I wish to raise the subject of the closure of Bretby Hall hospital in my constituency, a subject that raises issues not just for my area but for the rest of the country. I am grateful to my hon. and learned Friend the Member for Burton (Mr. Lawrence) for his advice on this matter.
Bretby Hall is a small, 86-bed orthopaedic unit, housed in a magnificent old property in south Derbyshire. The house once belonged to Lord Chesterfield, and has been an orthopaedic hospital since 1926, before the creation of the National Health Service. It is managed by the Southern Derbyshire health authority, which covers several constituencies, including those of Derby, and in turn by the Trent regional health authority. It is one of two main orthopaedic units in south Derbyshire, the other being at the Derbyshire royal infirmary at Derby, which does the main trauma and accident cases. Bretby is used only for cold surgery — that is, planned operations. The beds cannot be used for anything else, and in my eyes that is one of the hospital's virtues.
The closure arises not because of lack of money but because of increases. Under the resource allocation working party formula, both Trent and the Southern Derbyshire health authority are the gainers. Trent has 500 more posts as a result of the recent manpower review, and the Southern Derbyshire health authority has embarked on a large capital building programme at its two main district general hospital sites—Derbyshire royal infirmary and Derby City hospital.
Before the contracts were let, the DHSS sensibly asked how the additional facilities were to be used, and the consideration of the transfer of various small units, such as the Derwent hospital and the Derby children's hospital, has led to the problem that we now have. The main victim of this consideration has been Bretby. The closure is out for consultation, and the transfer. if it is agreed, will take place in 1986–87, following the provision there of a twin theatre and of an extra lift at Derby city hospital. The additional cost will be about £2 million, and there will be increased revenue costs as well.
I emphasise that the intention is that there should be no loss of service, and I am not criticising the district health authority. As a former chairman of the authority, I understand the pressures that it is under. It envisages some gains. It tells us that there will be more modern facilities — I have to add, somewhat more modern facilities, because a new theatre and physiotherapy department have only recently been provided at Bretby, the latter with private funds. There will be fewer beds in the new unit, for there will be a decrease from 86 to 76.
We are told that access may improve for some patients, but the letters that I have received from throughout Derbyshire, Staffordshire and Leicestershire suggest that access is not a problem for the patients who have been treated at Bretby. We are told that on the district general hospital site there will be less risk to patients, and perhaps better status for staff and more training facilities for staff of all kinds. That is not what the consultants say, and I stress that it is the consultants who work at Bretby and at other district hospital sites who are leading the fight to keep Bretby Hall open.
Something extremely special would be lost if Bretby Hall were to close; that is why I am so pleased to have the opportunity of raising the issue in an Adjournment debate. In the year that I have represented the neighbourhood of Bretby I have visited Bretby Hall hospital on a number of occasions. It is always a delight to visit it, for it has a very special atmosphere. It is special for reasons other than the fact that it is in a beautiful house, that there are wards in what was formerly a ballroom, that there is a former music room with a beautiful parquet floor and that every ward looks out over magnificent gardens with fields and the Derbyshire hills beyond. Whatever else we can do in Derby, we cannot provide those attractions.
I have no doubt that Bretby Hall is special because of the atmosphere of a small, friendly local unit. That atmosphere is real and it is understood by the patients and the staff. There are about 170 staff at Bretby and they are nearly all local people. They are deeply committed to working at the hospital. Bretby Hall has no difficulties in recruiting staff, even scarce and rare staff, such as theatre sisters. They will work at Bretby Hall but not in Derby, and they are most reluctant to move. The effect on staff morale of the proposed closure is disastrous. I suspect that if the decision is taken to close Bretby Hall we may well see over the next couple of years the progressive collapse of the unit. It may not be possible to maintain the service to patients in the way that we would like.
Bretby Hall is special in a number of ways. For example, it has never cancelled an operation. If an elderly constituent is booked in for a hip operation, he or she knows that it will take place. The patients know that they can count on the hospital. The through-put is astonishing. It is typical there to carry out a hip operation in an hour and a half and to get a patient home in 12 days flat. The average length of stay for an orthopaedic patient is nine days and that is being reduced. When I was there last week, the hospital was dealing with 10 patients in one theatre in one day. That is quite a record, but sometimes it is exceeded.
