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The noble Lord said: My Lords, on the whole, I steer clear of debates which discuss the future of individual hospitals. I realise that governments of all persuasions must sometimes take locally unpopular decisions in response to demographic and public health changes and to medical advances which allow a speedier turnaround in hospitals. During the past decade we have seen
The situation in other conurbations is similar but the decline has been slower than in London and more in line with national trends. In other conurbations, the average has gone down from four beds per thousand to just over three per thousand in the same period whereas, as I said, in London the level has gone down to 2·5 per thousand. A fall of 1·5 beds per thousand may not sound very much but applied to the 6·3 million population of London, it amounts to nearly 10,000 beds closed in the period of 10 to 12 years up to 1992.
I suggest that we have already reached an irreducible minimum, given the age structure of our population and its present state of health. In fact, we may have already gone too far in London. As a GP, I know both personally and from talking to colleagues that the situation over the past five years has become very tight indeed and it is getting worse not only in inner London but also in outer London. It is often very difficult to find a bed for an acutely ill patient.
Sir Bernard Tomlinson's report concentrated mainly on inner London. One reason that he felt that fewer beds were necessary in inner London was that patients attending inner London hospitals who lived in outer London could and should be treated and admitted where necessary by the hospital trust in their home districts, where the costs in fact were usually lower. However, as he subsequently said, he was not able to take the figures for outer London fully into account. Had he done so, he would have found that very few hospitals in outer London had any spare capacity. Edgware General and Barnet General Hospitals are both in that category.
As the Minister knows, the 400 acute beds at Edgware General Hospital, which the Wellhouse Trust currently plans to close, will not be replaced in the area of Barnet Health Authority. The new hospital at Barnet, when stage 2 is completed, will also have approximately 400 beds; that is the same as now. The question is where the patients currently using the 400 beds at Edgware General will go.
It was suggested to me by the chief executive of the project team at Edgware General Hospital, which I visited last week, that those patients will be absorbed by various other hospitals; for example, by Northwick Park Hospital, where 45 new beds are planned, and the Royal Free Hospital, and that some would go to the new Barnet General Hospital, possibly replacing patients from Hertfordshire or the New River health authorities which are now using the Barnet General Hospital and which would use other hospitals.
If the Barnet General Hospital is able to decant the patients which are coming from other health authorities, the Wellhouse Trust will lose some of the contract income which it receives at present and which it badly needs in its parlous financial state.
In fact, the decision to concentrate expensive acute care and the major trauma unit on one site was driven by the chronic mis-match between the cost of running Edgware General and Barnet General Hospitals and the weighted capitation funding of the health authority. There was not enough money to run the two hospitals. The health authority says that the decision to concentrate on the new Barnet General Hospital was clinically driven. Given the chronic under-funding of the two hospitals, I can understand that clinical staff may well opt for that. It will be much easier to provide services of a high standard in a brand new hospital rather than in the old Barnet General Hospital or in Edgware General Hospital, blighted as it is by a bleak and uncertain future.
In that decision, the needs of the population seem to have been forgotten. Edgware contains several wards with quite a high prevalence of social deprivation and ethnic minority immigrants. It also has two-thirds of the population of the whole health authority area conveniently clustered around Edgware General Hospital with quite frequent buses connecting residential districts to the central area where the hospital is. People are used to the hospital and find it friendly.
Travelling to other hospitals, with the possible exception of the Royal Free, would be expensive and will not be at all easy because of poor public transport. Bus services may well be provided from the Edgware General site to the new Barnet General Hospital, but it will still be six miles away and 45 minutes in time and it will not be free whenever anyone wants to visit auntie or mum in hospital.
A much lower proportion of the population of Edgware has access to cars than does the population of Barnet. It could be said of the wealthier people of Barnet in relation to the less well-off people of Edgware, "To he that hath shall be given a brand new hospital and from he that hath not shall be taken even the hospital that he hath".
I have not spoken about the closure of the accident and emergency department. I accept the argument that for major trauma, a well-equipped consultant-led unit is best. But I think that it is quite inadequate to replace Edgware's accident and emergency department, which has 40,000 attendances per year, if not more, with a nurse practitioner-run accident and treatment service. I have nothing against the work of nurse practitioners. They can play an enormously useful role. But they need medical backing and, so far, that is not planned.
I was told that a local hospital is planned on the Edgware site, keeping many of the buildings in operation. If so, where is the great saving coming from? I like the sound of that proposed hospital, especially if it includes an acute psychiatric unit, which is much needed. But why should there not be also some medical beds and some beds attached to the minor accident and treatment service for people who are not sufficiently ill to be transferred to the Barnet accident and emergency department but too ill to go home? There are many possibilities. I am merely putting forward a few suggestions.
I understand that £28 million is to be raised to pay for stage 1B, the second part of the building of the new Barnet General Hospital. Could that money, which will almost certainly have to come from government sources and not from the private sectorthere is quite a lot of difficulty as regards the operation of the PFI scheme in this casebe spent on the Edgware General site with an intelligent split of acute services between a smaller than planned Barnet General Hospital, which would equate with its smaller population, and the current perfectly adequate site and buildings at Edgware General, which is where the people are?
