My Lords, with the permission of the House, I wish to repeat a Statement on community hospitals made in the other place. The Statement is as follows:
“In the White Paper Our health, our care, our say: a new direction for community services in January, we outlined our proposals to create a new generation of community hospitals and services. Today I am announcing that we will make available up to £750 million of public capital investment to realise that vision and I am publishing guidance on how primary care trusts can access this money. A copy of the guidance, Our health, our care, our community: Investing in the future of community hospitals, has been placed in the Library, and copies are available for honourable Members from the Vote Office.
“Developments in medical technology and clinical practice are making it possible to provide far more care in local communities closer to where people live and even in people’s own homes. During the unprecedented public consultation for Our health, our care, our say, people made it clear that whenever it is safe and effective they want more convenient local and personal services with more consultations, diagnostic tests and treatments carried out in local facilities. Moving more services out of acute hospitals and into communities will help improve care for patients and deliver better value for money for taxpayers.
“We are already making a major investment in GPs’ premises and health and care centres, as well as community hospitals. One billion pounds of capital has been invested through the NHS local improvement finance trusts alone. We will now take the next step by making up to £150 million of capital available starting this year, and for each of the next five years—a total of up to £750 million—for the development of a new generation of community hospitals and services.
“This investment capital will be available to primary care trusts for a wide range of community schemes, including the redevelopment of some existing cottage hospitals. Services could include both in-patient and out-patient facilities, diagnostic tests, specialist clinics, minor surgery, health and social care services for people with long-term conditions, dentistry, rehabilitation, and palliative care and other services. For people who are seriously ill or injured, or people needing complex treatments, care will of course remain in acute hospitals, where patients can be treated by specialist teams using the most advanced technology.
“Primary care trusts that want to use the new investment capital will need to engage fully with local people to ensure that services are truly designed around the needs of patients and users. They will also be expected to work closely with other local partners, including GP practices and other NHS services, the local council, voluntary organisations and others in the independent sector to develop effective plans.
“We made it clear in the White Paper that decisions on the long-term future of existing community hospitals should not be made solely in response to short-term budgetary pressures that are not related to the viability of the community facility itself. We have asked strategic health authorities to assure themselves that all PCT proposals for changes to community hospitals are consistent with the long-term strategy of the White Paper to move care closer to patients’ homes, and to be reassured that local people have been properly consulted.
“Ultimately, however, changes in the configuration of local healthcare services in a particular area need local decision-making. Primary care trusts, with their broad perspective across hospital, community and primary care, are best placed to make those decisions in consultation with local people and their strategic health authority. This new investment fund will make it easier for PCTs to get the right services in the right place for the people they serve.
“Primary care trusts will be able to choose how they use the new capital available: investing it simply as public capital, extending the scope of their local investment finance trust scheme or adopting a new approach, a community venture. This is a more flexible joint venture approach that will provide the opportunity for a wider range of public, voluntary and private parties to pool their skills, or indeed their investment, for the benefit of the local community. Which model is adopted will be a matter for the PCT to decide.
“Whatever model is chosen, primary care trusts will of course need to demonstrate that investment proposals are sustainable and can be funded over the longer term. As we set out in the White Paper, we expect to see a strategic shift in how the NHS provides care, with a redirection of funding to support the provision of more convenient services in local communities. Primary care trusts that already have advanced plans for community services should submit their proposals to their strategic health authority by the end of September 2006. For schemes ready to start in 2007-08, proposals should reach the SHA by the end of December 2006, after which there will be a regular rolling programme managed through strategic health authorities.
“This new programme builds on the unprecedented investment that we have already made in the NHS. It will help to ensure even better services for patients, with better value for money. I commend it to the House”.
My Lords, that concludes the Statement.
My Lords, the House will be gratefulto the Minister for repeating the Statement. An announcement of new money for healthcare will always look like good news, and I very much hope that over the next five years this investment fund will provide a beneficial source of service improvements to patients throughout the country and to the PCTs that serve them.
At the same time one wonders how new this money is and how significant it will prove to be. These are capital moneys. Last year the NHS’s capital budget was underspent by £1.162 billion. There is no shortage of capital at this level. The shortages are in revenue funding. Over the past few months community hospitals have been closing not because PCTs have lacked capital, but because they have found their revenue budgets under acute pressure.
