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I beg to move.
That this House
recognises and supports the contribution of community hospitals to the care of patients within the National Health Service;
requests the Secretary of State for Health to commission a comprehensive database of community hospitals, their ownership and current roles;
and believes that the assets of community hospitals should remain for the benefit of their community while allowing them greater freedom to explore different ownership models.
I warmly welcome my hon. Friend the Minister to her new role. She will know that there are more than 300 community hospitals in England. I used to work at one of the very smallest at Moretonhampstead in the heart of Dartmoor, so I know just how important community hospitals are, especially to isolated rural communities. I may have lost one, but I fortunately gained four, and I am happy to represent Brixham, South Hams, Dartmouth and Totnes.
Community hospitals vary in size and function—some are urban, some are rural, for instance—but they share a common theme: they are deeply rooted in their communities and provide an extraordinary level of support with volunteering and charitable giving through leagues of friends. The reason for that support is clear: people value their personalised approach and want to be treated closer to home. Community hospitals score well on things such as dignity, respect and nutrition. We should be treasuring and enhancing their role because, although small is beautiful, unfortunately it can make them a tempting target for cuts.
The need for efficiencies in the health service is nothing new. I remember reading in 2009—before the general election—about the Nicholson challenge. We have known for some time that we have to make £20 billion of efficiency savings over the next four years—that is 4% efficiency gains year on year—but there is a misunderstanding about what this means. It is not about doing less of the same; it is about spending what we spend more efficiently and looking at the needs of our population. Over the next 20 years, the number of over-85s in our country will double.
In my constituency, Abingdon community hospital has played a fascinating role in supporting the wider NHS in Oxfordshire. It has assisted with the problem of bed blocking by supporting early and late-stage rehab and preventing patients from needing acute beds. I do not think that community hospitals should face cuts, given the role they can play in easing pressures on acute hospitals. Does my hon. Friend agree?
I agree absolutely. Their role in so-called step-down care and rehabilitation is vital, and I am glad to hear that it is happening well in Abingdon.
Seventy per cent. of the total spend on health and social care goes on people with long-term conditions. We should all understand that the burden of disease in England has completely changed—from tackling life-threatening emergencies to managing people with long-term, complex condition.
I congratulate my hon. Friend on securing this timely debate. She mentioned the growing elderly population, and nowhere is that more of an issue than in north Yorkshire. Does she agree that the Government—and this is a good opportunity for me to congratulate our new Minister, whom I hope will respond positively—should not be obsessed only with home care, which has its place, and that there will always be a place for community hospitals in our health care structure?
I wish to make the case for reinvigorating community hospitals as hubs for delivering the right care at the right time and in the right place. Of course, the right place, where possible, will always involve helping people to be independent in their own homes, but community hospitals have a vital role, through both step-up and step-down care, in helping to maintain that independence.
We should look at what community hospitals are capable of, because they are not just about in-patient beds: they provide a full range of diagnostics, minor injuries units, therapies—physiotherapy and occupational —and mental health care. In my constituency, people with cancer can access chemotherapy at Kingsbridge hospital, saving them a long roundtrip to Derriford hospital. Kingsbridge hospital—South Hams, I should say—supports a triangle centre helping people and their families living with cancer, while organisations such as Rowcroft hospice are looking to expand their care-at-home system through hubs in community hospitals and, at times, by utilising their beds and support. We can get so much more from community hospitals if we reinvigorate them.
We should not think of community hospitals as backwaters; they can be centres of great innovation. The nationally recognised Torbay pilot, which provides care based in the community, started at Brixham community hospital in my constituency and is now being consider for nationwide roll-out. That is a very good model.
I congratulate my hon. Friend on securing this important debate. She mentions the Torbay model, which is rightly a pilot and flagship for the integration of services, but does she envisage a situation in which not only are medical services integrated in one location but other emergency services can come together? The result could be enhanced training for people, such as firemen and policemen, who could qualify as paramedics and assistants to the medical services.
Indeed I do, and there are many community hospitals that support first responders in the way my hon. Friend describes. That is an important role, and there is perhaps even an extended role in housing, where step-down housing can enable people to make the transition back to full independence. Indeed, there are many such roles.
What are the current barriers to providing the right care at the right time and in the right place? I would like the Minister to deal with five points. First, the biggest challenge we need to address is the tariff and tariff reform. She will know that most acute hospitals are paid through a system known as payment by results, which creates some perverse incentives, whereby acute hospitals want to hoover up as much activity as possible. Often, people are treated in an acute setting when they could be more appropriately cared for in a community hospital setting or at home. Can the Minister update the House on the progress we are making on reforming the tariff, by, say, working towards a “whole year of care” model or looking at other ways to remove the incentive in the system that means that people cannot be transferred into community hospitals or provided with the right care in the right place?
I congratulate my hon. Friend on securing this debate and I entirely agree with her important point about the tariff and acute hospitals. I hope she agrees that it is also important to signpost patients to the right place, which, because we are talking about a caring issue, is in many cases a community hospital.
I thank my hon. Friend for making that important point. Quite often patients are not aware of the full range of services available in their community hospitals. We can do far better in signposting them. It is also important that GPs understand and support those services and make referrals to the right place.
The second issue I would like the Minister to address is the community hospital estate. She will be aware that many community hospitals around the country are being pushed into ownership by NHS Property Services. However, there are examples around the country of community hospitals that are owned by their communities, for example, or by a social enterprise. If those hospitals are unable to have ownership of their premises, that can hold them back if they have ambitions to expand their roles in future. Obviously we want to reassure the public that these valuable community assets remain in public ownership, as it were, but we also want to ensure more flexibility in their ownership model. I would therefore be grateful if the Minister addressed that point.
Thirdly, there is an accountability issue. There are occasions where having multiple providers operating out of a community hospital can cause confusion. Situations can arise where, because everybody is responsible, nobody is responsible, and accountability can end up being shunted around the system. Does the Minister agree that it would make more sense to have a single body, or even individual, with overall responsibility for what happens to patients and the way in which care is organised in a community hospital?
Fourthly, I want to raise an important point that goes beyond community hospitals to the whole way in which we look at a primary care based system, namely the looming crisis in general practice numbers. For the first time we now have a vacancy rate for GPs of 12% in the south-west. On top of that, in about four or five years we will have a retirement bulge—I am afraid that I have not helped the situation—and we are also moving, quite rightly, from a three-year period for general practitioner training to a four-year period. All that coming together means that across the country, the south-west included, we will face a shortage of skilled practitioners both to deliver commissioning and to staff our community hospitals. We need their support. It would be a great shame if GPs who were enthusiastic about getting involved in commissioning and helping out in their community hospitals were unable to do so because of their clinical commitments. Can the Minister therefore update the House on how we are going to stop the problem, which has been going on for years, of too many medical students going into training in acute hospital specialties? We need more of them to go into general practice.
Finally, will the Minister support the Community Hospitals Association? It does a tremendous job. In 2008 it received a £20,000 grant to help set up a detailed database that documented not only where community hospitals are but what they do. At this time of change I hope she agrees that it is particularly important that we keep track of what they are doing. The CHA has also highlighted innovation and helped to spread best practice, so I hope that she will give it further support.
No debate about community hospitals would be complete without thanking the leagues of friends, which around the country have provided millions of pounds. They do not provide luxuries; we are talking about major building projects, equipment, funds for care, volunteers who come into the hospital—an extraordinary level of support. We could not manage without them in our community hospitals. I know that the whole House will want to join me in paying tribute to our leagues of friends.
This is a call to arms to people listening to the debate. If you value your community hospital, let your GPs know, let your commissioners know, let HealthWatch know, let your local health and wellbeing boards know. If we want community hospitals to be treasured, as we all do in the House, we need to make that very clear.
Order. I advise Members that if I am to get everybody in I will have to introduce a seven-minute limit. If people start to take interventions, I will have to drop the limit again. Everybody will get in, but please be patient and let us try to ensure that everyone gets a fair chance.
I thank Dr Wollaston and the Backbench Business Committee for securing this important debate. We can see from the number of hon. Members across the Chamber who want to talk about this that it is a valid and timely debate. I also welcome the Minister to her new position in the Health team.
As many hon. Members and the Minister of State will know, community hospitals play a vital role in my constituency; Guisborough hospital and East Cleveland hospital are essential to East Cleveland’s health and well-being. I was privileged to secure an Adjournment debate on the future of community hospitals in the north-east on
With the Health and Social Care Act 2012 causing reorganisation that has cost the local NHS tens of millions of pounds on Teesside alone, it is perhaps not surprising that many trusts appear keen to centralise services to larger hospitals. In my constituency, we have already seen a significant reduction during this Parliament in the services available at Guisborough hospital, with the closure of the Chaloner ward and a reduction in minor injuries provision. Similarly, constituents have told me that they have been unable to receive the services that they need at East Cleveland hospital in Brotton. This is deeply worrying, as more than 50% of my constituency is rural, and I know how constituents without a car can struggle to attend hospitals further away, such as the James Cook university hospital near Marton, Easterside and Park End in the south Middlesbrough part of my constituency.
I know that this problem is unfortunately replicated around the country. In the South Tees Hospitals NHS Foundation Trust area alone, a district general hospital in Northallerton—the Friarage—and Redcar’s primary care hospital are facing problems due to the centralisation of services. With the reallocation of public health funds as well, which are used primarily for community nursing, we are seeing what I can only describe as a vice-like grip between the reduction in services in community hospitals and the reduction in funding for community nursing, especially for palliative care for elderly and vulnerable people.
