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I am grateful to have been able to secure this debate, and am pleased to see the Under-Secretary of State for Health, Yvette Cooper, here to answer the debate. I have always regarded her as one of the more able Ministers in her Department and it is a pleasure to be here with her. She may know that I shall see her colleague, the Under-Secretary of State for Health, Ms Blears, for a private meeting about this matter next week. I hope that the debate will be a useful preliminary discussion of some of the issues and that we shall perhaps be able to go into more detail next week.
I am sure that the Minister is well aware of the context, but it might help if I set that out. Cirencester is the largest town in my highly rural constituency, but the hospital is not typical. It is not as small as a typical rural community hospital nor as large as a normal district general hospital; it is in between. There are not many models for a hospital of that size in this country. That is why we begin to encounter the problems that we have. It is a delightful hospital, very well run by a matron who knows the name and medical condition of every single patient. It is spotlessly clean and people are treated with the highest possible care.
Nothing that I say implies any criticism whatsoever of the staff or administrators at the hospital, which provides 22 medical beds on Stratton ward, 50 assessment and rehabilitation beds on Colm and Windrush wards, 18 surgical beds on Beeches ward, 19 beds for mental health patients on Bourton ward, six endoscopy beds, a comprehensive range of out-patient services, 24-hour accident and emergency cover, an assessment and rehabilitation unit, a radiology unit and a phlebotomy department.
Our problem is that the range of accident and emergency services could be curtailed by the Royal College of Physicians and the Royal College of General Practitioners, which have recommended that the senior house officer posts at Cirencester hospital be withdrawn in the next few months because they do not offer adequate training. Although that recommendation has not been received formally, it is expected imminently. The problem, as I shall demonstrate, is with the ability to maintain full 24-hour accident and emergency cover when the senior house officers are withdrawn, because no surgery can take place unless there is proper medical cover.
While activity at the hospital has fallen by just under 1,000 cases—from 5,204 to 4,312—in the last three years, in the similar hospital at nearby Stroud it has increased by 25 per cent. Indeed activity at the maternity unit in Stroud has increased by 30 per cent. as the result of very diligent activity by the authorities in that area. When Cheltenham district general hospital and the Gloucester infirmary district general hospital are at breaking point, it makes eminent good sense—in fact it is a win-win situation—to increase activity at Cirencester and reduce the stress, strain and overstretch at those two district general hospitals.
Cirencester has a catchment area of some 25,000 to 30,000 people. The task is to persuade all the GPs when referring people to a consultant with the possibility of medical procedures to follow, and everybody who lives in that area when being referred, to consider Cirencester seriously. The theatre in Cirencester hospital is capable of some 2,000 operations, yet it is achieving only 1,000, or 50 per cent. of capacity. The answer is not to curtail and close facilities at Cirencester hospital; it is to use them better. The same applies to the cottage hospitals in my constituency—there are excellent, small cottage hospitals at Fairford, Bourton-on-the-Water and Moreton-in-Marsh. They should not be closed, but used better.
The funding formula does not fully reflect the circumstances of a highly rural area. As my neighbour, Mr. Drew knows, it costs more per head on the capitation formula to provide services in a rural area precisely because of the distances and the sizes of units involved. I ask the Minister seriously to consider that factor. I also ask her to look at whether the capitation formula adequately reflects the costs of treating elderly patients. My constituency has the third highest number of over-85-year-olds of any in the country. Cirencester has to deliver services that are particularly geared towards elderly people. It is a truism—the Minister will correct me if it is not—that half the cost of providing health care for any individual is incurred in the first year and the last year of his life. Clearly, a hospital like Cirencester can provide a very valuable service in that respect.
The reason for this debate is the threat of curtailment of the accident and emergency department at Cirencester. The local press has run a very high-profile campaign on the matter. Before Christmas, 3,000 people came to a demonstration in Cirencester town centre. Only a few times in its ancient history—Cirencester was the second largest town outside London in Roman Britain—has the town centre been closed to through traffic, but it was on that occasion. That suggests the severe concern of local people on the subject.
Whatever the future holds for Cirencester hospital—I hope that the Minister will assure me that it is rosy and that services are moving forward and increasing rather than decreasing—the annual worrying of my constituents must stop. Every time changes occur, the local press finds out, huge campaigns are whipped up, and elderly people in particular become worried. With the advent of the running of the primary care trust on a more local basis from
I would like to refer to the sad case of the treatment of a Mrs. Clark at Cheltenham general hospital. On the whole, the east Gloucestershire NHS health trust, which will soon be merged with the Gloucestershire royal NHS trust, has run a superb ship. Cheltenham general hospital gives good treatment to my constituents in the main, but Mrs. Clark's letter to me of
"I had on several occasions requested that I be helped to sit up in bed as my legs have been paralyzed and each time I was told to do it myself as they were busy".
