I wish to raise the subject of the lack of consultation over the proposed closure of the Cumberland hospital, Mitcham, next Friday, 30 November. It is a small, modern, well-equipped hospital in surroundings which give a rural atmosphere but within a few minutes' walk from Mitcham town centre. It is in an ideal position for the treatment of chest and geriatric cases, with which the hospital deals.
The hospital staff has an excellent morale, and the hospital is strongly supported by the local community. Over 17,000 signatures were collected within a few weeks to a petition protesting against the proposed closure. That petition was presented to No. 10 Downing Street by nurses from the hospital who marched for nearly six hours in pouring rain, many of them straight from night duty, to show their concern.
That indicates the way that the staff feel about the vital job they are performing at the hospital. That view—that the hospital is doing an outstandingly good job—is shared by all the patients in the hospital to whom I spoke during a lengthy visit on 19 October. That view is shared even by the Conservative-controlled Merton council. Like most who foolishly voted Conservative at the last election, they favour reduction in public expenditure, but never did they imagine that the axe could fall on such a healthy limb of the National Health Service, one which was doing such an excellent job for the local community. Nor did anybody else.
The consultant chest physician who is in charge of the hospital, Dr. Berry, first heard of the plan to close the hospital on 10 September, and the hospital is to close on 30 November. It is evident how little consultation must have taken place to enable compliance with that timetable. The consultant was not informed. Indeed, not even the staff, the patients, the local general practitioners or the community health council were informed of what was proposed. Since they have known, I have been deluged with letters of protest. It is a hospital that serves the local community well. It is strongly supported by local general practitioners who believe that they cannot do their job as effectively as they have in the past without the hospital.
Not only was there no planning or consultation with any of the groups or bodies that I have mentioned, but the area health authority was taken by surprise. It had had no intention of closing the hospital until it took a panic decision at the last moment. It is clear that that decision was taken under pressure from the Secretary of State.
The area health authority, which is now closing the hospital, has in the current year spent large sums on redecoration, double glazing and other improvements to the hospital. When I visited the hospital—it was effectively under sentence of death—on 19 October, the decision having been taken to close it about four weeks or five weeks previously, I found electricians still working on the rewiring. From the end of next week it will be exposed to wrecking by vandals. That is the sort of lunacy that results from panic decisions taken without proper consultation.
Both the local authority, which is Conservative-controlled, and the community health council believe that with proper planning and consultation the alleged saving of £268,000 which closing the hospital is expected to produce could have been achieved in far less damaging ways. I am far from conceding that such proposed reductions in spending are desirable, but if they have to be made they must be planned. If that were done, far less serious harm would result.
Even the Minister of State, Department of Health and Social Security is on record as opposing such decisions. On 9 October, at the Conservative Party conference, he said:
Small local hospitals which are efficient and vital to local communities must not be closed.
That description ideally fits Cumberland hospital. It is an efficient small local hospital which is vital to the local community. Consequently, it is not surprising that neither the Minister nor the Secretary of State has replied to the letter that I wrote to the Secretary of State on 23 October protesting at the proposed closure and presenting the evidence that justified a reconsideration of the decision. It was only this week, after I had obtained the approval of Mr. Speaker to initiate a debate on the Adjournment, that I heard from the Under-Secretary of State that he would reply to my letter orally during the debate. I shall listen to the hon. Gentleman's reply with great interest. I shall be surprised if he is able to meet the case set out in my letter.
It is true that it is called a "temporary" closure. However, when the staff have been dispersed, and when the empty building has been wrecked by vandals, the cost of reopening will more than cancel out any saving that will possibly be achieved. It is extremely improbable that, with or without any subsequent reopening, the saving estimated by the area health authority can possibly be achieved.
The London community health councils have collectively been carrying out a research project into the closures in London. It is an alarming piece of information that emerges from the project. By next March London will have lost nearly 3,000 beds as a consequence of panic closures that have been forced on area health authorities by the Secretary of State. As a consequence of the way in which the closures have been approached, it is extremely unlikely that, in practice, the savings that are contemplated will be achieved. For example, the staff will have to be dispersed, as will the patients. The cost of ambulance services to take patients to and from the further points where they will receive treatment will be much greater and the cost of repairs to neglected, empty hospitals will be great.
I am told that the commissioners who are currently running the Lambeth, Southwark and Lewisham health area have estimated that they will save £640,000 as a consequence of saving St. Olav's hospital. The community health council, with probably rather greater knowledge of the local circumstances, estimates that the real saving is likely to be no more than about £60,000. I suspect that the same reasoning, the same calculation and the same consequences will arise in regard to cost in the case of the Cumberland hospital, Mitcham and that any financial saving will be negligible in relation to the harm and suffering caused.