I can tell that the hon. Gentleman has a good memory, because that point was raised in my debate. While many services at that hospital have been closed in recent months, the maternity services at Guisborough were centralised at James Cook and the community was consulted on that. However, I did not see any proper community consultation when services at East Cleveland hospital and Guisborough were very much reduced.
Also, a massive number of long-serving, skilled nurses, mainly women, have been leaving Guisborough hospital before reaching retirement age. That is very worrying. They are choosing to go to other hospitals or simply to leave their careers altogether. The trust acknowledges that this is happening, and the reasons include stress, a lack of available nurses on the wards and the low-paying contracts being offered.
This seems to involve a central funding issue for the trust. The James Cook University hospital is now consulting the community on privatising wards at the hospital. So, while the trust is centralising services away from the community hospitals, it is also trying to find other funding sources to pay for the services that it has centralised. That suggests that this is a central funding issue and nothing else.
I sincerely hope, for the sake of my constituents, that the Minister takes urgent action to address the problems faced by district, general and community hospitals. Such action should include commissioning a database of information on what they do, providing trusts with the funds that they need to secure the future of those hospitals, and replacing the money that they have been forced to waste on an unwanted, unnecessary, top-down NHS reorganisation.
Community hospitals are really important in South East Cornwall. It is a rural constituency, and the two district general hospitals serving the area are located far away from my constituents. It takes at least an hour to travel to Derriford hospital in Plymouth, and those living at the western end of the constituency have to travel to Truro, which involves about the same travelling time. It is therefore important that patients and relatives can source many services from the two community hospitals in the constituency. One is in Liskeard; the other is St Barnabas hospital in Saltash, which is housed in a beautiful historic building.
When I met the Liskeard community hospital’s friends group, I learned that it had raised and spent more than £30,000 on equipment to assist the treatment of patients since the hospital was built relatively recently. I am proud of and grateful to the local community for donating so much time and effort to keep the hospital well equipped. This ultimately helps many local patients. The friends continue to work to raise money for up-to-date equipment to assist with patient comfort and diagnosis. I was fortunate enough to visit the hospital last summer and to see some of the brilliant equipment that has been provided by the league of friends.
I visited St Barnabas hospital in Saltash before the election, with my right hon. Friend Mr Lansley, and have seen for myself the wonderful facilities that it has, including some operating theatres. They are not utilised to their full extent, however, and I should like to ask the Minister to ensure that such facilities are fully utilised, especially in rural constituencies such as mine.
Liskeard community hospital offers a number of in-patient beds, in addition to a minor injuries unit that is open every day, an X-ray department that is open from Monday to Saturday, and a range of out-patient clinics. St. Barnabas, in addition to the facilities that I have described which could be more fully utilised, offers a small number of in-patient beds and a day-case surgery. In addition, a range of out-patient clinics is held on site, and the minor injury unit is open every day. I believe that there is capacity for expansion at both locations. That would benefit patients living in my very rural constituency, which has limited public transport. I hope that the Minister will take note of this and ensure that as many services as possible are rolled out to our valuable community hospitals.
I congratulate my hon. Friend Dr Wollaston on securing this debate, and I congratulate my hon. Friend
We are discussing community hospitals, which provide an important service in offering care to all our communities. I think there could be a renaissance in community hospital provision in the coming decades, not least because the vast majority of money in the national health service is spent not on all the exciting acute and surgical kit, but on the provision of care to the chronically unwell. Where better for the chronically unwell to be treated than in their communities?
I am particularly interested in this subject because I have recently published on it—and I commend my own publication to all colleagues in the Chamber! It is a 70-page document that my office and I managed to put together, and it was published in May this year. In it, I call for the closure of some acute hospitals and for the merger of community hospitals around what is commonly described as the hub-and-spoke health care model.
I am told by some experienced and seasoned politicians that this is quite dangerous stuff. I have called in the press for the local maternity unit not to reopen, and I have argued that having a casualty department at my local district general hospital would not be in the best interests of my constituents. People may say, “Good luck with your single term in office, Phillip”, but the reality is—I am being serious here—that what I am saying is in all our best interests. I would say that it is in the interests of those on both sides of the House—it is a pity that so few Opposition Members are in their places today—that we get behind the reality of what is happening in the delivery of health care.
I have not met anyone working in the medical profession who does not support the principle of the consolidation of acute and surgical services and the provision of chronic care in community settings, so this is undeniable. If anyone meets such a person, please put them in touch with me, as I would be interested to hear the argument for the status quo.
The reality is that acute and medical/surgical care is becoming increasingly complex, increasingly expensive to deliver and, in particular, increasingly difficult to staff. Nowadays, we do not have the “Sir Tufton Bufton” general surgeon as once there was; we have different qualified surgeons within the broad field of general surgery. If I have something wrong with my upper gastro-intestinal tract, I want to go to an upper GI specialist. I do not want to go to someone who does it occasionally; I want to go to someone who does it daily. This is clearly not possible on every district general site in the country.
We are beginning to see the realities. There is a consolidation of services ongoing in the south of London. It is politically sensitive, I gather, but it is going to happen, so everybody needs to wake up to it. It has already happened in Norwich; it is happening in Cambridge; and I gather it has happened in Swindon. That this is happening everywhere around the country is, I believe, a positive move. I do not seek to make any political point or to any political capital out of it because I know that if there were a Labour Government, it would be happening in any case. I would encourage not just existing MPs, but candidates at the next election to be more honest about this. As I say, it is really in all our best interests. Ultimately, we are here to try to secure a health service that provides the very best for all our constituents.
Let me move on to my specific regional case. To provide some background, I still work as a doctor, and I intend to continue working as one—not least because one morning in Slough is enough reality to keep my feet on the ground. In that capacity, I have formed the impression that what we need on the ground in Buckinghamshire, Berkshire and south-east Oxfordshire is a consolidation of acute and surgical services.
Having looked after approximately 50,000 patients in about 50 general practices throughout the Thames valley, referred patients to every acute centre and worked with every hospital except the Royal Berkshire, I feel that I may have something to say about this issue. I have concluded that we need a new hospital at junction 8/9 of the M4, and I am not alone in thinking that. Deloitte, which was paid significantly more money than I was to produce its wonderful report in 1989, reached exactly the same conclusion, and that was before Wycombe general hospital had been downgraded as a fully fledged acute surgical site.
I am in favour of the retention of all community hospitals in the region except two. One is Heatherwood, the hospital that has traditionally served my constituency— people may say that I just talk the talk, but in this instance I am walking the walk—and the other is St Mark’s in Maidenhead. I want to enhance the delivery of chronic medical services on the Brants Bridge site in Bracknell. That is the plan, and I am trying to build some grass-roots support for it. I am trying to emphasise—this brings me back to the topic of the debate—the importance of community hospitals, the importance of the services that they offer now, and the fact that they can offer enhanced services in the future.
Given an ageing and increasingly retired population and a diminishing economic position, we shall have to sell off sites to find the necessary capital funds. However, this is a positive story. We can have new acute emergency hospitals throughout the country, although I recognise that in rural areas they will have to be supported by helicopters and the like. We can provide better services, both in the community and in the central, specialised hospitals, delivering the very best health care in the 21st century. That is why I am a proud supporter of community hospitals. I hope that all Members of Parliament of all parties will step up to the plate and be honest about the situation, so that care for all patients can be improved in future.
It is an honour to follow Dr Lee, who made an excellent speech. I also congratulate Dr Wollaston on having initiated this important debate, and welcome the Minister, who has secured a deserved promotion. I think that we have all appreciated her analytical contributions to debates on health and on other matters.
I have only one simple point to make, which is better than my normal average. The fact is that community hospitals are in a slightly ambiguous category. Some are innovative, valued, highly rated and essential, while others are historical legacies of a previous age—expensive to run, limited in range, and out on a limb. Some areas depend on them, and some areas, such as mine, have absolutely none. I was a founder member of the all-party parliamentary group on small hospitals simply because my constituency contained a small acute general hospital. Dr Taylor was, of course, elected over an issue involving the closure of hospitals, which has been a shock to the whole political system ever since.
What a community hospital offers, what it consists of, how it is staffed and the services that it offers varies from one community to another, but what is universally the case is that, negatively or positively, we are now deciding what we will do about such hospitals and evaluating their place in the new system. There are three forces working against them. First, there are the perceived and evidenced benefits of specialisation—mentioned by the hon. Member for Bracknell—and the concentration of hospital services across many surgical and medical fields, leading to bigger and more expensively resourced general hospitals. Secondly, there is the encouragement given to GPs to provide more and more services in a primary care setting: tests, dermatology and the like. Thirdly, there is the encouragement given to non-NHS providers to offer clinical services at NHS prices. Given the additional fact that the last Government cut the umbilical cord which, in many instances, joined community hospitals to PCTs and effectively guaranteed their funding, the problem is clear.
The result of all that is that each community hospital has had to establish its own niche within an increasingly tightly regulated and exacting health economy. The range of services they provide varies: recuperative services, palliative services, minor injuries services, clinical and diagnostic services, blood tests, and—very importantly—the provision of satellite services for bigger players. It can look as if they are searching for a role, but their absence, closure or downgrading has the capacity to seriously unnerve communities and their MPs.