What I should like to hear from the Minister in the first instance, therefore, is how PCTs can confidently bid for money from this investment fund to build new community facilities when their revenue budgets are likely to be insufficient to enable them to fund the services that those facilities would provide. I do not believe this to be an uncommon situation. Indeed, the problem has been brought into even sharper focus this year as a result of the decision by Ministers to top-slice the growth money going to PCTs. How can PCTs afford to develop their services if the growth money has been cut in this way?
We all understand the desirability of shifting services out of acute settings and into the community—not just into intermediate care but, if it is possible and safe, into patients’ own homes. The Government have made numerous promises to create new community hospitals in local settings. They have spoken about the need to listen to local opinion and the wishes of doctors and patients in an area. Yet in parallel with those promises we have seen community hospitals closing. Whenever Ministers have been challenged on this, they say that it is a matter for PCTs. They talk of the need to reconfigure services.
I have grave doubts about the evidence base on which some of those assurances are founded. If you talk to Members of the other place in whose constituencies hospitals have closed, they speak not of reconfiguration driven by local wishes but of a diminution of services driven by budgetary constraints, and in the teeth of local opinion. Those constraints have their origins in part in the tariff. PCTs purchase care packages in acute settings on behalf of patients, and the tariff for that includes an element of recuperative care. If, following a patient’s treatment in hospital, it is considered that he can safely be moved out of the acute setting and into an intermediate care setting, the PCT has to find additional money to pay for that intermediate care, even though the original payment to the acute trust supposedly includes an element of post-operative care. What is happening to avoid that situation? My understanding is that the so-called unbundling of tariffs, separating out the acute portion of care from the intermediate care portion, will not happen until 2007-08 at the earliest. Is that correct?
I wonder whether the Minister is able to answer a couple of further questions. When PCTs examine the possibility of building a new community hospital, what population base should they regard as appropriate for such an investment? The language on this subject up to now has been that a community hospital should serve a population base of around 100,000 people. The language in the document published today is couched slightly differently. It speaks of community hospitals serving small populations rising to about 100,000. Is there any significance in that subtle change of language? Could it mean, for example, that a town of 40,000 people could warrant a separate community hospital? What range of population do the Government have in mind?
I also want to ask the Minister about partnerships between PCTs and non-NHS bodies in providing community services. To what extent have such partnerships, about which the Government have spoken warmly in the past, been pursued as an option by PCTs? Potentially, such partnerships offer considerable promise to the development of effective services, and it would be interesting to hear from the Minister how far they have developed.
Finally, I revert to the issue of hospital closures. We all, surely, want it to be the case that if a closure takes place it does so as a result of careful deliberation of what constitutes the best configuration of community and domiciliary services for patients in an area. We understand that represents government policy. What steps will the Government take to make sure that strategic health authorities and PCTs receive thenecessary guidance to place their decision-making on hospital closures on a footing that will command the confidence of local communities and will be seen tobe both fair and thorough?
My Lords, I, too, thank the Minister for repeating the Statement made in another place. Given that I have on a number of occasions in debates in your Lordships’ House talked about the need to move services away from acute hospitals to settings that are more advantageous and afford easier access to patients, he will not be surprised that when I woke up this morning to the press coverage of this announcement I felt rather hopeful. Like the noble Earl, Lord Howe, my hopes were somewhat dashed when I looked at the contents of the Statement and the supporting documentation. The noble Earl was right; this is an announcement of up to £150 million a year for five years only and there is no revenue funding attached. It is capital only. I echo the noble Earl in asking where this money comes from and what will not be purchased as a result that otherwise would have been.
When one turns to the detail in the document, the only advice given by the Department of Health on the matter of revenue funding is a series of different funding mechanisms such as LIFT and community enterprises, but there are no actual resources. This is being announced at a time when primary care trusts are shedding jobs right, left and centre. One of the PCTs in the area in which I live is in the process of shedding one in six of its staff. According to this announcement, PCTs have until the end of this financial year to put in yet another bid for one piece of central government funding. There is too little time to work out the optimum healthcare system for those patients they are trying to treat. PCTs and strategic health authorities are at the moment undergoing a massive reorganisation, which is driven wholly and solely by the need to meet stringent financial targets. I do not understand who will have the time to carry out the consultation required before they get to the point of submitting business plans to establish the new community entities.