I am glad to have the opportunity to confirm that that is so. I am paying a compliment also to my own constituents, and I am delighted that some of them are listening to the debate.
I have talked to the surgeons and I have asked them why Bretby Hall seems to be so successful. One reason is that it is a small hospital. I am told that it is quick and easy to transfer patients as it is not necessary to wait for a long time for porters or administrative staff. Over and over again the consultant surgeons have said: "It is simply easier to work in Bretby Hall and to get on with these things."
On these grounds alone, Bretby Hall is special. If one makes the effort to study the statistics and to compare Bretby Hall with other major orthopaedic units it is interesting to find that its through-put is much higher than that elsewhere. Compared with Oswestry and the royal orthopaedic hospital in Birmingham, the Woodlands, near which I used to live, the number of cases per theatre is revealing. Bretby Hall can deal with 200 hip operations while Oswestry can deal with only 154 and the Woodlands 190. As for operations on knees, Bretby Hall can deal with 102 per theatre while Oswestry deals with only 18 and the Woodlands only 28. Bretby Hall has four consultants while the Woodlands has 12 and Oswestry has 25. Bretby Hall operates on only four days a week instead of five elsewhere and it does not have the large number of permanent junior staff to assist that are to be found in other units. On these grounds alone, the future of Bretby Hall needs to be reconsidered.
These levels of achievement are to be found at Bretby Hall for reasons that are set out in a report from a working party to my right hon. Friend the Secretary of State for Social Services, which is known as the Duthie report on orthopaedic services. My hon. Friend the Parliamentary Under-Secretary of State will be well acquainted with the report, especially as Professor Duthie is one of his constituents. Paragraph 3.4.1 reads:
Because of its inevitably demanding nature, "trauma
that is, accidents—
will always take priority over elective surgery. Beds booked for elective patients in wards which receive both trauma and elective surgery become filled with accident and emergency cases and theatre time for elective surgery has to be used for traumatic cases …
Since few orthopaedic units have sufficient beds to cope with the influx of traumatic cases and at the same time to meet the demands of elective surgery, it is only in those places where trauma and elective beds are geographically separated that elective beds are protected. Where, within a single hospital, endeavours are made to reserve beds for elective cases trauma cases still overflow into them. It is without doubt for this reason that many see as the only solution of the waiting time problem the strict separation of facilities for traumatic and elective treatment.
There could not be a better description of the organisation of orthopaedic services in and around my constituency with elective work at Bretby Hall and trauma work at Derbyshire Royal infirmary.
Bretby Hall hospital raises one or two wider points. It is an orthopaedic hospital. Of all our long waiting lists, the waiting lists for orthopaedics is the worst, nationally and locally. At the time that Professor Duthie was making his report, the Trent region was the worst in the country for orthopaedics, and it is not all that much better now.
The most recent figures that I could obtain were in the Derby Evening Telegraph of 9 February 1984. In southern Derbyshire, almost 750 non-urgent orthopaedic cases out of a total waiting list of 1,755 have been waiting for longer than one year, and 31 of the 50 most urgent orthopaedic cases have been waiting for longer for one month. That is way beyond Government guidelines.
I suggest that, as we are messing around with orthopaedics, we need more assistance, not a transfer. Yesterday's research is today's routine activity. Improvements in anaesthesia especially mean that most elderly people can be treated safely and frequently under local anaesthetic. I am not sure that it would suit me to have my knee treated under a local anaesthetic, but it seems to suit many elderly people and they recover more quickly. One surgeon has estimated that we need about 10 per cent. more beds in orthopaedic surgery to cope with increases in the number of fractured femurs, let alone increased demand in other respects.
The Southern Derbyshire health authority has set up a working party on orthopaedics. I have two recommendations to make to that working party: first, provide more beds at Derby city hospital for all the difficult cases and reduce waiting lists; secondly, leave Bretby Hall alone. I feel strongly about that point.