There has been no consultation, because the area health authority calls this closure a "temporary closure". It is called a temporary closure in order to achieve a clear and blatant evasion of the statutory duty imposed on area health authorities by Statutory Instrument No. 2217 of 1973, which requires area health authorities to consult community health councils before closures which would significantly affect the Health Service provision in the area.
This is a device—it is almost acknowledged to be that—recommended by the Secretary of State to area health authorities in his now notorious "Dear Betty" letter of 27 August 1979, which quite blatantly invites maladministration by the area health authority; and because the Secretary of State also summarily demanded, in August this year, that Merton, Sutton and Wandsworth area health authority should cut £4 million from its budget by March 1980, he gave it little choice but to use the shabby weapon that he put into its hands.
One might have thought that that was precisely the kind of issue that the Health Service Commissioner was created to investigate and to expose, for if that is not maladministration, it is difficult to imagine what is. The local community health council most certainly thought that it was maladministration, and so did I. The council asked me to refer the matter to the Health Service Commissioner, and I did so. But I am afraid that neither in his capacity as Parliamentary Commissioner nor in his capacity as Health Service Commissioner did the Ombudsman consider that he could look into the matter. He rejected it on the ground that the community health council could sue the area health authority in the courts, and because it had a remedy in the courts he was not prepared to look into it.
That was an issue that had already been explored by the Lewisham community health council, which sought to bring proceedings to establish that the area health authority in its area was acting ultra vires in failing to consult it about the closure of hospitals. Those proceedings—it is not for me to say—might well have been successful, but they had to be nipped in the bud because the AHA said that it would not provide funds to community health councils to bring proceedings against it. The community health council therefore had to abandon proceedings.
It is really a farce for the Health Service Commissioner to say that he is not prepared to look into an alleged issue of maladministration because the CHC could sue the area health authority in the courts, when the community health council is itself dependent on the area health authority for its funds. The area health authority would scarcely be justified in spending its funds to sponsor litigation against itself.
I hope that the Parliamentary Commissioner—or the Health Service Commissioner—will reconsider his views as to the exercise of discretion in circumstances of this kind, because what we have as a result of his decision is a classic Catch 22 situation. The Commissioner cannot investigate it because one can sue in the courts; but one cannot possibly sue in the courts because one has no money to do so. I trust that this issue will be reconsidered by the House and by the Health Service Commissioner.
At the very last moment I appeal to the Under-Secretary to allow reason, common sense and the rule of law—the law which requires consultation—to take their course and to save an excellent hospital—the Cumberland—and allow it to continue to serve the local community.
The hon. Member for Mitcham and Morden (Mr. Douglas-Mann) spoke cogently in support of the Cumberland hospital, which is clearly a popular institution. I well understand the concern that he expressed and the concern of his constituents. He made it quite plain that the closure of a valued small local hospital such as the Cumberland cannot be contemplated lightly. He also argued that consultative safeguards are needed to ensure that proposals to close or change the use of such a hospital cannot be railroaded through without regard for local interests. The Government share these views.
In replying to the hon. Member, I am grateful for the opportunity to confirm the importance that we attach to small hospitals and to consultation about changes in health services generally. Although I shall also seek to show that the application of these two principles must be tempered by the financial context, I hope to dispel some of the worst anxieties about the future of the Cumberland, and I shall also give details of further guidance to health authorities about the role of consultation.
The hon. Member knows that recent events in the Merton, Sutton and Wandsworth area health authority, including the proposal to close the Cumberland temporarily, are a direct consequence of the financial situation facing the National Health Service and that that, in turn, is a consequence of the national economic situation. We have to face facts. Expectations must be kept within the limits of what the country can reasonably afford. Our predecessors failed in this respect. Our intention is to fulfil our undertaking that future growth in services is based on the resources made available by a strong and expanding economy. As the economy improves, therefore, we shall be able to do more for the National Health Service.
Meanwhile, we have made clear that, despite the difficulties, health authorities must stay within their budgets and that no more money can be made available this year. It is the responsibility of the regional health authority to see that the total expenditure within its region, by the area health authorities and by the regional health authority itself, remains within the cash limits given to it. In order to do this, each area health authority must take whatever action is necessary to keep its expenditure within the funds allocated to it by the regional health authority and to ensure that it is able to contain next year's expenditure within the allocation it can reasonably expect in that year.
Merton, Sutton and Wandsworth is one of the London health authorities that faces particular difficulties this year. Like all health authorities, it has had to cope with increased costs. Although the Government have honoured previous undertakings and have provided additional money to meet pay awards, this has proved insufficient for the authority to meet the full extent of inflation and other rising costs. No more money can be made available.