The letter points out what happens in our larger district general hospitals. People do not have time to treat patients with the necessary care and attention. I make no special criticism of Cheltenham general hospital, as all our district general hospitals are under the same stress. However, the case for Cirencester hospital is strengthened by the argument. If we can reduce the number of patients who go to Cheltenham through increased use of Cirencester, it is a win-win situation.
I return to the subject of the loss of junior doctors at Cirencester. As I said, there are two options as to how the cover can be maintained. A rota of general practitioners could provide resident on-site medical cover, or resident on-site medical cover for up to four nights of the week could be provided by staff grades or other medical grades, with non-resident GP on-call cover.
The first option is preferable, as it would enable the range of services currently provided at Cirencester to continue unchanged, with the exception of a small number of emergency cases. It would provide a more experienced level of cover, compared to that which would be provided by the relatively inexperienced senior house officers. I shall come back to the subject of experience. The second option would require a reduction in elective surgical activity, as it would not be possible to have in-patient cases when there was no resident medical cover, as is self-evident. A cessation of emergency admissions would also be required, as in the first option. In addition, it would be necessary to review the clinical protocols governing accident and emergency admissions, and it is likely that a few conditions would be excluded from admission during the night and at weekends. However, attendances during those hours are few. We all understand that accident and emergency services must be governed by protocols. Of course, the more serious and life-threatening cases will go to the district general hospitals, even during the day but especially at night, because those hospitals have intensive care beds and full consultant cover, but my constituents want 24-hour accident and emergency cover to be maintained at Cirencester.
The matter was due to be concluded last night, but unfortunately was not. This is what happened. The project director of the Cotswold and Vale primary care trust, Richard James, said:
"We remain extremely optimistic following yesterday evening's meeting but it is clear that a number of detailed tasks need to be completed in order for this agreed approach to be implemented successfully. Everyone left the meeting feeling positive that we could conclude the detailed work successfully and that the necessary medical cover could be put in place."
That has been the situation for two months. We still have no agreement and we know that cover is likely to be withdrawn on
This is a question of allocations, and I have already alluded to the fact that the Cotswold and Vale primary care trust is perceived to have spent more than it should have done. However, the reason why it has spent more than it should have done is because it is in a rural area and has a higher percentage of elderly patients. That means that the number of patients per GP is higher than the national average. Another relevant factor is that, in the health service, the requirements of elderly people are often overlooked. When elderly people go to see their doctor or consultant or go into hospital for a medical procedure, they are often confused and not as articulate as younger people. They are not as quick at explaining their problems or understanding what their GP or consultant tells them. We sometimes do not give elderly people the respect that they deserve in the health service.
The people of Cirencester love their hospital. They want all services there, especially the accident and emergency cover, to be maintained. They are looking to the Minister for reassurance today, especially about the need for trained doctors to take over from SHOs. I hope that that reassurance will be forthcoming and I look forward to continuing this discussion with the Minister's colleague at next week's meeting.
I congratulate Mr. Clifton-Brown on securing a debate on the future of Cirencester hospital, which is held in high regard by his constituents. I welcome the tribute that he paid to the staff at Cirencester hospital. I wish to respond as far as I can to the points that he raised, but I shall also ensure that the Parliamentary Under-Secretary of State for Health, my hon. Friend Ms Blears, is aware of the issues raised in the debate so that she can follow them up in more detail.
As the hon. Gentleman will know, responsibility for deciding what services are provided at the hospital and how they are delivered rests with the local NHS bodies in Gloucestershire, in particular with the East Gloucestershire NHS trust and the Cotswold and Vale primary care trust. The key decisions about Cirencester hospital must be taken locally and where appropriate with proper public consultation. Ministers become involved only when a matter is referred to them by the local community health council—or, in future, by the scrutiny committees of local authorities. Nevertheless, I am aware of the concerns that the hon. Gentleman has raised. I shall respond, as far as I can, about the local position; and I will place it in the context of the national approach to the provision of acute care.