Hard-headed health economists and medics regard this as emotional populism; they see people getting upset about the survival of their community hospital as, in effect, a costly attachment to buildings. However, they misunderstand the public—and, to some extent, the rural—psyche. People have reasonable and rational expectations concerning the clinical quality of services, and the NHS tries to state them, define them and meet them. People also have reasonable, but generally unstated, expectations about access to services, and the NHS often dodges them, declines to state them, or shuffles off responsibility to the Department for Transport. People will travel to the ends of the earth for life-saving specialist care, but they see no reason in the modern age to travel 10 miles for a simple blood test or the triaging of bumps and falls.
We have to accept that acute care will increasingly take place only in ever-larger city hospitals, but there will be hassle for everybody, including relatives, if prolonged recuperation or chronic diseases are treated in the same place. It is true that over time GPs will do more and send fewer patients to hospital, but no GP will ever provide 24/7 open access. Very few GPs are now on call, and they do not offer the full raft of community hospital services.
If community hospitals are to have a long-term future, we have to be clear about access, access standards, what the reasonable standards of access are and what each citizen can reasonably expect from the NHS—a subject on which I had an Adjournment debate a few months ago. If that is not done, the future of community hospitals will be left to market forces to play out, which is not a game I see community hospitals winning.
I congratulate my hon. Friend Dr Wollaston on securing this debate. We are discussing an important topic and there are many wide-ranging issues to be addressed. I also congratulate the Minister on having been appointed to her new role. We all look forward to working with her.
Community hospitals do not just provide excellent clinical medical care. They are also places where patients feel the warmth of the community, which adds to a sense of well-being that is also part of their recovery. One reason why people feel so strongly about having community hospitals close and accessible is because it means friends and relatives can attend, which helps to make patients feel well. That is not just emotional clap-trap.
My hon. Friend the Member for Totnes put her finger on a key point when she said that this is about the community and trying to extend and expand the range of community services that are available. My community hospitals in Teignbridge are going from strength to strength, and there is a move towards integrating social and health care. That will be the salvation of community hospitals in the future. I support my hon. Friend’s comments about volunteers, too. The league of friends and the community transport in my three hospitals are first class. Without them, our community hospitals would not be nearly as successful and happy.
My three hospitals are quite different, but they all have minor injuries units and X-ray facilities, and provide a variety of services to the old and the young. Dawlish was the first private finance initiative hospital ever built, and patient surveys consistently put it in the top three of the 22 Devon hospitals. Remarkably, Teignmouth still has an operating theatre, as well as a physio unit funded by the league of friends—well done! Newton Abbot got the 2007 PFI deal of the year. Unusually, it has a maternity unit, as well as a first-class stroke unit.
My hon. Friend the Member for Totnes also raised the important issue of ownership. I raised this matter last year in a Westminster Hall debate. It is crucial that we get clarity about how ownership is to be managed once the asset is transferred from the primary care trust. In the case of Teignmouth hospital, the property is owned outright by the PCT. As I understand it, that property will be transferred to NHS Property Services Ltd. My local community has put in £850,000, so how does it feel about that? What will happen on future fundraising? Will the money just go into a central pot? What terms and conditions will be imposed on the service provider?
The situations at Newton Abbot and Dawlish are much more complicated, because those hospitals are the subjects of PFI contracts. That means that the buildings are owned by a private contractor and are, in effect, rented out to the service provider subject to two charges, an availability fee and a service charge, both of which have historically been extraordinarily high. In those cases, the contracts will be transferred to the NHS Commissioning Board. That raises a number of legal questions about the validity of the transfer, given the nature of that contract, and about the ability of the new owner to renegotiate the contract. Why do I talk about renegotiation? I do so because it is well known from evidence in the press that some of the charges that have been levied are disproportionately high. What can we do to enable such a renegotiation? Clearly it will be completely inappropriate for a local trust provider to undertake such a renegotiation, so will the NHS Commissioning Board do it?
My hon. Friend Jesse Norman has been brilliant in raising a campaign to look at renegotiating these contracts. The Government have already started to look at the whole management issue of these contracts to see whether costs can be cut, and they reckon that a substantial saving has been made and 5% savings can be achieved. They have established a fund of more than £1.5 billion for this; that is the amount that any one trust can get over 25 years to assist with the blighting cost, but that can be obtained only in exceptional and historic circumstances. The fund has been used, but generally that has been in much larger cases involving much bigger hospitals; I cannot see a community hospital being able to pass the test of having exceptional and historic problems. So what can the Government do to help those hospitals blighted with the burden of a PFI contract? I have heard of hospitals that, under the service charge, have had to pay £333 just to change a light bulb. I am pleased to say that that was not the case in my local hospital, but my goodness me that sort of situation has to change.
My hon. Friend rightly raises the issue of PFI and asks what the Government can do. I would venture to suggest that the previous Health Secretary’s decision to approve the county council’s assistance to the health trust so that it could buy out the PFI contract that was crippling Hexham hospital is exactly the right way forward. Under that approach, a PFI arrangement is bought out and a much better financial basis is put in place—an ongoing future financial basis approved by all.
My hon. Friend makes absolutely the right point, but the tragedy is that few communities can afford that sort of buy-out. As he rightly says, if we could achieve that, it would undoubtedly be the answer.
All we need from the Minister is some clarity as to exactly how these properties are to be transferred; what the position with the local community will be when properties are owned by NHS Property Services Ltd; and what the position will be on the PFI contracts when they get passed across to the NHS Commissioning Board. Clarification on those matters would be helpful and it is now urgently needed, because local trusts that are looking at continuing to run these hospitals need certainty about what they are going to be including in their budgets, and the sorts of figures that the availability fee and the service charge take out are phenomenal. The availability fees at my local hospitals range from 18 to 35%; that is the fee simply to repay the funding costs of the overall PFI arrangement. The service charge can also be high, reaching 18 to 20%. Set against that, private investors are currently seeing returns of up to 50%. That is huge and it seems unreasonable. The previous Government entered into a voluntary arrangement whereby any excess profits, particularly as a result of contracts being bundled by external private bodies, should be shared between the taxpayer and the private investor.
All those tools, which are available for the Government, need to be used. We need certainty and manageable budgets so that our community hospitals can thrive and so that money is available for what we really need—the services.
I, too, thank my hon. Friend Dr Wollaston for securing this very important debate, which, as she will see from my speech, is very timely given what is happening in my constituency. I also congratulate the Under-Secretary of State for Health, my hon. Friend Anna Soubry, on her elevation to the Front Bench. It is always fantastic to see someone from the midlands in that position.
I want to pick up on points that were made in the last two speeches. My hon. Friend Anne Marie Morris spoke about the ownership of the hospital and the future and John Pugh said that market forces determined the future of some hospitals. That was apt given what is happening in Cannock, where we have a situation with our community hospital.
Cannock community hospital was built in the 1980s. It is a fantastic facility with many years of life left in it, but over the past 20 years it has seen a gradual decline in use and is now chronically underused. It has gone from having nine wards when it was opened to having only two, and just last week the kitchens were closed to save £200,000-odd a year. Cannock forms part of the Mid Staffordshire NHS Foundation Trust and shares it with Stafford hospital, and many colleagues will be aware of the problems there and the extra funding the Government have had to put in. The trust that controls Cannock and Stafford hospitals has a problem, as it is losing £15 million a year and £8 million of that through running Cannock community hospital. That cannot go on.
There are only three options for Cannock. First, it could be sold off and the remaining services could be transferred to Stafford hospital, which is a bigger acute hospital, with some of the receipts from the sale being used to expand services at Stafford and to accommodate them. That is unacceptable to my constituents, local people and local politicians on both sides of the divide. We are not willing to see our local hospital close—a hospital that was bought with local money from the National Coal Board and with local donations. There are therefore only two other options to secure the future of Cannock hospital, given that it is such a loss-making enterprise; it costs some £34 million a year to run and pulls in about £24 million from the commissioning of services.
The first of those options is for the GPs to fill the hospital. I am sceptical about that because they have not filled it so far and it takes a brave man to persuade the clinical commissioning groups that they must fill the hospital so that it becomes a going concern that does not lose any money and is fully utilised. GPs simply have not done that in the past. If we cannot fill it with services, I have come to the conclusion—I have just come from giving interviews to the local media on this point—that the only solution to secure the future of our community hospital is for the district council to purchase the facility or purchase a controlling part of the hospital estate. A clause in the contract would mean that the council could use the part of the estate it owned only to meet health and social care needs.
I think the future for our hospital will be for Cannock Chase district council to buy 50% or 60% of the estate—or even all of it—and decant some of the health and social care services that it runs into it, including GPs’ surgeries, walk-in clinics, polyclinics, advice centres and so on. The hospital would once again be a going concern. It was valued just four months ago at £34 million, so Members can see that even buying 50% of it would cost the council £16 million to £17 million. As a council with a turnover of several million pounds a year that can borrow £80 million a year, that is feasible. I hope today to set up a working group of local hospital bosses, council leaders and officers, the friends of Cannock hospital and any local stakeholder who wants to be involved. I do not know what the answer is or how feasible this might be, but I see no other way of securing our hospital’s future and getting it utilised again unless the district council steps in, buys part of the estate and utilises it itself, or even buys the whole estate and leases part of it back to the trust, which currently uses part of it for rheumatology, orthopaedics and eye surgery but not all of it.
I will conclude briefly by asking the Minister whether she and her Department would approve, in principle, of district councils helping to secure the future of our beloved community hospitals in that way. If so, perhaps she would consider sending an official from the Department to serve on the steering committee we are setting up to investigate the possibility so that they can guide us on how best to secure the future of our community hospital and retain its use for health and social care services, as the current reality is that it is losing money and financially is not a going concern in the long term.
