in the trust.

Thirdly—this is the point that I particularly want to address to the Minister—not only should there be a management that is committed to the hospital and to making it work, but that management should be given a workable financial situation. Here the Government have a plain responsibility. They signed off a bad PFI deal, which has now clearly come unstuck. The Government acknowledged that when they gave the trust a £6 million a year subsidy. They have now withdrawn that, admittedly step by step and not all at once; but the fact that they ever gave it shows that they were concerned that the PFI deal was a poor one. Now that the subsidy has been withdrawn, the costs of the PFI are coming home to roost. The situation is still bad. The PFI charge for the hospital is 10.4 per cent. of its annual income, which is nearly double the average charge of 5.8 per cent. That is the handicap under which the hospital starts.

The Government also precipitated the crisis that is affecting the hospital. They changed the regime governing all hospital trusts, away from the old-fashioned borrow and broker, by which hospital trusts could at the end of the year broker an arrangement so that even if they made a loss it would be worked out with surpluses from other trusts and so on. Two years ago, when there was a deficit in NHS funds nationwide, that was scrapped, and we now have a transparent and accountable system. I welcome that, but it led to the exposure of the difficulties into which the trust had fallen, and the Government precipitated that.

The Government have in addition brought in a national payment-by-results scheme. The problem with it is that the tariffs are based on average costs throughout the country, whereas the trust, because of its difficult PFI agreement, has higher than average costs. It is reckoned that the gap between the high-cost trust and an average-cost trust is between £7 million and £12 million a year, and that is a further disadvantage for the operation of the hospitals trust in Bromley.

The Government have some money: as a result of the tightening of the regime for all NHS trusts throughout the country, compared with two years ago, when there was a £500 million deficit, they now boast of a £1.8 billion surplus. Therefore there is money to deal with such difficulties, which are fallout from the action taken by them. Whenever I talk to the people who run the London NHS, they always say money is not a problem. The Government should take that into account.

If the interim chief executive officer of a hospitals trust can say quite openly that it will take between 50 and 100 years to pay off its debt, that is a ludicrous situation. Clearly, something must be done before then, and quickly; otherwise there will be an overhang that will destroy the hospital’s morale and ability to act. I therefore want a debt write-off in some form. That is necessary so that the hospital can be placed in a position where it can take decisions on medical grounds, not purely driven by financial requirements.

A fourth matter that I should like taken into account in the discussions that relate to the Bromley hospitals trust and all the reviews and consultations is the idea that we should use the facilities that we already have. There are proposals in the document “A picture of health” to move elective surgery from Orpington, and day surgery from the Princess Royal university hospital, somewhere else. However, both those facilities are new and work well. Why spend money to close them and move them elsewhere? That does not seem economically sensible. As the trust said in its evidence in relation to the document, with respect to the day surgery unit:

“The DSU at the PRUH consists of 6 operating theatres that are supported by 40 patient spaces. This is therefore the largest stand-alone DSU in OSEL”—

outer south-east London. The evidence continued:

“Indicative figures for a proposed ISTC at QMS quoted costs of £30 million...In addition...we consider that expanding the PRU DSU to 3 lists per day would mean that all the population could be treated without any added capital expenditure”.

That is the view of the hospitals trust, and I support it. It seems stupid to spend money when facilities exist and work well.

On the waste front, let us not waste money on big ideas that do not work locally. Lord Darzi’s health care for London strategy would mean, if applied to Bromley, that having spent £120 million on new hospital facilities, we would take income from them by diverting business to specialist hospitals and polyclinics. Of course, neither the specialist hospitals nor the polyclinics exist; it will cost money to build them. Therefore, we would be reducing the chances for the district general hospital to make money; it would make further losses and the Government would spend taxpayers’ money on building new facilities. As Professor Harrison of the King’s Fund said:

“There has been a complete failure to bring the elements of policy together...When they started PFI 10 years ago they were just blithely modernising hospitals and the ideas which are now prominent about centralising specialisation and shifting care into the community weren’t strong policy commitments. So the policies are now out of sync. It’s a mess.”

It is indeed a mess.

My conclusion is that modern facilities exist in the Bromley hospitals NHS Trust and there is an excellent medical staff. Therefore, the opportunities to provide good health care for the people of Bromley exist. The Government have a responsibility, for the reasons that I have given, to put the trust in a position to deliver that, but the Government can do so only if they take sensible decisions along the lines that I have described. Having taken them, they should let local people get on with it. There is no time to lose.