It seems that, once again, the Government have fallen into an obvious trap—that of equating standards of healthcare with standards of buildings. Healthcare is not about buildings, but about staff and the access by patients to those staff. Lacking in all this is any indication of how these new centres will relate either to acute hospitals, which are undergoing a huge transformation and shedding many of the services that they used to provide, or to enhanced GP practices. Nowhere in this documentation is there any mention of crucial matters such as what the referral and decision-making systems for patients will be. One comes to the conclusion that, while the new premises that may result from this announcement may well be attractive and well equipped, there is no guarantee whatever that patients will have quicker access to appropriate services from clinicians who are capable of making correct decisions on the basis of their diagnosis.
There seems to have been almost no research into, or thought given to, the impact of the establishment of these new services on acute centres, patient referral, or GP surgeries, which in many cases are working hard to get themselves ready for the new PBC—practice-based commissioning—regime but simply do not have adequate premises in which to offer enhanced services. Like the noble Earl, I too wish to know what advice will be given to PCTs and strategic health authorities about the optimum configuration for acute facilities, ISTCs, walk-in centres and some of the new community hospitals.
Finally, at a time when old community hospitals, which have served their populations well and which have adapted to changing healthcare needs, are closing, this announcement is not only short-term, but is highly inappropriate and comes without an evidence base. The last thing that the NHS needed today was another centralised, short-term announcement of small amounts of competitive funding. This is not a strategic response to changing healthcare needs and, therefore, is a missed opportunity.
My Lords, I was going to thank the noble Earl and the noble Baroness, Lady Barker, for their support for this proposal, but, as the noble Baroness went on and on, her support seemed to be extremely grudging. This is a strategic document. It sets out very clearly that there is a new direction in which parts of the NHS can travel, consistent with our White Paper. Some of the noble Baroness’s remarks suggested that there were not already community hospitals doing some of the things that are set out in this document. We are responding to the concerns of people in the NHS about being given support to take forward this agenda.
I was at Edgware General Hospital yesterday, where services have already been taken out of acute buildings and provided in a community setting, with specialists working in that community hospital and doing operations there that were previously carried out in an acute hospital. The guidance contains many examples of where people have put partnerships together but have found that capital is a blockage to making progress in this area. We are responding to what people say that they need locally. They wanted encouragement to take forward a community hospital agenda. We have given them that encouragement in this document.
I have to say to the noble Baroness, Lady Barker, that we feel that people are mature and can make many of these local judgments for themselves. We have set out the range of services that it is possible to provide. We do not need to set out guidance that prescribes in every detail what people locally need to provide in their communities. We are trying to create a flexible capability for people to respond to their local services. We are not like the Liberal Democrats, wanting to try to control this from the centre. It is absolutely clear that there is no need to change the GP referral systems with community hospitals. They are working perfectly well now, and I do not agree with the noble Baroness that we need more guidance on this issue.
I turn to the questions and comments of the noble Earl, Lord Howe. I agree that some parts of the NHS are finding it difficult to manage their revenue allocations, but it is worth bearing in mind that the allocations this year are about 9.5 per cent higher than they were last year and that next year they will be another 9.5 per cent or so higher than this year. I remind the noble Earl that not all primary care trusts are in deficit. Many of them are creating surpluses so that they can develop their services. In this document, we are responding to their concerns by taking forward an agenda of moving services closer to home. We have put this document into the public arena because we know that a number of trusts now have proposals to take forward particular projects, and we want to give them the opportunity to do so.
The noble Earl asked whether there was a subtle change in the population range for community hospitals. The answer is no. We have repeated the figure of 100,000 but we want to be a bit more flexible here by saying that there may be circumstances in which smaller communities can have a facility that meets their local needs. There is no significance to the figure other than providing a bit more flexibility.
I am grateful for the noble Earl's support on partnerships. What he said is very much our view. With this document, we are trying to encourage people to think widely about the number of people and services with which they might involve themselves in these projects. We have tried to create a model in the form of a flexible community venture so that other public sector organisations, such as the local authority, may bring some of their patterns of revenue and capital into play. Voluntary organisations may wish to join these ventures and private sector organisations may also have something to offer. We know that as we sit here today projects are being developed with people coming forward in a wide range of partnerships.
The noble Earl rightly asked about the tariff. The tariff can already be unbundled if people choose to separate the components. We will be providing more guidance for the year 2007-08. The big, more formal, change on unbundling is likely to take place in 2008-09. People in the NHS have told us that they can use capital to help to re-engineer services in order to lower costs and revenue expenditure. Part of the reason for making the funding available is to enable them to do that.