The provision of acute services, in hospitals large and small, is one of the central pillars of the NHS. We must clearly ensure that those services are the very best possible, and that they provide modern patterns of care fit for the 21st century. When we talk of modernising medical care, it is easy to think of sophisticated, high-tech treatments being provided in large, specialist hospitals. It is certainly true that many complex services and high-risk conditions require a critical mass that can be found only in larger centres. However, that is only part of the story.
In determining care for the new century, it is critical that we place at the centre of our thinking the views of the people and patients that the NHS is here to serve—including the hon. Gentleman's constituents. The public place a high value on locally available acute care, which means providing treatment as close as practicable to where they live, given the constraints of quality and safety. They want hospitals to serve local communities and to be focused on their needs.
We need to strike an appropriate balance between the convenience of having local services and the requirement to concentrate expertise for reasons of safety and quality. We should not fool ourselves into thinking that the best that the NHS can offer can always be provided on our doorstep. However, many needs can and should be met locally—close to home—by delivering care through networks of skilled providers working together and not in isolation. It is a strategy that is based on local solutions in a national framework. It is a strategy that recognises that small units such as Cirencester hospital have a vital role—not only today but in future—in delivering high-quality care.
I turn to the specific issues that the hon. Gentleman raises. Current public concerns about the hospital focus on the probable removal, later this year, of the junior doctors who provide overnight and weekend medical cover. I know that that is perceived to be a threat to the services at the hospital, particularly to the accident and emergency department. I can tell the hon. Gentleman that I have been assured today that the East Gloucestershire NHS trust and the Cotswold and Vale primary care group are fully committed to maintaining the current level of services at the hospital.
I understand that a meeting yesterday between the trusts and local general practitioners may have gone a long way towards meeting local concerns, enabling Cirencester hospital broadly to maintain its current level of services despite changes to the way in which junior doctors work within the trust. I am concerned by the points made by the hon. Gentleman, because they do not entirely fit with the briefing that I received of that meeting. The matter may need to be discussed in further detail with my hon. Friend the Member for Salford, but I will say more about that shortly.
I am advised that the current pressure for change at Cirencester has arisen as a result of medical staffing and clinical governance obligations. At issue are questions about the increasing specialisation of clinical staff, rising standards, minimising clinical risks—and, perhaps most important, changes to the training regimes and hours of work of junior medical staff. Four senior house officers are based at Cirencester; they provide the resident medical staff overnight and at weekends, supported by on-call GPs.
The Royal College of Physicians and the Royal College of General Practitioners have recommended to the Specialist Training Authority, which recognises the senior house officer posts at Cirencester hospital, that the experience offered at Cirencester is not adequate for training purposes. The Specialist Training Authority has not yet made a decision on whether to continue to recognise the posts for training purposes, but it is expected to be received later this month. However, I understand that the post graduate dean for the south and west region is concerned that middle and senior medical cover and support for those junior trainee doctors is not adequate, and that the associated clinical governance risks do not need to be taken.
The outcome, as the hon. Gentleman suggested, is likely to be the withdrawal of senior house officers from Cirencester and their relocation to Cheltenham in February 2002. That will enable their basic training and support from senior doctors to be enhanced, so that they can gain a wider range of clinical experience. I am sure that the hon. Gentleman would agree that it is important that junior doctors should be properly trained, have the necessary experience and be able to provide the high-quality care that is expected by not only his constituents but patients across the country. Under those circumstances, the key issue is to secure alternative medical staffing arrangements overnight and during the weekend period for Cirencester hospital. Daytime cover is adequately provided through a combination of consultant presence, GP clinical assistance and staff grades.
East Gloucestershire NHS trust and the Cotswold and Vale primary care group are in discussions with medical staff to ensure that alternative arrangements are in place to provide medical cover. As the hon. Gentleman says, the preferred option is for the rota of GPs to provide resident on-site medical cover. That option would provide a more experienced level of cover compared to the relatively inexperienced senior house officers. The hon. Gentleman may be interested to know that the reports that I received from the meeting that took place yesterday said that broad agreement on the proposed new arrangements was reached with local GPs by the trust and primary care trust. Although some contractual details remain to be worked through, it is anticipated that the new arrangements will start on
The proposed new arrangements will mean that services at the hospital remain substantially unchanged, with a doctor-led accident and emergency department open 24 hours a day, seven days a week, and the continuation of the in-patient medical and surgical services. As a result, patients attending accident and emergency are likely to see more experienced doctors than they do at present. I am told that there will be a small reduction in emergency admissions as a result of changes to clinical protocols on admittance, but that the reduction would have occurred because of the demands of clinical governance even were junior doctors to remain at the hospital.