I, too, congratulate my hon. Friend Dr Wollaston on securing the debate and speaking about community hospitals with such passion and experience. May I also congratulate the Under-Secretary of State for Health, my hon. Friend Anna Soubry, and say how pleased I am that the debate is taking place within a few days of her promotion, which means that she can hear from the Front Bench what a tremendous asset community hospitals are to all our communities? It is disappointing that only the shadow Minister and the Opposition Whip, Nic Dakin, are on the Opposition Benches for this important debate.
Our experience in West Worcestershire can certainly contribute to a debate on the ownership of community hospitals, because we have three in the constituency: Malvern, Pershore and Tenbury Wells. They all have slightly different models of ownership, and I think that diversity of ownership model is something that has led to their success and will lead to their longevity. I thought that it might be worth sharing with colleagues the different approaches that have been used.
I will take this opportunity to pay tribute to my predecessor, now Lord Spicer, who fought for a new community hospital for Malvern for most of the 36 years he represented West Worcestershire. We used to have a hospital in a beautiful old building dating from the late 19th century, but it had become too small and too old and, although beautiful, was no longer fit for purpose—to use the famous NHS phrase. Everyone in the community, including the league of friends, accepted that was the case and campaigned for many years for a new build hospital. A site was secured in the 1970s but sat empty and derelict for the better part of three decades until the day when my predecessor got the phone call from Mr Bradshaw to tell him that a new community hospital would be built in Malvern. It was a great day of celebration after so many decades of campaigning. Indeed, if any Members are in Malvern in the near future, they will see what a spectacular hospital has been built for the community. It opened just over a year ago. It is owned entirely by the Worcestershire Health and Care NHS Trust, which of course is taking the opportunity to sell the old hospital building to help pay for the substantial cost of the new one—about £17 million.
We have another new hospital in West Worcestershire in the town of Pershore. Again, the town had a very old building, although not quite as old as the one in Malvern. Wychavon district council took the unique and unusual decision to create a new build hospital in the centre of town. It used its reserves to do that, and it was able to rent the building out to the local NHS trust. It is paid a much better rate of return on its cash than it would have received if it had left it in the bank—certainly an Icelandic bank, as in the case of some other Worcestershire district councils. This has proved to be a good investment for the district council and a good asset for the community. Both new builds are greatly valued by South Worcestershire clinical commissioning group, which is beginning to review the full range of hospitals, including acute hospitals, in Worcestershire. I am hearing very positive things about finding additional uses for the community hospitals.
Let me finally mention Tenbury community hospital, which has an incredibly successful and active league of friends. The town has only about 2,500 residents, but over the years the league has raised millions of pounds, not only for equipment for the hospital but for its fabric. We have seen two new wards open in the past 12 months. Tenbury hospital therefore almost has a shared ownership not only with the NHS but with the league of friends. Because the league’s investment has been so substantial, it would be unthinkable for the NHS to treat the building as an asset that it could sell on. All three hospitals are well used and increasing the range of services that they can provide in the local area.
I may have saved the Department some time in relation to the motion by delivering a comprehensive database of the community hospitals in West Worcestershire. Thank you, Mr Speaker, for allowing me to put on record the community’s appreciation of the services and buildings that we enjoy in my constituency.
I welcome the Minister to her seat. I would be grateful if she could nod if she has received a large brown envelope marked “Urgent” which I sent to her office in the House of Commons only two days ago. Perhaps she has not quite got it yet because she has had her feet under the desk for only a couple of days; however, it is sitting there somewhere. I mention it because it contains a report whose author is sitting in the Gallery, as is Jan Turnbull, who is chairman of the Swanage league of friends, and Dr Tim Morris, a former Swanage GP.I think they would like to be assured that I have done my job in getting that excellent report to the Minister.
I suspect that a lot of people have been down to Swanage; it is a beautiful place. I challenge anyone, whether they are healthy or ill, to go into Swanage hospital and not automatically to feel better. They will be in a cosy home where Claire Thompson, the cook, produces cakes to die for; I have been greatly honoured to have one given to me. That wonderful cosy atmosphere not only facilitates a good service but sends people home feeling better, which is crucial.
I ask, plead with, beg the Minister to carry out an audit of the 320 community hospitals in the UK before any are closed. I believe that the Government wish to increase care in the community. I always get slightly nervous when I hear that expression because that approach was tried once before by an eminent Prime Minister and I am not quite sure that it went entirely right.
In our neck of the woods, the proposal is to close Swanage hospital and instead to send community nurses out into residential care homes where mainly elderly people—former in-patients—would be put. I would like to give the House the image of these nurses—albeit well-intentioned, well-trained and all the rest of it—arriving at a certain time of day in their vans, unloading all the medical clutter, crashing into someone’s room and saying, “Don’t panic, Mrs Jones—care is here”, when instead Mrs Jones could be tucked up in bed in Swanage hospital, which has been there since 1890, being looked after 24 hours a day. Surely that is the better option, and I suggest that in the long run the other option would turn out to be far more expensive.
Swanage hospital provides outpatient clinics, 15 inpatient beds and a 24-hour minor injuries unit, and it is particularly noted for post-acute care for stroke victims before they go home. Twenty-one consultants visit the hospital weekly, some performing minor and intermediate surgery in its operating theatre, and one GP attends daily. This is not an underused facility. The hospital staff, the league of friends and consultants want the service expanded, not closed; yet the clinical commissioning group, bless it, or CCG, which sounds rather sinister—I do not like these acronyms—wants to close it and introduce a polyclinic in its place. I had wondered whether this was to be a home for parrots or carrots, but it is for people—a polyclinic is, believe it or not, for people. I am sure that the proposal is well-meaning, that it will be well-funded and built with a lot of plastic, and that patients will go there. Yes, it is true that it will provide minor day surgery and slightly more extended services than those that GPs can offer at present, but it will not have in-patient beds or general anaesthetic, which are what the consultants want Swanage to retain.
Some miles down the road in Wareham, one of the options being suggested is to build a new hospital at a cost of, I guess, £24 million to £35 million, £36 million or £37 million. Why? Where is this money coming from? The league of friends has raised hundreds of thousands of pounds and invested it in its hospital. It now has £1.4 million sitting in a bank account waiting to be invested.
Sadly, the impetus behind this particular move is those GPs in Swanage who want to move to new premises. To be fair—they are not here to speak for themselves—their building is probably not fit for purpose. However, there is room next door to Swanage hospital, in a lovely, cosy place, for them to put their new clinic—it is in the town and ready to go. Instead, they want to put a polyclinic on the outskirts of town, which would be less accessible.
The situation is a tragedy. Again, I ask, plead with, demand that the Minister hold an audit of the 320 hospitals before any are closed, so that the Government can carry on doing what they are doing. In many ways, we all sympathise: money is tight, the cost of the NHS is rising inexorably and we cannot go on like this. We have to consider a more efficient way of providing a service for our patients, but closing a much-loved and much-used cottage hospital in Swanage is not the way forward. I urge the Minister to see this beautiful place, and I invite her to do so, and to meet Claire Thompson. Jan Turnbull is in the Public Gallery and we can guarantee the Minister a cake when she visits.
Before I close, I want to raise one last point that worries me, namely that there is evidence of referrals being suppressed. I have heard this in other debates and meetings that I have had about cottage hospitals. It is said that the aim of the NHS is to claim that such hospitals are underused, but that is entirely disingenuous and, if true, absolutely and categorically wrong. Again—I make no excuse for this—on behalf of my constituents, the hospital, the league of friends and the matron, Jane Williams, I plead with, beg, ask and demand that the Minister please, please, please hold an audit before anything else is done.
I feel shy speaking in front of this extremely distinguished audience. It is impressive to take part in a debate involving people with so much expertise. I was impressed by the extraordinary confidence with which my hon. Friend Dr Lee said things that we would not dare say to any of our constituents by calling for the closure, no less, of one of the community hospitals in Bracknell on the grounds of efficiency. The sense that expertise can deliver controversial and exciting policies is moving. It is also moving for me to be able to thank my hon. Friend Dr Wollaston for securing the debate, and to congratulate the Minister on her new position.
The debate on community hospitals should be held in a larger debate, and it is a debate that Conservatives should be proud to have: the ancient debate of the big against the small. The reason community hospitals are under threat, have been under threat and always will be under threat—I mean this not in a political sense, but simply ideologically—is the problem of the small.
In 2005, one in four members of the population in Cumbria signed a petition to keep our community hospitals open. Today, we face serious issues of the internal market and the tariff structure of the NHS, which may make it tempting for commissioners not to refer patients to community hospitals. All of that is about big and small. It is the same argument as that between the big supermarket and the small shop and between the small dairy farm and the big dairy farm.
This argument goes all the way back to the foundation of the NHS. One remembers Bevan’s great statement:
“I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.”—[Hansard, 30 April 1946; Vol. 422, c. 44.]
In that moment, Bevan, in founding the NHS, set up the fundamental challenge. My hon. Friend the Member for Bracknell expressed the problem clearly in explaining that in the choice between acute surgical care and local care of chronic conditions, we have the choice between fancy machines, specialisation and surgeons who perform the same operation again and again, and what is required for a new situation and a new population. We are no longer in the late 1940s.