I have gone on for rather longer than I meant to and I have not even mentioned the possible role of improved primary care. I am delighted that that is receiving increased financial support, but however good primary health care becomes it cannot, in the short run, make any difference to bed needs. In deprived areas particularly, improved primary health care may even find undiagnosed, treatable conditions which can be helped by hospital treatment. I give your Lordships the example of arthritis of the hip which a less literate, articulate person may not present adequately to the doctor if there was only a cursory primary health care service. Cataracts are another example. The possibility of increased beds being necessary as a result of improved primary health care was recently pointed out by the King's Fund Report. It certainly equates with some work that I am doing at present.
I think that there is good reason to question whether the proposed changes in Edgware will produce any improvement in healthcare for local people. In fact, I believe that there is a serious danger that the current plans will lead to chaos. There is a danger that lives will be lost as a result of taking acute services away from a major centre of population, as well as siting the accident and emergency department away from the main line railway and the M.1 motorway where there is always the possibility of a serious accident. The accident and emergency department of Edgware General Hospital is now very well situated to cope with such incidents.
Of course, we can always expect local residents to support their hospital, but that result is quite unusual. I hope that the Minister and her right honourable colleague the Secretary of State will bear it in mind as well as all the other points that I made.
Baroness Jay of Paddington: My Lords, I should like to thank my noble friend for introducing his timely and important Unstarred Question in such a comprehensive way. He gave your Lordships a very authoritative description of the particular problems of Barnet and of the two hospitals which are subject to change. I believe that my noble friend also illustrated the way in which the particular problems of Barnet and of the closure at Edgware General Hospital reflect some of the questions and discussions which we have had in this House about the general situation in London healthcare over the past few years.
I should like to focus not on the particular problems of Edgware, although they are, of course, relevant to the general description that I want to discuss about London's problems, but on the way in which they demonstrate the general issues which we have discussed so often. I believe that it has become generally accepted in the Houseand, indeed, in a wider discussion on the needs of Londoners for particular healthcarethat there is and has been for some time a need for change in the pattern of services enjoyed by the residents of the capital.
As we delved more deeply into the issues which have been highlighted by the different reports about particular problems of London as a whole and the specific issues which arise around individual hospitals, we learnt and understoodand we on these Benches would say that we have learnt such lessons rather quicker than some people on the other side of the Housesome more points about the particular needs of London which were perhaps less clear when we all embarked on the discussion in which we agreed that some change in the provision of services was needed.
I believe the points that my noble friend made about the closure at Edgware General Hospital do in fact, as I said, reflect many of those points on which we have begun to learn some lessons which perhaps were not as clear as they were when we began to discuss these issues.
The first point to which my noble friend referred to in some detail as it applied to the Barnet healthcare situation was the question of bed numbers in London, the needs of Londoners for acute care in their particular
My contention is that we, as I said, have not been able to resolve those issues. There are queries over the important question regarding the needs for acute beds in London which are not clear. We have the conflicting evidence of experts like Professor Brian Jarman and the inner-London chief executives all of whom seem to suggest that there is a need to maintain the level of bed provision in inner London and, indeed, in outer London. Then we have other assertions that those figures are based on different bases and are, therefore, not relevant for comparison. I mention that because it is one of the fundamental questions over which there is a difficulty of analysis and, therefore, a difficulty about taking hard and fast decisions.
My noble friend referred to the role of the PFI and its potential for funding Phase IB of the new provision of healthcare in Barnet. That is something which, in a sense, was not even on the agenda when we began to discuss the substitution of provision in London. The role of the PFI has become of relevance much more recently than that and, as my noble friend very vividly described, could in fact lead to greater complexities and uncertainties about the way in which the needs of that particular population are to be fulfilled.
Then there is the further question about the shift of resources from the acute sector to primary care and the primary sector, something upon which the Government (and, indeed, those of us who hope that there can be some successful change in the provision of services) have based an enormous amount of their confidence in making the changes that they propose. However, we really do not knowand, again, this is something over which queries have arisen very recentlywhether any shift of resources to primary care would in fact reduce the demand for acute beds or whether it would, as is sometimes suggested, increase it. That, again, is another major question over which there is still a query and upon which we do not have the kind of hard and fast basis of knowledge that we need in order to take such very swingeing decisions about the transfer of services.
However, what we do know is that during the last period emergency admissions to hospitals have increased; and, again, that was not evident, in the way that it is now, at the beginning of our discussions. But there does not seem to be any general answer as to why that is so. The fact that emergency admissions are increasing is a new factor and a different problem as regards the provision of services. It is something that we should certainly be concerned to try to answer more adequately than we can at present before we make further changes in the reduction of acute sector beds in London.
