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NHS: Community Hospitals and Maternity Units

Volume 686: debated on Monday 30 October 2006

rose to ask Her Majesty’s Government what is their policy towards community hospitals and maternity units.

The noble Baroness said: My Lords, I start by thanking noble Lords for taking part in this short debate and the Minister for answering it. He is after all, according to the Health Service Journal, the fifth most powerful person in the NHS, so I am sure he will be able to answer my questions, of which I have given notice, with ease.

The Minister and I are united in that care should be closer to home. My father was a GP. Patients came to the house and in my home we literally had blood on the carpet. Six miles from where I live we have a much-prized community hospital in which a few years ago I had successful minor surgery. My husband’s great-grandfather donated a similar hospital to the people of Lyndhurst. I have given birth to two of our three sons at home, so I think I know what care closer to home, or indeed in the home, can mean.

It was Voltaire who said,

“if you wish to converse with me, define your terms”.

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 asone 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 after neighbours. Reputation is everything in a small community. You never know who you are going to meet in Tesco on Saturday morning.

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 theway 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 better book elsewhere”. Others are reluctant to book a place in a birthing centre which is under threat. It may not be there when the great day arrives.

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?

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 programme locally, as it is a community hospital that has had its day and is now developing an alternative service.

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 are taking to strengthen expert strategic service commissioning in the development of hospitals for the future?

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?

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 is11.4 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 by Professor Arulkumaran, head of obstetrics atSt George's Hospital. A number of workforce streams were identified, requiring leadership and implementation by midwives and obstetricians. These have now been addressed. I highlight this tragic situation to demonstrate that, where no performance management of clinical care is in place and no accountability is being exercised through the organisation, up to and including the board members, tragedies such as this occur.

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 fromthe 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.

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 that they can spend so much more money and still face a barrage of hostile complaint from the public. The policy on community hospitals is an example of this. My noble friend set out the problems that are occurring around the country, which are rather more typical, perhaps I may respectfully say, than the example given by the noble Baroness, Lady Murphy.

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,

“huge cash boost for community hospitals”,

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:

“It wouldn’t be unusual for Labour Party press officers to attend meetings with ministers”.

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 the Labour Party chairman, plus this array of political advisers, should be allowed to give their views on such an official submission. It is beyond belief that the Labour Party press officer should have been invited and utterly incredible that not one of the six or seven advisers actually took a note of anything that took place at the meeting. I find that simply unbelievable. Without that we cannot judge whether party political interests entered into what should have been an impartial and objective process.

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?

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.

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 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 over2 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?

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 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.

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 to39 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 ofcuts. But, as of last month, we are being told by David Nicholson that there may be as many as60 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:

“We want to ensure that maternity services are women focused and family centred. This means increasing choice for women and their partners over where and how they have their baby”.

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 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

“Pregnant women would be best served by maternity departments big enough to sustain a 24-hour, consultant-led service. That would require work to be concentrated in fewer hospitals.

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.

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. 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?

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 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 over42 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 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 into 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.

The noble Baroness, Lady Cumberlege, raised the request of my former colleague, Stephen Ladyman, for an economic appraisal in developing quality standards in birth centres. In July the department commissioned the National Perinatal Epidemiology Unit to conduct a three-year study into the effectiveness, acceptability and efficiency of maternity units. The study will evaluate the cost-effectiveness of midwife-led units and consultant-led units. This part of the study will start next year and will be completed in spring 2008. The department has also agreed to write to the Healthcare Commission, suggesting that once the conclusions in the study have been published, it should work with the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the Birth Centre Network to develop operating standards for stand-alone midwife-led maternity units. I agree with the noble Baroness, Lady Masham, that the safety of mothers and babies has to be paramount.

It is sometimes worth concentrating on a particular area that shows what can be done. In some places the kind of service we want to see is already happening. The Crowborough Birthing Centre is a small unit adjacent to Crowborough War Memorial Hospital, a community hospital. The birthing centre has six beds, is open 24 hours a day and is run by a dedicated team of experienced midwives. It offers just the high quality of care we would all like to see.

David Nicholson was somewhat misquoted: he is not setting out to close maternity services. He was getting the NHS and others to address the fact that sometimes we need to look at the way particular services are provided in some parts of the country and whether we need to reshape those services. Whether we use “reconfiguration” or some other term, it means that we must make them safe and fit for purpose.

My Lords, I am very grateful to the noble Lord. I was hoping—I am still hoping—that he would find time to deal with the point made about the wholly improper meeting referred to by my noble friend Lord Fowler. I hope the Minister will leave time for that. Will he?

My Lords, if the noble and learned Lord was a little more patient and did not interrupt, we would be able to get to that, but he has now taken a little more time away from the time I have to deal with the remarks of a number of noble Lords. The noble Lord, Lord Fowler, was not the only person to raise questions and issues. I was trying to address those as a courtesy to the whole House.

We have talked a lot about service reconfigurations. This is, of course, one of the issues the noble Lord, Lord Fowler, has a deep interest in, with regard to this meeting, which he is so concerned about. The point to bear in mind is that we expect people to review their services and make sure that they are fit for purpose. This is something that PCTs and strategic health authorities must, under statute, do in consultation with their local population. Local people have the power to appeal decisions through the overview and scrutiny committees, which can, if necessary, refer decisions to the Secretary of State and the Independent Reconfiguration Panel. That is a well established procedure, but it does not mean that we can never have any public debate about making sure our services are fit for purpose.

The noble Baroness, Lady Murphy, raised the issue of unbundling the tariff.

My Lords, the noble Lord has not answered the point I made about the directly party political meeting, in which he was involved, and which could have a profound impact upon community hospitals. Is that not a disgraceful omission on his part?

My Lords, one minute has been taken out of my time by the interventions of the excitable noble Lord and his colleague. I hope to be allowed to address the concerns raised by all noble Lords in this debate. I was going to get round to the question of the noble Lord, Lord Fowler, and I have another minute in which to speak. Let us stay calm and he will have an answer, but first I want to address the point made by the noble Baroness, Lady Murphy, about unbundling the tariff. Tomorrow there will be guidance on this posted on the Department of Health website.

I was rather looking forward to dealing with the noble Lord, Lord Fowler. Let me reassure him that I was at the meeting. As a Minister of State I do not have any special advisers, nor does my good friend the honourable Mr Andy Burnham. The Secretary of State has special advisers in the same way that other Cabinet Ministers have done under successive Governments. What I would say to the noble Lord—and I was a civil servant when he was the Secretary of State—is that I respect the fact that when he was in that position, he and his colleagues would, quite rightly, discuss areas where there might be public anxieties about changes of policy. I was in attendance on some of those occasions and I am going to respect the confidentiality of the discussions, just as I am going to respect the confidentiality of the discussions I had on the occasion he mentioned with my political colleagues. That is a perfectly sensible way for any Government to conduct themselves.

In conclusion, over the next few years the NHS will be transformed by the extra money we have put in and we will provide vastly improved maternity services in conjunction with a new generation of community hospitals. We have had an interesting debate and I am sorry it has not satisfied all noble Lords in terms of its outcome.