If I may be so presumptuous in this distinguished company, I will put Cumbria forward as an example. We are an interesting example, because we are ahead of the rest of the country in one thing: Cumbria has more deaths than births, but a rising population. That is not, as one might imagine, because we have discovered resurrection; it is because we have old people moving to our constituency. The population of the constituency is getting older at a national record rate. We are about to go from one in six of the population being over 65 to one in three of the population being over 65. The number of people who are over 85 is about to double. The number of people with Alzheimer’s in my constituency is about to double. All that points, above all, to one thing—community hospitals. What people at that age need is not necessarily the technical services and equipment that are provided by acute hospitals, nor the specialties of their surgeons, but preventive care. That can be delivered through the hubs of which we have all spoken.
To give a local example, my neighbour recently broke her hip. To many of us in this Chamber, that seems fundamentally to be a problem of cost. It costs £350 to move her in an ambulance from her home to the hospital, it costs a minimum of £2,000 to admit her to the hospital, and it costs tens of thousands of pounds in ongoing costs as she struggles to get better and gets into other chronic conditions. But why did she fall? She fell because her husband died. The chance of somebody dying doubles in the year following the death of their husband. She was in trouble because she could not get anybody to take her to an optician. She was not eating properly, because nobody was able to take her to the supermarket regularly.
Those are things that the extraordinary network of local charities and community activity is in a fantastic position to provide, guided by the community hospital. In Cumbria, Cruse Bereavement Care provides counselling to people who are bereaved and Eden Carers could perhaps have taken my neighbour to the optician. Every Member has such organisations in their constituency.
They have their equivalents of Hospice at Home and the Eden Valley hospice. There are also the first responders and other members of the emergency services. My hon. Friend Guy Opperman champions the air ambulance and others of us champion mountain rescue. It goes all the way down to Age UK and the Alzheimer’s Society. Indeed, we have made fantastic progress in neuroscience support at a community hospital level.
I conclude with a plea to the Minister. This is not just about good language. It is easy to talk about prevention, but also very easy to carry out bad prevention and waste an enormous amount of money tacking down carpets in the houses of people who do not need their carpets tacked down. My constituency includes surprised people who have suddenly found themselves given a new shower that they did not particularly feel they needed. What we need is the local knowledge, care and compassion that can target those resources. The Minister is now in a position to move just 2% or 3% of the budget towards community hospitals and community care and away from acute trusts.
Shortly before I was elected, I was contacted by some nurses from Rowley Regis community hospital in my constituency who had just been told that the hospital’s in-patient wards would be closing. Rowley hospital was one of the last community hospitals to be built under the last Conservative Government using central funds rather than through a private finance initiative project. It had always offered a mix of in-patient and out-patient care, and with about 100 beds it was considerably smaller than nearby hospitals such as Dudley’s Russells Hall, West Bromwich’s Sandwell general or Birmingham’s City hospital.
The last Government’s preference for large super-hospitals meant that the local NHS trust, like others around the country, felt under pressure to move in-patient services from small community hospitals such as Rowley. Staff at the hospital and members of the local community feared that the closure of the hospital’s two remaining wards was part of an agenda to turn it into a polyclinic, which the Government were pushing heavily. There is no question but that without in-patient care, Rowley would be more like a walk-in centre and clinic than what most people think of as being a hospital.
The campaign to keep in-patient care at Rowley brought the whole community together. Working with local residents, staff and patient groups, we gathered petitions against the loss of in-patient care, manned town centre stalls, delivered leaflets and wrote letters. The independent Facebook group alone attracted well over 1,000 supporters. Local people wanted to keep services at their local community hospital.
I know that, as other Members have mentioned, Members of all parties will have run similar campaigns in their constituencies. The campaign was a great success. My right hon. Friend the Leader of the House, who was then the shadow Health Secretary, joined me for meetings at the hospital with the NHS trust and hospital staff. He promised that under a Conservative Government services would be maintained where the local population, as service users, and local GPs as commissioners, demanded them. I was therefore proud when, last year, the trust invited me to open the Henderson reablement unit, a new in-patient ward that cares for patients recovering from serious illness. The Henderson unit is now a busy and successful part of the hospital, and I know that the trust is exploring ways to bring further in-patient services to Rowley hospital.
Community hospitals such as Rowley are an essential part of the national health service. They are important because the NHS is not just about drugs and operations, it is about care and about helping people make a full recovery in a supportive environment. Rowley Regis hospital cares for patients who are recovering from life-changing illnesses and injuries while they are unable to care for themselves. The care goes beyond medical treatment and physical therapy, helping patients to regain the ability and confidence to carry out necessary everyday tasks in a safe and supportive environment.
The staff at the hospital are fantastic examples of the very best of our national health service, showcasing the blend of professionalism and compassion on which the NHS at its best relies. Patients feel that they are given more individual and personalised care than would be possible at a large district general hospital.
The hospital itself is a pleasant place to be, which is particularly important for elderly patients whose lives, after a lifetime of independence and living at home, have been turned upside down by a serious fall—such as the one mentioned by my hon. Friend Rory Stewart—or a stroke. Patients can enjoy the beautiful gardens, and socialise in the well-designed communal areas, and when I talk to in-patients at Rowley I find that they are overwhelmingly positive about their environment and the care they are receiving. Being at the heart of the local community, rather than in a larger town a long bus journey away, helps to soften the anxiety of being away from families and friends, and it is easier for families to visit and help relatives through their recovery.
People are extremely proud of Rowley Regis hospital, and I would be pleased to welcome the Minister to Rowley so that she can see it for herself. I know, however, that Rowley is not unique, and other hon. Members have mentioned their experiences of local community hospitals. Community hospitals around the country are important to the patients they care for and treat—the kind of care that is extremely difficult to replicate in a larger hospital. I hope the new Minister will ensure that community hospitals remain a key part of a national health service that, at its heart, recognises that one size really does not fit all.
At this moment, Mr Speaker, you must be feeling like Shakespeare’s Henry V at Agincourt, and I suggest you will look back on
I strongly look forward to hearing the gentle, reticent, shy, self-effacing style that the Minister has characteristically formed throughout the past two and a half years as an MP. Some have described her as Nottinghamshire’s modern Boadicea of Broxtowe, which may stick in the future. If she is able to survive the cake-fests of south Dorset, and future requests to visit many a hospital, she will surely go far.
I must make a brief declaration because I would not be in this House were it not for my campaigning as a lawyer on behalf of community hospitals, and the fact that my grandmother was an NHS matron. Furthermore, over the past two and a half years, I have probably spent more time in hospital than any other Member of Parliament, conducting an in-depth study of all aspects of NHS treatment. Due to the fact that I was not a very good jockey, I have conducted an in-depth study of orthopaedic skills because I repeatedly seemed to come a cropper at the second last at Stratford, and various other delightful destinations. I am also fundraiser for various charitable organisations in my constituency—the Great North Air Ambulance service and the National Brain Appeal.
The subject of the debate is community hospitals. Amid the requests for preservation, strengthening and support, I want to enlighten the House with some success stories. The Haltwhistle hospital in Northumberland—a small community hospital in the heart of the town—is being completely rebuilt. There have been efforts to rebuild it for many years, and that is now happening on the same site in exactly the right way. That is what all hon. Members would like for their community hospitals. People in Northumberland would suggest that its integrated care is the way forward. There are standard community beds and care beds, and even one room for the larger patient, which is known in the trade as a bariatric room. That is a proper, integrated, long-term local solution in the community, for the community and involving the community. That must be the way forward.
Ilkeston community hospital in my community is held in great affection. Recently, one ward closed—the decision divided opinion among local GPs. We need to examine what services are provided and remind local residents and patients what facilities are available and what procedures they can obtain locally.
I endorse entirely what my hon. Friend says and am sure the Minister has taken due note of her comments.
I want to sell and extol the groundbreaking decision in Northumberland in favour of the PFI buy-out of Hexham general hospital. The hospital was built and opened under the former Prime Minister—the right hon. Member for Sedgefield as was—with a substantial PFI that patently impeded its ability to function, but it is among the first in the country to have been bought out by the local community. The way forward must be to try to refinance and improve the financial situation of such hospitals.
Northumberland has a rebuilt community hospital and a general hospital at Hexham, which delivers all the services, including cancer care and maternity, that we would like in local facilities. That should continue, but the problem I want to raise with the Minister is the future of rural health care—the problem will also apply to my hon. Friend Rory Stewart and any number of representatives of truly rural communities. Community hospitals are clearly at the heart of that, but the way in which community hospitals integrate in rural health care is one of the significant challenges for the Department of Health in the next five, 10, 15 and 20 years. I suggest that the way ahead must be for rural health care to become more automated—we should provide computer facilities for prescriptions and check-ups—but we must also integrate facilities using examples such as the Torbay and Haltwhistle models. We should also attempt to provide paramedic and GP services in an integrated way. It is good that Andrew Gwynne, the shadow Minister, is in the Chamber, because that will take co-operation between the unions and between local facilities. Any problems should be overcome if we make the point that people in the community are helping one another.
The future of integrated services—health care, fire, police or ambulance services—must be addressed by whoever is in government. I strongly urge the Minister to come to Northumberland to see the flagship model of the health service and the great job that my trust is doing.
I congratulate my hon. Friend Dr Wollaston on securing this debate. I also congratulate the Minister on her appointment, and all of us who are committed to the future of community hospitals look forward to her comments in a few moments. This is not a party-political debate—I hope—but the complete absence of Labour Back Benchers probably explains the difficulties that we had in promoting the case of community hospitals during the 13 years of a Labour Government.