I congratulate the hon. Member for Orpington (Mr. Horam) on securing the debate on Bromley Hospitals NHS Trust. I congratulate, too, the health staff in his constituency on their hard work to improve services and performance. The hon. Gentleman will be pleased to know that the figures on the issues that he raised about accident and emergency and hospital-based infections are moving in the right direction, and millions of people—not just in his constituency but around the country—receive high-quality, safe services every day. However, he is aware, as I am, of the serious challenges that have confronted health care provision in south-east London for some time now. They go back several years.

In spite of record investment in the NHS—Bromley primary care trust received a 30 per cent. increase in funding for the three years between 2003 and 2006, and a 17 per cent. increase for the two years between 2006 and 2008—Bromley Hospitals NHS Trust, along with the three other outer south-east London NHS trusts, continues to report a deficit, and the Bromley trust was designated as one of the financially challenged trusts at the end of 2006-07, reporting a forecast year-end deficit of £18.5 million for 2007-08. The financial problems of that trust resulted from poor financial management over several years, but the new executive team is tackling the issues, and, as the hon. Gentleman acknowledged, although he expressed some scepticism, their plan is to break even in the financial year 2008-09.

As a result of some of the challenges, what to do about health care in south-east London has been hotly debated now for a considerable time, but at long last the health service in the area has come together with proposals that have gone out to consultation. The hon. Gentleman, being very interested in the subject, will I am sure be aware of the details of the proposals, and I do not want to go through them in detail now, but I want to highlight the fact that the Princess Royal hospital in Farnborough, the main part of the Bromley Hospitals NHS Trust, has been proposed as a major admitting hospital under all three options subject to the consultation. Indeed, under all the options, his hospital’s services would be enhanced.

Enhancements would include improvements to maternity, including more options for mothers, midwife-led and home births and 98-hour consultant cover; an enhanced critical care facility with improved quality for patients; and improved specialist rotas for medically ill patients, allowing them to be admitted under a doctor who specialises in their condition.

I am also aware of the representations that the hon. Gentleman mentioned about the future of elective services at Orpington hospital. They will be considered in the round as part of the consultation, but I assure him that whatever the outcome of the final consultation, Orpington hospital will continue to provide a valuable outpatient and diagnostic service to his community.

We all know that it is natural for concerns to be raised when changes are proposed to how health care is organised in a particular area, but changes are not made for change’s sake or to save money, although waste and duplication in public services should be deprecated. The reason for the proposals affecting south-east London is that doctors there tell us that the current pattern of care delivers a substandard service to the public and even puts lives at risk. The four medical directors of the hospitals involved said:

“We have looked at the best way to provide hospital services for the whole population. We have not been talking about which site provides the service, but rather how we can best meet the hospital needs of the 1 million people in the area as a whole. There is a high level of consensus amongst colleagues about the recommendations we are making. It has taken a lot of work to get this far, and everyone is very excited about the opportunity for those who deliver the service to take advantage of this opportunity to provide better care for our patients.”

Professor Sir George Alberti, the country’s leading expert in service design and in emergency care in particular, said:

“It has been obvious for some time that safe, high quality services will not be possible in the future unless services in outer south-east London are redesigned.”

The Minister may be aware of other papers produced by substantial numbers of consultants, such as those at Queen Mary’s hospital in Sidcup, which state the contrary opinion that although some of the change is certainly necessary, some is not, and that to close down new facilities that work well in favour of facilities not yet built is complete madness.

I am sure that the hon. Gentleman will acknowledge that it is also in the nature of consultations on service reorganisation for some consultants at hospitals that do not expect to come out as well as others to have a different view. It is the job of health care professionals and the management of primary care trusts in south-east London to sift through all the proposals and work out in consultation and in a transparent and open way what the best outcomes are for the public in the area, rather than bowing to special pleading on behalf of some professionals.

Obviously, some people are arguing for their own interest, but I would not like the Minister to go away with the idea that the consultants are united on the issue.

I would never do that. They very rarely are on a process such as this.

To continue, George Alberti said:

“Many good ideas are included in the current proposals…we were impressed by the enthusiasm for making tangible improvements…None of the Emergency departments are adequately staffed with consultants. It is recommended by the College of Emergency Medicine that there should be eight to 12 consultants per Emergency department, with the aim of having a consultant presence in the department from 8.00 am to 12 midnight, 7 days per week. None come close to this.”