One of the last recommendations of the Duthie report was:
No specialist orthopaedic hospital, however small or isolated, should be closed unless it can first be guarateed that the facility planned to replace it will provide the same or a better standard of service for an equal or increased number of patients within a similar period of time.
Bretby Hall is special for two other reasons. First, it is in an old house. That is typical of the NHS, especially in the provinces. Reinstatement of that house could be expensive, but I challenge the notion that an old property is always dearer to run. The NHS does not charge depreciation or interest on its capital, so it is a little difficult to compare an old and a new hospital, but my experience of local government suggests that new buildings are invariably more expensive and frequently a great deal more expensive than the existing facilities.
The Southern Derbyshire health authority figures show that there will be an increase in running costs after the transfer of £127,000 a year, and that is for 10 fewer beds. I challenge the notion that it has to be NHS money. Bretby Hall is a grade II listed building. Is it so impossible to get the Department of the Environment and the Department of Health and Social Services together so that we can restore Bretby Hall, the house, to its former glory and enable NHS money to be spent as it should be — on equipment, drugs, services, and so on? I should be grateful for the Minister's comments.
Finally, there is the classic dilemma of the countryside versus the city. I used to be responsible for a big city hospital. I am now responsible for a country area of 50,000 electors and a city area of 26,000 electors and I am conscious of the need to serve all my constituents and of the health authority's responsibility to cover an enormous area of Derbyshire.
I question the wisdom of always putting services in the towns and cities and expecting country people to travel to them. That may be fine for people in Derby, but it is not fine for the large number of people who live nowhere near the city. I question the wisdom of closing all our little hospitals. In the past five years, 112 small units have been closed. Admittedly, more beds have been provided, but they have been in bigger units, with an average of more than 300 beds each.
In questioning the wisdom of closing all the little units and putting all the services on one site, I realise that I am questioning the whole pattern of NHS hospital planning, but I suspect that much of it is 20 years out of date. The concept of the big city hospital on a single site was perfect for the 1950s and the 1960s when our cities were growing, but it took 20 years to obtain the money, which I appreciate has been provided by the Government. Nevertheless, the plans do not reflect the changing pattern of population. All our major cities are losing population, so the services are moving into the cities as the population moves out.
The pattern of treatment is also changing. Orthopaedics did not exist 20 years ago. Now that it is a basic, standard service, it might be better to provide small, perhaps multipurpose local hospitals and units with ready availability of basic services such as orthopaedics instead of constantly building monoliths in towns.
Despite the good will of a decent, caring health authority and all the arguments for the transfer of orthopaedic services to Derby, there is a deep-seated, unhappy feeling in my constituency that closing Bretby Hall hospital and others like it all over the country is a mistake. I hope that the authorities will take heed of what has been said and reconsider their plans.
I am very pleased that my hon. Friend the Member for Derbyshire, South (Mrs. Currie) has raised the important issue of Bretby orthopaedic hospital. I am also glad to note that my hon. and learned Friend the Member for Burton (Mr. Lawrence), with his characteristic care and concern for these matters, has been present to take part in the debate.
It is a little early in my speech to give way. I must first devote my attention to the remarks of my hon. Friend the Member for Derbyshire, South.
The orphopaedic services provided by Bretby hospital are well known and the buildings housing them are known as a fine example of Victorian architecture. I was glad that my hon. Friend linked those two points as she did.
I wish to deal with four matters. First, there is the consultation process which surrounds any closure proposal. Secondly, there is the relationship between the important points raised by my hon. Friend about the capital programme and the recommendations of the Duthie report and the constant dilemma in the Health Service of large versus small and urban versus rural. Thirdly, I wish to deal with an important issue concerning the staff and the morale of the excellent staff who work at the hospital. Finally, I wish to say a little about the building, although some of the issues are matters for my right hon. Friend the Secretary of State for the Environment and not for me or my colleagues at the Department of Health and Social Security.
I appreciate that any decision about the hospital would affect people in a wide area.