Finally, when you put services closer to people, people get quicker access. With regard to the suggestion that community hospitals are closing, the Community Hospitals Association website states that for every closure in recent years, a new hospital has been opened. This body has responsibilities in relation to community hospitals and I do not think that it views the situation in quite the gloomy way that the noble Earl and the noble Baroness have done.
My Lords, I welcome the Minister's announcement of this new money, particularly as the White Paper, Our health, our care, our say, said that money was needed to give the proposal some teeth. Although it may not strictly be new money—it is retargeted money—we all know that, in the health service, revenue money follows capital and buildings. Although I wholly agree with the noble Baroness, Lady Barker, that it is people, not buildings, who provide the health services, people in the community need office space, places for meetings, treatments and so on, so I strongly welcome this.
How will the Minister guarantee—I say this having witnessed the closure of many dozens of community hospitals in the NHS through the 1970s, 1980s and 1990s—that the new community hospitals will be different from the old community hospitals in providing a truly cost-effective solution, and not, as so often happened with the old ones, a white elephant sitting in a community that could not provide the technological advances of the new central district general hospitals?
My Lords, I am grateful for the noble Baroness’s support. I share her view that we need to make these new facilities sustainable and cost-effective. What is changing, and what people who read the document carefully will realise, is that we are trying to raise people's sights in terms of the range of services—diagnostic services, in particular—that can be made available. Medical technology and knowledge have moved on. We are able to provide many more procedures on a day-care basis. That is another opportunity that probably was not available in the same way in the 1970s and 1980s.
The examples in the document show that people are already putting together a much wider range of services than were traditionally provided in a cottage hospital. The NHS is much better at business planning, and the document emphasises the importance of putting together a range of services that meet people's needs and can be funded over the long haul. I hope that that reassures the noble Baroness. We shall ensure that the strategic health authorities oversee these plans so that they are sustainable for local communities.
My Lords, I wonder whether the Minister can offer some hope and help to the situation prevailing in my home town of Sudbury, where two community hospitals are currently under sentence of death—fairly imminent death. Until two years ago, that would have been acceptable, because a new community hospital was planned. Since then, however, the decision has been taken not to proceed with that new community hospital. I do not want to go into the whys and wherefores, except to say that there was—as the noble Lord said that there would be vis-à-vis this new pot of money—extensive consultation with GPs, the community, and the rest of it, with virtually a 100 per cent response that a new community hospital was desperately needed following the death of the two old ones. Does the Minister think that the announcement today will allow the Suffolk West Primary Care Trust to review the decision that was recently taken? I am asking whether he sees any leeway or flexibility that might allow a reversal of that decision. I am particularly mindful of what the noble Earl, Lord Howe, said, about the problem of revenue funding. I should be grateful for any advice that the Minister can give.
My Lords, I cannot, so to speak, reprieve any individual community hospital. That is not the purpose of this announcement. It is down to people locally in the form of the PCT to make decisions based on all the available evidence. Since the publication of the White Paper, we have tried to say to the NHS that, before making short-term decisions about closing particular facilities or changing particular services, it should think about the longer-term direction of travel towards moving services closer to where people live, as set out in the White Paper. The guidance tries to raise people's sights on the range of services and is certainly intended to give strong support to the general idea of community hospitals having a wider range of services closer to people. I remind the noble Lord, Lord Phillips, that changes in primary care trust configurations will come into operation on 1 October this year. It will be for many of the new primary care trusts to ensure that the decisions are appropriate for communities in their particular areas.
My Lords, while welcoming this document with my noble friend, I ask for the Minister’s reassurance on behalf of another group of communities: those with specialist needs. I speak with a particular interest in children with cardiac difficulties. These communities would prefer not to have their services close to home but to have the best possible services that specialists can provide. Many children with, for example, hyperplastic left heart syndrome depend on a few specialists who know how to carry out a set of complex heart operations. I am looking for reassurance on their behalf that, while we develop this community service—which, as I say, I welcome—their needs will be thoroughly recognised. There are fears, particularly in Birmingham, that services are being lost.