In addition to this immediate difficulty, Merton, Sutton and Wandsworth is one of the London health authorities which for some time has been running a level of services which, judged by the objective criteria established by the Department's Resource Allocation Working Party, is more generous than that found througout the country generally. As a result of attempts to rectify this situation in recent years, Merton, Sutton and Wandsworth has attracted a lesser share of the growth available to the NHS than those areas away from London which are relatively poorly endowed with services.
At the same time, however, development of services in Merton, Sutton and Wandsworth has not stood still. As a result, the area health authority faces this year not only a squeeze on strictly enforced cash limits but also the necessity to correct an inbuilt over-commitment to a level of services it cannot afford. If the authority does not correct this over-commitment, it will continue to amass an ever-accumulating deficit which could be supported only at the cost of sacrifices by other areas in the South West Thames region, all of which have their own pressing needs. Corrective action cannot be postponed. The deficit at the end of this year has been estimated at £5·6 million, and any delay will mean that the eventual and inescapable antidote will be even more painful.
Accordingly, the authority established a working party last summer which included representatives of the medical staff
and observers from the three community health councils to consider how the necessary savings might be made. In October, the AHA accepted the proposed package of economy measures aimed at saving an estimated total of £5·8 million in a full year. We have urged on authorities the need to do everything they can to make savings without affecting patient services, and I am glad to see that the AHA has indeed sought to reduce administrative costs among its economies. But administration had previously been pruned, and more administrative cuts could not possibly provide savings of the order which this authority requires. Regretfully, we have to accept that savings must be found in patient services. My right hon. Friend the Secretary of State made this clear in the House when he said:
some health authorities—this applies especially to those in London—are faced with the need to make real cuts this year so as to remain within their cash limits".—[Official Report, 17 July 1979; Vol. 970, c. 1435.]
The authority's economy measures include reduction in services at both large and small hospitals. I understand that the authority included the temporary closure of the small hospitals rather than concentrating solely on ward closures in the main district hospitals because of the generally lower bed occupancy in the small hospitals; because of the wider range of clinical facilities available in the larger hospitals; and because the temporary closure of small hospitals also helps to save on overheads through the complete cessation of support services such as catering. The authority's view is that, in the short term, the savings to be made by the temporary closure of small hospitals are less damaging to patient care than the equivalent financial savings in the main district hospitals.
The Government have taken the line that they should not intervene in properly taken decisions by health authorities on the short-term measures necessary to live within cash limits. This is right because these are decisions best taken by local management. Some critics have tried to drive a wedge between this policy and the Government's commitment to small and valued hospitals such as the Cumberland, which in some instances have been the chosen means of making savings. The hon. Gentleman did that this evening. To these critics, I would answer that we expect health authorities to behave responsibly and not to make administratively convenient savings at the cost of greater hardship to patients and lasting damage to the Health Service. I would therefore expect an authority that proposes to close a small hospital to satisfy itself that this was indeed the most immediately effective source of economies and that it would not cause lasting damage.
In this connection, I would emphasise that the present decision to close the Cumberland hospital can only be temporary in effect. My right hon. Friend has made clear to health authorities that any proposal affecting the long-term future of the units involved in short-term economies must be referred to full consultation. If local interests express this through the CHCs, and they disagree with this proposal, it has to come to Ministers for resolution. We shall examine such cases very carefully in the light of the now widespread conviction that small local hospitals have a vital role to play in the provision of the wide range of services that are needed.
I am pleased to hear the assurance that it is likely that the closure of Cumberland hospital will be only temporary. Can the hon. Gentleman give an indication of the cost involved in reopening a hospital that has been closed, and also the cost of the damage to the services involved in dispersing the staff and gathering them together again to re-establish what was a viable and effective unit?
Indeed, the area health authority expects to save about £300,000 by the temporary closure. I understand that very little additional cost should arise elsewhere, because no extra beds or staff are being provided in other hospitals. I note what the hon. Gentleman said about vandalism. I understand that security will be provided by the staffing which it is necessary to maintain because of the continuing out-patient services. I also understand that the grounds are to be used temporarily by the Metropolitan Police dog team training unit—surely a formidable deterrent to local vandals.
I said that unless the authority made savings it faced an estimated deficit of £5·6 million at the end of this year. To wipe out this deficit by economies introduced half-way through the year, as was necessary in this case, would require cuts whose total value in a full year would amount to £11·2 million. As the hon. Member knows, the economy programme that the authority has, in fact, adopted was estimated to save £5·8 million in a full year, and some of the measures which take time to introduce will not produce even a half-year's savings in the current financial year. The authority must therefore find other means at least to mitigate its immediate cash problem this year.