Does my hon. Friend appreciate that this excellent hospital draws patients from a very wide area, including north-west Leicestershire, so that there is great concern about this over a much wider area than Derbyshire?
I am grateful to my hon. Friend for drawing attention to that important matter and I shall certainly bear in mind what he says about the number of patients drawn from his constituency and their opinion of the hospital.
I must say at the outset that I am in a difficult position today in terms of saying anything definite to my hon. Friend the Member for Derbyshire, South as no decision has been made to close the hospital. I understand that the southern Derbyshire health authority will shortly be issuing, or has already issued, a consultation document about the hospital. The consultation which is to follow will be carried out according to procedures clearly laid down by the Department. Obviously tonight I must not and cannot in any way prejudge the outcome of the consultations which the southern Derbyshire health authority is currently undertaking, but I am sure that it will consider all proposals carefully.
I can assure my hon. Friend the Member for Derbyshire, South that, if the proposals come to my right hon. and learned Friend the Minister and myself, any decision will be taken only after the most painstaking and thorough consideration of the case. Should such a recommendation come to us, I should be delighted to see my hon. Friend and any of her constituents to discuss the case in person further before any decision is taken.
I was pleased that my hon. Friend referred to the important work done on orthopaedics by my distinguished constituent, Professor Duthie. The working party chaired by Professor Duthie was set up to consider the problem of waiting times for outpatient appointments and admission to hospital for orthopaedic patients. I was very interested to hear about the regime of patient management in the hospital. We certainly recognise the need to reduce orthopaedic waiting lists and times. Indeed, perhaps waiting times are as significant as waiting lists in this context.
We are urging health authorities to make the fullest use of the report in considering how to improve the services offered to orthopaedic patients in their districts. I am glad that that is being put into effect by the Trent regional health authority, under its excellent chairman, Mr. Michael Carlisle, who has asked all districts in its region to review orthopaedic services in the light of the recommendations of Professor Duthie's own report. I am convinced that in formulating its proposals for Bretby hall orthopaedic hospital the southern Derbyshire health authority will take account of the report's conclusions, particularly as they relate to the use of small hospitals such as Bretby hall.
My hon. Friend rightly pointed to one of the report's recommendations, to the effect that no such hospital should be closed—I had a small bet with myself that she would pick on this recommendation, and happily she did—unless alternative services
of the same or a better standard for an equal or increased number of patients
can be provided. That is a significant sentence. I am sure that it is a view shared by the admirable League of Friends of Bretby hospital. I understand that it does invaluable work. Indeed, I pay tribute to that great unsung army who work within the NHS — the leagues of friends of hospitals—who do so much good, and who do not get the public recognition which they so often deserve. However, what they do is deeply appreciated by my right hon. Friend the Secretary of State and myself.
I come to the next important issue, which involves the relationship of the capital programme, the debate about large and small hospitals, and the implications of the Duthie report. As someone who may have to consider proposals about this hospital at a future date, I can only speak tonight in general terms about this important issue. The pattern of a district's health services will inevitably change over time, particularly where there are plans for major redevelopment, as is the case in southern Derbyshire. I suspect that those plans for major redevelopment may, indeed, have implications for the constituents of my hon. Friend the Member for Leicestershire, North-West (Mr. Ashby), who is in the Chamber tonight.
During the next 10 years the health authority has a very ambitious capital programme, which is likely to total more than £40 million at current prices. The programme includes the redevelopment of services at Derby city hospital, to where the health authority proposes, I understand, to transfer the services now at Bretby hall. There are also major capital developments under way at the Derbyshire royal infirmary and at Ilkeston general hospital. When one invests £40 million in a development scheme, it must involve the appraisal and continuing reappraisal of the services already given. It must mean that we look at the pattern of service delivery.
Health authorities up and down the country are rightly having to go through that re-examination. As my hon. Friend the Member for Derbyshire, South knows all too well, the NHS is now seeing the biggest programme of integrated building development and redevelopment that has been seen at any time since 1948. The programme involves the spending, on current plans, of more than £1 billion on some 140 separate schemes throughout the country. A Minister in my Department could be forgiven for asking, from time to time, "What cuts?" It is the biggest building explosion and capital reconstruction of the NHS that Britain has ever seen.