My Lords, of course I accept the noble Baroness’s general point. We are concerned that specialist services are appropriately commissioned, which is why I commissioned a review by Sir David Carter, the former Chief Medical Officer for Scotland. We published his report on specialised commissioning to ensure that those specialised needs were properly met and that people in the NHS came together in commissioning mode to ensure that the specialised services were not neglected and were properly provided for.
My Lords, can the Minister help me with Cheltenham, where I grew up? When this Statement receives the publicity that I think it will, there will be considerable confusion. Prima facie, we are going to provide local and personal services wherever that is safe and more convenient. Two segments of hospital work in Cheltenham are being moved 12 miles away to Gloucester: paediatrics and maternity. Neither is necessarily wholly covered by this paper, but the population will be very confused by, on the one hand, the decisions that have already been taken and, on the other, what is now proposed in this paper. Can the Minister please help me?
My Lords, the community hospitals document and today’s announcement in no way suggest to local people that there may not be some need to modify aspects of their service provision, as may well be going on in the part of the country that my noble friend mentions. We are not saying that all those changes that are being consulted on—and where change may indeed be needed—should be put into abeyance while this document is considered and absorbed by people locally. We are saying that, when people in the NHS have to reconfigure local services for a variety of reasons, they must take into account the options relating to services that might be put into a community hospital. I shall be happy to look into my noble friend’s concerns if he writes to me.
My Lords, there is potential in that area, so I can reassure the noble Lord in that regard. It will be down to local people to work out the best—the safest as well as the most convenient—way to provide particular services, which is the big message of this announcement. We must leave that to the clinicians, managers and local populations to sort out for themselves in particular localities.
My Lords, I am sure that the noble Lord does not expect me to commit the Assembly in any way in this area. I believe that the Assembly already has access to this information, but I will make sure of that. However, I am sure it will wish to consider how these ideas can most appropriately be applied in Wales.
My Lords, I welcome the Minister’s Statement. It concentrates on capital provision for building new community hospitals, but is there a possibility that community hospitals that have closed may benefit from this new money if local circumstances allow? For example, some years ago, I was greatly involved in a campaign to save a much-loved community hospital in Burford, in the Cotswolds, which provided in-patient care for patients discharged from acute hospitals, had a newly built local accident and emergency department, which had been paid for by more than £200,000 raised locally, and provided outpatient services, minor surgery and many other services. If local primary care trusts agree, could some of this money be used to reopen that hospital, which is still—to use a common phrase—fit for purpose?
My Lords, where local primary care trusts and other stakeholders decide that a particular facility could be refurbished or reopened to meet a particular need and have a well thought-out plan that can be sustained financially, it will be possible for them to seek capital money to redevelop or reopen those facilities, provided the services are what the local community needs and can be sustained.
My Lords, is the Minister aware that there is considerable concern throughout the country about cuts in the number of specialist nurses and occupational therapists who help people with long-term conditions? Can he assure the House that people with long-term conditions such as Parkinson’s disease, rheumatoid arthritis, diabetes, multiple sclerosis and cancer get the right sorts of drugs? Who will monitor those drugs if such people are treated closer to their homes? Can the Minister assure the House that consultants will come out to see patients who cannot come in to see them and that there will be highly trained staff to treat patients, not just cheap care assistants, which happens in many hospitals?
My Lords, these changes are to ensure that safe and effective services are provided closer to people. We know that specialists in existing community hospitals—for example, the one I visited yesterday—carry out sessions and see people in that setting. We expect that to continue. These changes mean that there will be a range of specialist and general services in community hospitals. I share the noble Baroness’s support for the splendid work done by specialist nurses, such as those concerned with Parkinson’s. We hope that that will continue, but more of the work will take place in community settings in future.
My Lords, I welcome these proposals, but how will local populations be able to put pressure on primary care trusts to establish local hospitals? I fear that there will be some inertiain transferring services from acute hospitals to community hospitals. What pressure can be put on the primary care trust to establish these community hospitals, which may sometimes be extremely difficult?
My Lords, I welcome the noble Lord’s support for these proposals. It is down to people locally to use methods open to them to bring their views to the attention of the primary care trust. That can involve their MPs working together, sending petitions or involving their local councillors and local authorities, and, possibly in some cases, using voluntary organisations to make their views known. Some of these deputations have sat in my room and they are articulate in putting across their views. The NHS has to think about how to respond best to some of the concerns. In many places, it is getting better at engaging in public consultation about how to reshape services.