In an age when large organisations seem to be swallowing up smaller ones, it is refreshing to find that in my county of Dorset we have 11 small hospitals, what we used to call cottage hospitals but now refer to as community hospitals. The term was coined in reaction to the hospital plan of 1962, which pressed for resources to be concentrated into hospitals of 300 beds or more, an inevitable consequence of which was the closure of smaller ones. Opposition to this came from the newly formed Association of General Practitioner Hospitals, now the Community Hospitals Association. It was the association’s chairman at the time, Sandy Cavenagh, who revealed that more than half the patients treated in general hospital beds could be cared for equally well or better—and at lower cost—in a small hospital near their homes.
Community hospitals survived, especially in my area, the south-west, which has 80 of the 300 or so remaining such hospitals. Dorset’s 11 community hospitals compares favourably with larger and richer counties. Two of the jewels of this array of community hospitals are in my constituency in Shaftesbury and Blandford, and with the greatest respect to John Pugh, a little bit of history is important here.
In Shaftesbury there was no formal provision for the sick of the town until 1874. There had been an infirmary in the abbey, but that disappeared along with the abbey itself during the dissolution in 1539. After that there was nothing until the building of the workhouse in 1840, and its sick ward was only for the inmates. So when the Marquis of Westminster’s widow and daughter wanted to honour his memory, a cottage hospital for those in and around Shaftesbury seemed appropriate. The marquis had owned large estates in the area and had done much to improve the lot of his tenants, and this project was in keeping with his philanthropic attitude. His widow, the dowager marchioness, therefore gave the area the land. The foundation stone was laid in 1871, and the hospital was formally opened by the bishop of Salisbury three years later. It was originally designed for a mere six patients, the poor of the town, and it was anticipated that they would be attended by their own doctors. The hospital was run by the matron—as indeed it is today.
The building was enlarged in 1907. An operating theatre, donated by another dowager marchioness of Westminster, was opened. It is still there, but it is no longer an operating theatre. The hospital’s running costs increased, and the Shaftesbury carnival committee stepped in, and for many years the proceeds from the carnival were donated to the hospital. The committee was rather more powerful than would be expected of such a body nowadays. Indeed, in 1923, it disapproved so strongly of the matron that it refused to hold a carnival that year. The resulting loss of revenue meant that the hospital had to be closed, and the matron then resigned.
Similarly, before 1889 Blandford did not have anywhere to look after the sick and its hospital was funded by the Portman family, which generously donated the land and buildings for the hospital. The present site of the hospital was given by the second Viscount Portman.
About 1,500 patients pass through Shaftesbury hospital, and the friends organisation, which I commend, has estimated that what is done in that hospital saves more than 60,000 miles of travel that would otherwise be covered going to Salisbury district hospital. Such journeys are expensive, stressful and inconvenient to patients, and of course involve unnecessary car use. In its present role, that hospital serves 18,000 patients a year, and the other hospital in my constituency, at Blandford, is thought to serve about 20,000 every year.
The key issue I would like to address is the ownership of these hospitals. Currently, all Dorset’s hospitals are run by Dorset HealthCare University NHS Foundation Trust, which was originally a mental health trust. When the clinical commissioning groups are up and running, the GPs, who are key to the development of today’s community hospitals, should be recognised again as part of the community, and the community hospitals should be owned by the communities they serve. The friends organisations are key to equipping our local hospitals and at the core of that community interest. I believe that we should harness their enthusiasm and expertise, along with that of GPs, in returning ownership of our community hospitals to the communities they serve.
I congratulate Dr Wollaston on securing this debate.
My part of Somerset has some fantastic community hospitals—Burnham-on-Sea, Glastonbury—but I would like to draw particular attention to Shepton Mallet, which provides a valuable and popular service to local people in my area of rural Somerset, despite the fact that several of its buildings are substandard as a result of serious under-investment. Many patients who cannot be treated at home are admitted to our community hospitals by local GPs, who love these places, instead of being sent to acute hospitals in Bath, Bristol, Yeovil and Taunton. Most of those journeys are about 20 to 25 miles, but local people accept that acute hospitals will be some distance away. There is no expectation that we should be able to access an acute hospital on our doorstep in such a rural area.
There are 174 communities in my constituency, and people will happily travel from them to those main hospitals. Some spend time in our local hospitals following treatment at an acute hospital—it is clearly a stage of recuperation—so that they can be close to their home, friends and family. My father was a patient, and he was a frequent visitor to Wells cottage hospital, which is now unfortunately closed. It was an essential part of his recuperation, and there were many happy visits that kept his spirits up and helped his recovery. People came to read or just talk to him.
The point will not have been missed that community hospitals help to free up scarce and much more expensive beds in the bigger hospitals. Some of our patients are there because caring for them in their homes has failed or is just not an option. Many patients are elderly or infirm, as often are their relatives, and visiting distant hospitals regularly is a great hardship, stressful and, for some, impossible. Public transport provision in Somerset is limited at best, diminishing in many areas and in most cases almost non-existent in rural patches, as a direct result of the withdrawal of support for public transport by the county council.
The latest Somerset joint strategy needs assessment on population changes shows rapid increases in elderly patient numbers in the county over the next 30 years—the expected lifetime of most of our NHS estate buildings. In round terms, the number of over-85-year-olds in the county has doubled in the past 25 years and is expected at least to double again by 2030. Two thirds of our NHS patients are already over 65.
The community hospital is cost-effective and provides an essential and popular service to the people of Shepton and those in what is a vast local area. Losing its beds would mean a significant reduction in the quality of services to the local community. Despite that, Shepton Mallet hospital is under threat of closure. An NHS review of community services for Shepton Mallet is taking place and is focusing on the 17 beds in the community hospital. There is no review of beds in the other 12 community hospitals in Somerset. Campaigners can only assume that Shepton is being singled out, because the NHS has not maintained the hospital properly, despite spending millions on new and other community hospitals. However, in one of the many meetings that I have held with the save our hospital beds campaign group, I was given figures from the NHS that showed that, even as late as this April, bed occupancy has been extremely high. Indeed, April’s figures show the occupancy rate at over 96%.
Last week I was at the summer fete in Glastonbury, and last month I was at the summer fete at Shepton Mallet hospital. I pay tribute to the leagues of friends of the Shepton Mallet and other community hospitals, and to Mid Somerset Newspapers, which publishes the Shepton Mallet Journal. The friends have done a fantastic job of rallying the people of Shepton and the local press, including the Journal, and have generated enthusiastic support for the save our hospital beds campaign over the past few months. I have received hundreds and hundreds of letters, e-mails and petitions, and have attended many meetings about the issue with concerned local people, which only goes to prove that the hospital is popular and greatly valued. There are now definite indications that the sheer weight of public concern expressed and the influence of our great GPs, working quietly behind the scenes, have had an effect. I pay particular tribute to the local GPs, especially Dr Chris Howes, who keeps trying to retire, but has been busier than ever finding a sensible, practical, realistic and workable solution to the problem facing Shepton. The first aim of the save our hospital beds campaign has been achieved, with the immediate threat of ill-considered cuts averted, and proper evidence gathering and an options appraisal process are now taking place. However, the hospital is not yet safe. Closure would result in short-term savings, but losing the beds would mean a significant reduction in the quality of service to the local community.
I finish by asking the Minister for an assurance that the coalition Government are committed to ensuring that local people and local doctors, as well as other health professionals, are consulted fairly and fully about any changes to the role and ownership of our popular, local and essential community hospitals, and that she agrees that none should be closed without agreement and very good cause indeed.
I congratulate my hon. Friend Dr Wollaston on securing this debate and thank her for doing so. She brings her experience as a doctor, her common sense and some really solid views to the Chamber, and we should listen to her even more.
I think it was my hon. Friend Guy Opperman who described our new Minister as Boadicea. I would welcome her down to Tiverton for a visit to our hospital, but I would rather she took the knives off the chariot as she comes through. Otherwise, we would be delighted to see her.
I think it was my hon. Friend Rory Stewart who made the point about rural constituencies. I am sure that his is bigger than mine, but my constituency covers some 400 square miles. We should remember that community hospitals—I have them in Tiverton, Honiton and Seaton—are essential. We also have, like it or not, an ageing population, both among those living in the area and among those who would love to retire there. Devon is a beautiful county and I very much welcome retired people who come there, but the facilities are of course needed. The point has been made by other hon. Members, but the issue is not just the treatment that elderly patients require; it is also about the time it takes to get to a hospital and the need to get there quite quickly. Distance is a problem for many rural patients, especially elderly patients. I would love to have more bus services, but we cannot have them in rural areas, given the sheer lack of numbers of people who travel by bus. It is essential for us to keep our community hospitals running.
I want to talk about one particular hospital and about its management. Dr Frank O’Kelly runs a clinical practice and commissioning service in Tiverton. He works closely with the hospital and is convinced that we need to get much closer to the people when providing services. I will give a bit of history of Tiverton hospital. Until 2006 it was run by a small community-based PCT in mid-Devon with no acute trust. It was at its most productive at this time and was hailed as one of the best in the country. I must declare an interest as in 2008 my granddaughter was born in Tiverton hospital. Since then it has been run by NHS Devon very much from north Devon, and it is not being used to its full potential. That is where Dr O’Kelly has some good ideas.
The Tiverton patient-centred care project has been reviewing since February 2012 what is happening and what is to be done to improve the situation at Tiverton hospital, yet it is still not delivering any practical help. There is no doubt that openness and transparency have been the basis of the project, with all the papers published, and five lay members attend the meetings that Dr O’Kelly organises. The league of friends has been hugely supportive, and with Exeter university devised its own questionnaire for the public. The NHS questionnaire achieved about 800 returns while the league of friends survey produced 3,000. Dr Kelly’s idea is to get local people interested in how this service is delivered.