It is possible within accounting practice to make some adjustments to the cash flow, but there are limits on how far this is technically feasible. Moreover, these adjustments do not enable the authority to continue living beyond its means by accounting wizardry. They merely extend the period in which to solve the underlying problem of over-expenditure. Another possible short-term palliative arises from the fact that the overriding requirement is for regions to deliver their cash limit. I understand that the South West Thamas RHA may be able to accommodate some of the area health authority's cash deficit this year but this, too, merely buys time in which to cope with the underlying problem.
Since these are only partial and temporary expendients, it was therefore essential that the AHA took an urgent decision on the proposals submitted by its working party in October. I should like to explain how the statutory consultation procedure applies in these circumstances and why the action taken by the authority is not illegal or an abuse of its powers, as has been alleged.
Statutory Instrument No. 2217 of 1973 requires that an AHA should consult local interests in the form of CHCs about any substantial variation in services in the council's district and lays down a procedure for doing so. The regulations contain a proviso, however, that this requirement shall not apply to any proposal on which the authority is satisfied that, in the interests of the Health Service, a decision has to be taken without allowing time for consultation.
There are various reasons why an AHA may consider that it does not have time to consult and that any delay while consultation took place would be against the best interest of patients and staff. As a matter of law, as well as good management practice, the degree of urgency and the reasons for it are properly left to the authority to decide. There are some obvious reasons, such as the danger to staff or patients, through infection or the physical condition of the building, which might require an urgent decision without consultation. But, in adidtion, there are authorities like Merton, Sutton and Wandsworth, which face the prospect of running out of cash before the end of the financial year. In these circumstances, it is inescapable that financial stringency should be cited as a reason for urgent decisions to proceed with the temporary closures without prior formal consultation.
Quite clearly, it would not be in the interests of patients or staff for the authority to find itself, towards the end of the financial year, without the money to run any of its services. The hon. Gentleman will be aware that the need for urgent economies as a reason for waiving consultation was recently tested and upheld in the High Court in the case brought by the London borough of Lewisham against the commissioners for Lambeth, Southwark and Lewisham.
This is not to say that there was no consultation of any kind. As I have mentioned, the authority's working party, which met through the summer to consider possible economy measures, included representatives of the medical staff and of the three CHCs. Nor does it mean that what has happened is now permanently a fait accompli, on which there will be no further consultation. My right hon. Friend wrote in affectionate terms in August to Mrs. Betty Paterson, chairman of the North West Thames regional health authority, about consultation in circumstances of financial stringency. His letter has been widely circulated in the Health Service—widely quoted, but sometimes misunderstood.
My Department will shortly be issuing further guidance to health authorities to clarify the formal requirements for consultation. This will re-emphasise the point made in the earlier letter: that the area health authority is required to notify CHCs of urgently taken decisions, and the reasons for not submitting these to consultation. It will also re-emphasise our view that any permanent changes should continue to be subject to the appropriate consultation process, including cases where action has already been taken on a temporary basis.
Shortly after the authority took its decision on economies, the chairman wrote to the three CHCs, with the necessary explanation and promising further consultation. Some of the measures taken represent the bringing forward of proposals which would have arisen in due course as a result of strategic plans. In those where the change or closure will be permanent, the authority intends to proceed with formal consultation as quickly as administrative resources allow. For the rest, the authority's action will largely depend on the financial situation next year. But there will, in any event, shortly be consultation on the likely effects of the decisions taken and canvassing of the CHCs' views on the long-term future of the units and the services concerned.
I understand that the Cumberland hospital is one of the hospitals not affected by existing proposals in the AHA's strategic plans. As the hon. Member pointed out, it is in good repair, has good facilities, and fulfils a genuine local need. It is generally reckoned to be a splendid hospital, admirably supported by a loyal and active League of Friends. Naturally the authority wishes to put it back into use as soon as resources permit. Recent reports in the press implying that current maintenance work is a waste of money are therefore ill founded. The form in which the authority hopes eventually to reopen the hospital will depend on the discussion and consultation described in the chairman's letter to the CHCs. I do not want to prejudge these, but I shall ensure that the area health authority is aware of the points that the hon. Member and his constituents have made in the letters he has sent to my right hon. Friend.
The financial situation within the NHS as a whole is unavoidably the backdrop to the situation at the Cumberland hospital. I do not want to leave the impression that this is a setting of unremitting gloom. Spending in the Health Service next year will remain at the level previously planned. Though there has been a tight squeeze this year because of cash limits and the economic situation, the planned volume of spending for the next year is in line with last year's White Paper—a 3 per cent. increase over the latest estimate for the current year. The impact in Merton, Sutton and Wandsworth will depend on the allocations yet to be determined for the regional health authority and by those, in turn, for the area health authorities. But, nationally, these figures mean that the planned increase will restore this year's squeeze and add the future ½ per cent. real growth previously planned.