The trust is working to maximise nurse-led services and to use telemedicine links effectively to maximise the scope of services. All beds will continue to be provided, and beds released by the changes will be used to provide increased elderly care rehabilitation and intermediate care services. The post-graduate dean for the south and west region is currently considering the creation of GP registrar posts in intermediate care. If that is agreed and posts are allocated locally, it would provide an additional level of medical cover to the hospital.
There is one other aspect of medical cover that I did not mention, but would be grateful if the Minister could address. Some consultants are resistant to maintaining lists in Cirencester hospital, because it is more convenient for them administratively to have people travelling to the district general hospital in Cheltenham. That is unacceptable to my constituents. If there are the required number of people in need of treatment in Cirencester, the consultant should be prepared to travel. It should not be the case that the list at Cirencester hospital is cancelled at the first opportunity.
I shall ensure that that issue is examined by the time the hon. Gentleman meets my hon. Friend. When it is clinically safe and high-quality care can be provided, we want to provide as much care as possible in local areas for the convenience of patients.
The presence of doctors in training is not essential for the provision of strong and vibrant local hospital services. I believe that the local NHS community is committed to ensuring that Cirencester hospital continues to provide a wide range of acute services for the people of the Cotswolds. The Government's view is that smaller units such as Cirencester have a vital role to play as part of the national health service.
The hon. Gentleman referred to the increasing focus on local decision making through the primary care trusts. He is right that the shift of power and resources towards the primary care trusts means that decisions about local hospitals can increasingly be taken with the interests of the local population in mind. We must also move away from the idea of hospitals as stand-alone institutions, each providing a specialist set of services. Instead we should ensure that the comprehensive range of services is provided across a diverse mix of institutions, be that primary care, care in the community, or care in a local hospital such as Cirencester and in the larger district general hospitals. Cancer networks have been developed to improve linkages across hospitals and between acute and primary care. That needs to take place in many other areas. It provides many opportunities for small hospitals across the country, many of which are working hard to develop their role and to embrace new ways of working. The challenge is to deliver the right care, in the right place at the right time. That means making maximum use of those local resources, but also of the primary care centres, to deliver and co-ordinate a local population's care.
As the hon. Gentleman mentioned, the care of older people requires close working between hospitals, primary care and social care. He also expressed concern about the funding formula. As he will be aware, the funding formula is under review and the NHS plan committed us to introduce a new and fairer funding formula for the NHS and to get resources to areas of greatest need. He will also be aware that we have representations from every part of the country, all raising their local concerns and pressures. In my own area, the concern is that there are fewer elderly people than in other parts of the country because life expectancy is considerably lower. Ensuring that those factors are included as part of the funding formula is clearly a complex matter, which is why such a major review is taking place.
The hon. Gentleman also asked me to confirm whether the most expensive care was provided in the last year of someone's life. That is true. The beginning and end of life are the most expensive times in terms of health care provision, and when the NHS understandably invests most in providing support. He also asked about the case of a constituent in Cheltenham hospital. He should refer his constituent to the NHS complaints procedure, as there may well be issues that should be taken up properly by Cheltenham hospital.
The Government are committed to having a mix of levels of care provision, not simply in the Cirencester area, but across the country. That care will be provided at the specialist level but also at the local level. We clearly do not simply want giant hospitals as isolated centres of excellence. We are entering a new era of health care provision where new technologies offer clinicians the opportunity to work together, to share expertise and to give clinical opinions to their peers, not necessarily through face to face contact but perhaps via phone, video conference or telemedicine links. The increasing use of modern technology to improve communications between consultants and medical professionals should provide even greater opportunities for smaller hospitals and local centres of care to provide all kinds of care that they could not provide in the past.
In conclusion, there are huge opportunities for the people of Cirencester and the local NHS to look at new and different ways of providing care. Clearly they have already been doing so by considering ways in which they can respond to the challenges posed by changes in junior doctors' hours and their training needs. I hope that we will be able to resolve the issue of last night's meeting and ensure that a satisfactory decision is taken rapidly to reassure the hon. Gentleman's constituents about the kind of care that will continue at Cirencester, and to ensure a viable and healthy future for that hospital.
I thank the Minister for her sympathetic and comprehensive reply. The debate has been useful and I look forward to continuing the discussion with her colleague next week.