I would like the Minister to know the key points that Dr Kelly wants to raise. The idea for Tiverton could be rolled out across the country. His plan is that the whole hospital is recommissioned and a single accountable provider brought in to run the hospital and community services. This could be NHS, private or a social enterprise. The provider would need to have as its only focus the community service and tailoring it to maximise capability.
Ultimately, clinicians and organisations running facilities come and go, but the population whom they serve do not. The population are left with time-limited results of those changes, depending on the length of tenure of the organisations. So to refer again to Dr Frank O’Kelly, his advice to the politicians would be to give the population much more power so that commissioners and providers are reminded who the customer really is. For a community hospital, this could take the form of a community governing body to which the providers and commissioners were accountable. I want to emphasise that local people need to have a much more genuine say in how their hospital is run so that they do not feel that they are caught up in a bureaucratic web and cannot put their views forward.
Tiverton community hospital is an excellent facility. It is pretty new and it could be used to deliver a great deal more local services to patients who need them. So Minister, please, if you have time, come to Tiverton and see what we are trying to do.
I thank the Backbench Business Committee for granting this important debate today and I congratulate Dr Wollaston on the eloquent case that she made in opening it. I also congratulate and welcome the new Minister to her place. She was a slightly unconventional Parliamentary Private Secretary to the former Minister of State for Health, Mr Burns. I say “unconventional” because, as Guy Opperman observed, PPSs are usually seen and not heard. I am sure that she will be even more vocal now that she has the freedom to speak from the Government Front Bench, and I look forward to our exchanges in the coming weeks and months.
As many Members have testified today, community hospitals play an important role in the communities they serve. They provide rehabilitation and follow-up care, and they can help to move care, diagnostics and minor injury and out-patient services, among others, from acute hospitals back to the community. They provide planned and unplanned acute care and diagnostic services for patients closer to home, and contribute to the local community by providing employment opportunities and support for community-based groups.
It is clear that people generally prefer medical treatments to be taken nearer to their homes and families, whether that involves palliative care, minor injury services or maternity care, and those are exactly the services that community hospitals can help to deliver. Indeed, the Department of Health has estimated that about 25% of hospital patients could be better cared for at home or in the community.
Community hospitals usually also have good relationships with their local communities, and are often supported by local fundraising. We have heard from a number of hon. Members today about the great work being done by friends groups up and down the country. I pay tribute to those groups, and to the staff and volunteers who work to make those groups and the hospitals happen. Staff in community hospitals can also build personal relationships with local patients and carers as they deliver continuous care from outside the hospital environment. That is an important point that should not be overlooked.
It is fair to say that community hospitals continue to play an important part in local health care provision. Their role is valued, and we are right to support it. Labour continues to be committed to community hospitals, when they represent the best solutions for local communities. I take the point made by John Pugh that they might not be the solution everywhere.
My own constituency is served by three large district general hospitals and not one community hospital, but I acknowledge that other parts of the country have a very different geographical make-up, and that community hospitals are the right way forward for the provision of health care in those communities.
Community hospitals can provide a vital step between social care and acute care, and Labour would seek to develop them further. For example, it might be possible for GP or dentistry services to be offered in more community hospitals, which could make some that are only marginally viable at the moment more viable for the future. That possibility should be explored.
Some concerns remain, however, and I hope that the Minister will be able to offer the House some reassurance today. One of the most pressing tasks for the NHS in the coming years will be better to co-ordinate services around the needs of patients, and that might well mean that community hospitals have to change the way in which they provide services and the buildings from which they provide them. She will know, however, of our concerns about the Government’s structural reforms, which will make the co-ordination and delivery of services far more difficult. We believe that the future requires the integration of care, yet the Government’s policies are driving us more towards fragmentation. We know that they are already having a profound effect on the NHS. A recent survey of NHS chairs and chief executives by the NHS Confederation found that 28% described the current financial position as
“the worst they had ever experienced”.
A further 46% said the position was “very serious”.
It is also clear that the financial challenge will continue for many years after 2015, and all this could have an effect on community hospitals, whether it be the reduction of minor injuries provision, the closure of wards or the downgrading of services. As Dr Lee suggested in what I thought was a thoughtful contribution, these can sometimes be the right choices for an area. Sometimes, however, they will not be and they will just be financially driven; here, there is a danger that community hospitals will provide an easy cut for bureaucrats.
The hon. Gentleman will be aware that 3,000 community beds in community hospitals were shut under the previous Government. Is he going to enlighten us about what his policy is, specifically in respect of any particular cuts to community hospitals? Is he in favour of them, against them, or is there no policy?
Community hospitals have a vital role to play. As we have discussed in the debate, however, they may not be the right approach everywhere. We remain committed to community hospitals. The last Labour Government introduced a fund specifically for them. It is fair to say that that fund was not automatically taken up by primary care trusts up and down the country. Some areas had different viewpoints on the role of community hospitals. The Labour party has a commitment to community hospitals where they are the right choice for the local communities.
A further point about the impact of the Health and Social Care Act 2012 is that with responsibility for commissioning health care services moving into the hands of clinical commissioning groups and with primary care trusts no longer being in existence, there is a real danger that the role of community hospitals could be overlooked. Will the Minister reassure us that community hospitals will not be unfairly penalised in the new internal market of the NHS?
We should bear in mind further issues about the possibility of creeping privatisation—an issue that we, at least, are concerned about. The whole health service is currently in a state of flux, but as the reforms in the NHS kick in, it is perfectly feasible for commissioning groups to look outside the NHS to the private sector to provide even more of their services than in the past. This has already happened in Suffolk in March, when Serco won a £140 million contract to manage, among other things, the area’s community hospitals.
It could well be that when trusts are faced with the choice of reducing clinical services, they will look to being more centralised for financial reasons and take services away from the community and, indeed, in some cases from district general hospitals, too. This will almost certainly have an effect on any extensions to these services in community hospitals. Clearly, community hospitals and other community health services need to be able to compete on a fair playing field with other health providers, and I would ask the Minister how she will support that practically.
I would like to ask about some of the additional funding arrangements in the NHS—an issue raised by the hon. Member for Totnes in her opening comments. Previously in the NHS, payment by results was introduced to finance care and treatment according to a national tariff. It was intended to reduce variation in the prices paid by different parts of the country and to encourage providers to do more work, particularly helping to reduce waiting times.
Community services, however, are not covered by payment by results and are instead paid under a block contract negotiated with the local commissioner. I know that some community hospitals are concerned that they will have to make greater budget reductions than providers covered by payment by results. Some community hospitals are concerned that the commissioner will reduce the size of the block contracts, which is easier to do than stopping activity under a tariff.
From April 2013, the NHS Commissioning Board and Monitor will set the national tariff, and we are encouraged that the Government have expressed an interest in expanding payment by results to community services. If payment by results is expanded, it must be done in a way that supports integrated care and does not disadvantage care that is delivered in a community setting. How will the Minister ensure that we do not have a pricing system that disadvantages care that is delivered in community settings and particularly in community hospitals?
Let me deal briefly with the issue of estate ownership, which has been touched on by a number of Members. Many community hospitals do not own the buildings from which they operate, which affects their ability to raise capital to create new services for patients because they cannot secure finance or loans against the value of their buildings. As we have already heard during the debate, earlier this year the last Health Secretary announced that a Government-owned firm, NHS Property Services Ltd, would take over the ownership and management of the existing primary care trust estate and dispose of property that was surplus to NHS requirements. Community hospitals will depend on the setting of affordable long-term rents by NHS Property Services Ltd. I hope the Minister will tell us how the firm will work with community providers, including social enterprises.
There should be no doubt that Opposition Members support the principle of community hospitals. Indeed, we rightly established a fund to support and develop the community hospitals that represented the best choice for local communities. A future Labour Government would also aim to develop community services further within community hospitals. For example, as I have already suggested, it may be possible for more GP, dentistry or other services to be offered by them, and I think that that opportunity should be explored further.
We are concerned about some of the wording of the motion, which calls for community hospitals to have
“greater freedom to explore different ownership models”.
We would need more details of any parameters before agreeing to such an arrangement. It could lead to an opportunity for further creeping privatisation of our national health service, which is something that the Labour party will not support or give carte blanche. For that reason, Labour will abstain on the motion.
The motion also calls for a national database of community hospitals. Historically their number and location was not monitored, as that was a matter for primary care trusts. However, we believe that in the new NHS, with confusion over where responsibility lies, there may well be a case for a national database. We would be interested to hear more details of what the hon. Member for Totnes has proposed, because we believe that it could give some value to the Department of Health in the future.
We should pay tribute to the important work that community hospitals undertake, the quality of the health care that they give to local people, and the commitment and dedication of all their staff, from medical professionals to porters and cleaners. The Government should be doing all that they can to ensure that patients can make real choices about receiving the health care that they need near to their homes. It remains to be seen how the Government’s changes to our NHS will affect community services and community hospitals. I look forward to hearing from the Minister how she will protect the role of community hospitals, which are valued and must continue to have a role in the more integrated and people-centred health care system that I hope we all support.
Let me begin by congratulating my hon. Friend Dr Wollaston on securing the debate, and congratulating not just those who added their names to her motion but all who have spoken in what has been a very interesting and, indeed, passionate debate. In fact it has not really been a debate, because there has been an outbreak of agreement, certainly on the Government Benches, as so many speakers have spoken with such passion about the community hospitals in their constituencies.