Similarly, the outer south-east London surgery and critical care group said:

“Some patients require ‘critical care’ in the Intensive Care Units—either as the result of an accident or emergency…There is considerable evidence to show there is a better chance of survival in a larger unit”.

The outer south-east London maternity group said that the Royal College of Obstetricians and Gynaecologists recommends that the consultant presence on labour wards be increased from 40 to 98 hours a week. The group agreed recently that

“the…standards for 98 hour consultant cover, which will provide safer maternity care, can be achieved if services are reconfigured across the four hospitals”.

I admit that clinician support for one or another of the options on the table is not unanimous, but it is strong.

Formal consultation on the proposals ended on 13 April. I am informed that about 9,500 responses have been received. They are being collated and will be independently reviewed by Imperial College’s Centre for Health Management. I understand that the team in charge of developing the proposals expects to make the consultation results publicly available in June this year, and that the primary care trusts aim to take a final decision at the meeting of their joint committee this summer.

To respond to the hon. Gentleman’s points about finances, I referred earlier to the fact that Bromley is one of a small number of financially challenged trusts. Most of the financially challenged trusts with which we had to contend some years ago have reached solutions to their problems. Indeed, most of the 17 announced last year have now agreed solutions with their strategic health authorities that will help resolve their problems. The four in south-east London are slightly behind the curve because of the seriousness and complexity of their problems and the connection with reorganisation. However, I understand that NHS London’s provider agency continues to work with each trust to develop a range of options for solving indebtedness while maintaining standards of patient care and value for money.

I cannot promise the debt write-off requested by the hon. Gentleman, as that would not be fair to other trusts that have been through serious problems and taken difficult decisions to get themselves into financial balance. We have managed to find solutions for trusts in other parts of the country, enabling them to agree long-term recovery plans so that services are not negatively affected and they can get on with planning patient care without constant concern for a long-standing debt hanging over them. I assure the hon. Gentleman that my Department is working closely with the London strategic health authority to identify solutions for the trusts in his area similar to those that we have implemented in other parts of the country.

The Minister says that the four trusts are behind time in achieving some results. When does he expect results will be forthcoming—this year or next year, perhaps? When can we expect some results?

Within the course of this year, I hope, as we proceed with the consultation and the outcome of the consultation as a package. I hope that the strategic health authority will be able to reach an arrangement with the trust similar to the arrangements reached by other SHAs with the small number of remaining financially challenged trusts around the country. I cannot give the hon. Gentleman a categorical assurance of that, but it is my hope.

The hon. Gentleman raised local issues about audiology waits, which I know have been a problem in his area. I am told by Bromley hospital that it currently reports no waits of more than six weeks for audiology assessments. In January 2008, Bromley Hospitals NHS Trust received an extra £250,000 from Bromley PCT to meet the increased demand for audiology services. The funding has allowed the trust to appoint an additional audiologist to work with the team and to send a significant number of patients to Guy’s for treatment. On the Primrose centre, I am advised that the trust is willing to reach an agreement and confident of reaching one that will satisfy him and his constituent about the problem. If he writes to me about it, I will send him written clarification that he might find helpful.

I am sure that the hon. Gentleman recognises—I think that he acknowledged it in his speech—that the status quo is not an option for the NHS in south-east London. It has gone through a difficult period for historical reasons, but it is now coming through and has finally developed a vision of the area for the future. I hope that after the consultation is over, the PCTs can agree on a forward strategy behind which we can all unite. The health service in his area has made huge progress in the past few years despite the difficult backdrop, thanks to the hard work and dedication of its staff. With increased funding, that has enabled the provision of better care for patients.

When we talk about reorganisation, we are not talking about cost-cutting, although in a situation such as Bromley’s where there are historical financial difficulties, it is always difficult to attempt any reorganisation without people claiming that it is about cutting costs. However, I hope that I have illustrated with views taken from leading doctors and other clinicians in the hon. Gentleman’s area that we intend to reorganise to provide better, safer services for his constituents, better outcomes for patients and better safety and quality of care. That is what is driving change.

I hope that the hon. Gentleman is reassured that whatever happens—this is not necessarily the case for some of his fellow south-east London MPs—the hospitals in his constituency have a very positive future indeed. They will enjoy an enhanced future, whatever option is decided on. I appreciate his role and interest in expressing his constituents’ concerns about the future of health services in his area, and I encourage him to continue to engage locally with the NHS to help it improve services.

Question put and agreed to.

Adjourned accordingly at one minute to Two o’clock.