Sometimes such redevelopment may—and I pick my words carefully — involve the closure of certain hospitals, some of which may be small, others of which may be out of date. Out-of-date plant is hard to maintain, and needs to be replaced. That is not a negative approach. It is not about closures or cuts; it is about providing an improved quality of health care for all those in the district. If we can focus our attention on the need of the patients rather than on the needs of buildings, that is the correct way to see whether we are delivering services to our clients in the right way.
In a modern Health Service, that can mean increasing centralisation of some, although not necessarily all, of the services that the NHS must provide. However, I appreciate that we need to strike a balance between the effective use of expensive medical technology, highly trained nursing and ancillary staffs, and ensuring that the services are accessible to the community which which serve and they are wanted by it. That is not an easy task. It would be wholly wrong for the NHS to attempt to concentrate all its medicine in city centre hospitals. Equally, it would be a delusion for us to think that we can supply to every small hospital the complete range of modern medical techniques. I know that my hon. Friend agrees with that.
I am sure that the health authority will be considering the health care needs of all the people in southern Derbyshire, whether they live in Derby, in the smaller rural communities or across the county boundaries in Leicestershire. Whatever the outcome of the proposals for Bretby hall, it must be proper and desirable that health authorities should examine and reappraise how all their services might be delivered to the public more effectively and economically. It is especially galling for health authorities, when they take the trouble to think about the services that they deliver, that every time they publish a document looking at their services the press talks about cuts. A modern Health Service cannot stand still; it must change—we hope for the better.
Thirdly, and far from lastly, I must say a word about the excellent nursing staff who, I understand from what my hon. Friend told me before the debate, work at Bretby Hall along with ancillary and technical staff. Orthopaedic nursing is skilled and important. The staff must be concerned. The consultation procedure requires health authorities to include in any consultation document propoals for the alternative employment of staff, but that may not always be easy when facilities are being transferred from one hospital to another. I am sure that this is recognised by health authorities throughout the country. Of course, all staff interests have ample opportunity to comment on the proposals during the next three months. I hope that they will take that opportunity. Indeed, I should be surprised if they were not planning to do so.
I find myself in some difficulty on the question of the building. As my hon. Friend recognised, the importance of the listed building—I understand that it is Victorian turreted—is not an issue for my Department but for the Department of the Environment. However, I want to say a few words about the building's future. The NHS prides itself on the care with which it treats historic buildings. The future use of Bretby Hall cannot be considered until a decision has been reached about the future location of orthopaedic services in the area. I cannot do anything that would pre-empt the consultations that are now under way. However, the health authority is aware of the listed status of the building, and this will be an important factor in considering its future use.
Our guidance to health authorities on the correct handling of listed buildings is clear and unequivocal and we make our displeasure known rapidly to any health authority which plays ducks and drakes with the historic fabric of houses that are in our care. The relevant guidance, in the NHS "Handbook on Land Transactions", says that an authority
should not arrange for the demolition of, alteration to, or extension of a listed building in a way to affect its character, without the prior written agreement of the local planning authority.
That leaves no doubt about where a health authority's duty lies, and I am happy to remind authorities of that tonight. If a planning authority objects to a health authority's proposal for the use of a listed building, the case would be referred to Ministers for decision. I hope that that reassures my hon. Friend that, whatever the outcome of the consultations on the future of Bretby Hall as a hospital, its place as part of our architectural heritage is not threatened.
I realise that tonight I have not been able to give any firm commitments in response to many of the questions which my hon. Friend asked and which, I know, concern my other hon. Friends. I hope she recognises that this is not because of any lack of concern, but because of a wish not to undermine or prejudge the local considerations taking place on how the needs of southern Derbyshire can best be served. I hope that if I have done nothing else tonight I have reassured my hon. Friend that none of the important issues which she has raised will go by default.