I should also say thank you to all who have congratulated me on my appointment, and have said some rather kind things. I am sure that normal service will soon be resumed. Sadly, my right hon. Friend Mr Burns, the former Minister with responsibility for health services, has now departed from that post and gone to another place, as it were—to another Department. We all miss him and thank him for his great service and his commitment to the national health service. He explained to Tom Blenkinsop during a debate in June about community hospitals in the north-east that this Government support improvements in community hospitals across the country. That is because we know that community hospitals make it easier for people to get care and treatment closer to where they live. They allow large hospitals to discharge patients safely into more appropriate care. They free hospital beds for people who need them. Community hospitals allow many patients to avoid travelling to large hospitals—and many of those large, acute hospitals are in cities, with all the attendant problems of transport, parking and so forth.
Our community hospitals provide a wide range of vital services, including minor injury clinics and intensive rehabilitation, on patients’ doorsteps. They can also help save the local NHS money by moving services out of acute hospitals and closer to the people who use them. People are often rightly very protective of their community hospitals, as we have heard from many Members this afternoon. They deliver essential services, and provide employment for people who live nearby and spaces for community groups. It is therefore understandable that community hospitals are fiercely defended and inspire such loyalty.
If I am to retain responsibility for community hospitals, I shall be a busy Minister. I shall be going up to the north-east to Middlesbrough and Cleveland, to South East Cornwall, Bracknell, Newton Abbot, Cannock Chase, West Worcestershire, South Dorset, Penrith and The Border, Halesowen and Rowley Regis, Hexham, North Dorset, Wells, Tiverton and Honiton, including Seaton, and Denton and Reddish—although not to Southport as it does not have a community hospital. I am grateful for all those invitations, and if I can, I certainly will accept them.
My hon. Friend delivered a speech that was, as ever, thoughtful, inspiring and well-informed, and she asked a number of questions of me. If I do not answer all the points she raised, I hope she will forgive me, and she will certainly get a letter from me answering all of them. Let me state at the outset, however, that she has made a very powerful case in relation to the Community Hospitals Association and its database. Funding for that database was stopped. I cannot promise that it will be restored, but I can say this: I have asked my officials to look at that decision again with great care.
I anticipate that we will not have a vote on this motion, and it is of interest that the two Opposition Members present will abstain if there is a vote, because we have rightly heard a cacophony of voices from the Government Benches in support of community hospitals.
My hon. Friend asked about tariffs, as did Andrew Gwynne. It may be of some assistance, especially to my hon. Friend Rory Stewart, for me to state that work is under way in the Department, looking at a payment system for patients suffering from long-term conditions. That includes services delivered in community settings. I trust that provides some hope. From 2013 and into 2014, tariff settings will be decided by Monitor and the NHS Commissioning Board. My hon. Friend the Member for Totnes made a powerful point about the potential importance of tariffs in ensuring the future of our community hospitals.
A good point was made about the decline in the number of GPs in some areas. I hope my hon. Friend will take comfort from the fact that my information is that there is a 50% target in respect of medical trainees going into general practice—I do not much like targets, but this could be a good one—and a taskforce has been set up to try to achieve that.
The future of community hospitals will, I hope, be secure in many of our communities, but it has to be said that many of the concerns Members have raised relate to local decisions, and it would not be right for me, as the Minister, to interfere in any of those decisions. My door is always open and I am always happy to meet hon. Members and any of their constituents. I may not be able to help in Cannock Chase, in Rowley, where there is difficulty, in Wells or in some other places, but I am happy to provide such support, assistance or advice as I am able to give.
Hon. Members have rightly discussed the future of the estate. I am conscious of the time, Madam Deputy Speaker, so I hope you will forgive me if I read out this part of my speech. It is important that hon. Members know and understand that the Health and Social Care Act 2012 required new ownership arrangements for current PCT estates. That means that providers such as community foundation trusts, NHS trusts and NHS foundation trusts will be able to take over those parts of the PCT estate that are used for clinical services. That includes the community hospital estate, but—this is an important but—we have put safeguards in place so that providers cannot just sell off newly acquired land and make a quick profit. Estates must be offered back to the Secretary of State for Health if, for example, the provider fails to keep the service delivery contract associated with the property or if the property becomes vacant. In addition, where any former estate becomes surplus to NHS requirements 50% of any financial gain made by the provider must be paid back to the Secretary of State and will go straight to front-line NHS services.
A Department of Health-owned limited company called NHS Property Services Ltd, to which reference has been made, will take on the remaining estate, as announced in January this year. Its key objective will be to provide clean, safe and cost-effective buildings for use by community and primary care services. I would like to assure every hon. Member, and every member of the public, that any community hospital building taken on by this company will be well looked after. Local clinicians will decide how those estates are used; whether new buildings are built or existing ones are closed will be up to them, as will all decisions about local patient services. As I have said, it is right that these decisions are taken locally. In reality, patients and the public will not notice any difference, at least in the short term. In the longer term, they will see that the NHS estate is managed more efficiently, by people who know what they are doing; that money will go to improve properties and front-line services.
NHS Property Services Ltd will own and manage buildings that are needed by the NHS. However, it will also be able to release savings from its properties that are declared surplus to NHS requirements. That money will be used further to improve property provision in the NHS. All PCT properties will transfer to either NHS providers or NHS Property Services Ltd on
Should the tenant, be it a community hospital or whatever else, seek to expand and should it need further facilities, is there a dialogue it will be able to have with the company to get it to extend the premises?
I am grateful for that question, but I shall be blunt and say that I do not know the answer. I will make inquiries and I will certainly make sure that the hon. Gentleman gets a full report in response.
Under the statutory provisions, while a building is needed to deliver NHS services, no NHS organisation will be allowed to sell it off. So there is no question of useful NHS property being sold to or transferred to organisations outside the NHS. At the same time, this means that a league of friends—a number of hon. Members have spoken with great fondness and admiration in support of leagues of friends, and I am sure that they will relay this to their local league of friends and their community hospitals—is unable to own the freehold of an operational NHS property. A league of friends is able to bid to become an owner of a community hospital only when it is declared surplus to NHS and public sector requirements. Current Government policy is that surplus property should normally be sold by auction or competitive tender. In such cases, the hospital league of friends would be given the opportunity to bid for the property along with all other interested parties. A league of friends could form a social enterprise to compete to provide services from a community hospital but, even then, as a social enterprise rather than an NHS body it could not take ownership of the assets of the community hospital. That might disappoint some, but I hope that in many ways it will give people comfort for the future and go some way towards addressing many of the points raised by my hon. Friend the Member for Totnes.
In conclusion, the Government have taken steps to secure the assets of community hospitals and ensure they are used for the benefit of their community. Those decisions will be made by people qualified to do so. That is the best thing for the hospitals and it is certainly the best thing for the communities that they serve. It is quite clear why so many people speak out so strongly and forcefully about community hospitals; it is because of the great work that they do. On behalf of the Government, I want to pay tribute to everybody who works in community hospitals and all the organisations that support them. I thank everybody who has contributed to the debate, which has been a very good exposition of the fine qualities of our community hospitals and, in particular, the organisations, such as the leagues of friends, that do so much to make them the great hospitals that they invariably are.
I thank the Minister for her reply.
Who could forget the passionate cry from the heart from my hon. Friend Richard Drax and the invitation to take cake in Swanage hospital? How wonderful it was to hear an alternative vision for the future from my hon. Friend Guy Opperman and to hear how we could see community hospitals as the heart of community care provision. I hope that the commissioners in south Dorset will see the light and see that that is a much better alternative.
Many Members have contributed to the debate and I am grateful to them all. We heard from Tom Blenkinsop and from my hon. Friend Sheryll Murray, particularly about the difficulties of rurality and transport. We heard likewise from John Pugh. We want to tackle rural health inequalities and the speech made by my hon. Friend the Member for South East Cornwall clearly made the point that if we do not have transport, that contributes to health inequalities. We heard from my hon. Friends the Members for Bracknell (Dr Lee) and for Penrith and The Border (Rory Stewart) about the need for leadership and how we can deliver the right care at the right time and in the right place.
My hon. Friend Harriett Baldwin made a knowledgeable contribution about different ownership models in her constituency. My hon. Friend Anne Marie Morris, whose constituency neighbours mine, paid tribute to the marvellous stroke service that operates out of her community hospital. She also spoke knowledgeably about the problems with PFI in the NHS that have dogged so many hospitals and burdened the NHS with unnecessary debt. My hon. Friend James Morris spoke about the campaign to keep in-patient beds at Rowley and it is clearly disappointing that we will not be able to see more direct intervention on unnecessary closures in parts of the area.
It was good to hear the speech from the shadow Minister, Andrew Gwynne, but Labour Members are not so much abstaining as absenting themselves from the debate, which is clearly disappointing. I assure him that I fully understand that there must be reassurance for the future that community hospitals will always stay for the benefit of their local communities and that it is good to hear the Minister reiterate that very important point. If we are going to see the contribution from leagues of friends continuing for the future, they must have absolute confidence that those valuable community assets will always stay for the benefit of local communities.
I thank all Members for their contributions and pay tribute to all the staff and leagues of friends of our wonderful community hospitals.
Question put and agreed to.
That this House recognises and supports the contribution of community hospitals to the care of patients within the National Health Service; requests the Secretary of State for Health to commission a comprehensive database of community hospitals, their ownership and current roles; and believes that the assets of community hospitals should remain for the benefit of their community while allowing them greater freedom to explore different ownership models.