The nature of the primary care with which we seek to replace acute care is another area which is still rather grey. We know that in some areas replacing A&E provision, as is suggested at Edgware General, with small injuries units can be successful. I know my part
All of these matters are reflected in the intensity of local feeling against these changes which my noble friend Lord Rea has described so vividly. When she introduced these changes, the Secretary of State at that time, the right honourable Mrs. Bottomley, said that the changes would not be made, particularly on the accident and emergency front, until she or her successor could guarantee that the ambulance services and other back-up arrangements were in place and that there was some visible provision of replacement beds in Phase (IB) of the Barnet Hospital. However, I fear that I join those members of the local pressure groups who are so concerned about this matter in having a lack of confidence in the reality of that coming about near enough in the future to make it possible to take these basic decisions at this time. I have begun to think that much of this planning for the future of the service in London is what I would call the "virtual reality" of health service strategy.
On a previous occasion when we debated this matter in your Lordships' House the noble Baroness, Lady Cumberlege, told me that the results of the deliberations of the London Implementation Group were there for all to see. However, since the noble Baroness told me that, I have spent some time asking many people who work at the coal-face, as it were, of the London health services to show me the visible demonstration of what is happening as regards the transfer of resources which we were all told would replace the closures of acute services. On the evidence of some not entirely convincing examples the pattern of services does not seem to have changed as visibly, as obviously or as comprehensively as one might have thought as a result of the injection of resources and the confidence which has been displayed in them from the centre on the part of the Department of Health.
We now have a new Secretary of State, as my noble friend Lord Rea said. In the past few months he has been seen to be perfectly honest and to be much less rigid as regards sticking to some plans and being firm in his convictions that they were absolutely right than his predecessor was. One could almost describe him as having been mollifying in areas such as pay demands
There is, notably, the new King's Fund mark two inquiry into the state of services in London in the future. I declare an interest as a member of that commission. The fundamental issue for Londoners is to retain their confidence in the NHS and to retain the confidence that the NHS will maintain a level of services which people can feel secure about even if those services are to be provided in a rather different form. I end by referring to the comments of the new Secretary of State in an article which he wrote soon after he took office with regard to the service in London,
The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I am pleased to respond to the noble Lord and indeed to the noble Baroness on this issue. It is an important topic, as the noble Baroness has said. This debate gives me a valuable opportunity to explain to your Lordships' House the significant improvements in healthcare that the Government have approved for this part of North London. Not only will there be a brand new hospital at Barnet (which is already under construction) but Edgware Hospital will continue to have an important future as a local hospital providing valuable services to local people.
I am well aware that the future of Edgware Hospital has recently been the subject of at times heated debate in another place. Honourable Members have quite rightly represented the concerns of their constituents on this matter and your Lordships have indeed reiterated some of those concerns here tonight.
My right honourable friend the Secretary of State for Health has made clear that he does not intend to revisit the decisions taken by previous Secretaries of State. In implementing those decisions, however, he is committed to ensuring that, at each stage of implementation, the quality of services is at least maintained and wherever possible improved. The future changes at Edgware are designed to provide higher quality, improved services for patients. The current split site arrangements and consequent duplication of facilities between the Barnet
The health authority has plans for the future which provide for facilities to be developed at both Barnet and Edgware. The plans offer a better quality of service to patients as well as more efficient use of resources. That is in accordance with the intentions of my right honourable friend the Secretary of State who has made it clear that plans for future healthcare in this part of London must deliver high quality services to patients both in Edgware and in Barnet.
Those plans have emerged from a process of extensive and thorough consultation. The Barnet Health Authority and the trust have consistently sought to involve the public in their deliberations through a series of public meetings and the distribution of leaflets and articles in the local press. They have gone to great lengths to explain the compelling reasons and the benefits for patients from the planned changes.
As I said at the start of my speech, my right honourable friend the Secretary of State has made clear that he does not intend to revisit decisions taken by his predecessor. It is important for me to stress that the future of Edgware Hospital as a significant provider of healthcare is not in doubt. The hospital will continue to meet wide-ranging needs of people in the area through extensive provision of services.
As your Lordships will be aware, a large proportion of patients making use of hospital services do so either at outpatient clinics or increasingly through day case provision. These services will continue at Edgware. The health authority and trust are also considering proposals for the development of accident care for the people of Edgware as well as services for elderly people and for children and a new rehabilitation service on the Edgware site. Final decisions on the precise nature of services to be provided at Edgware still have to be taken.
It must also be emphasised that the changes at Edgware Hospital will not occur overnight. They are dependent upon completion of the redevelopment of Barnet General Hospital and the expansion of services at Northwick Park and the Royal Free Hospital. Only when the alternative facilities elsewhere are completed and are accessible and capable of providing an improved service to patients will the major changes take place at Edgware.
As your Lordships are aware, it is intended that the full range of acute services will be provided at the redeveloped Barnet General Hospital. I can assure your Lordships that the facilities being developed will be of a very high quality.
Work began in November last year on a £29 million first phase of the redevelopment. Taking forward the decision on Edgware will mean that the second and final phase can go ahead at a cost of £33 million. In effect, this will mean the construction of an entirely new hospital offering excellent specialist acute facilities. The new Accident and Emergency Department will be one of the most up to date in London capable of treating 70,000 patients a year to the highest clinical standards.
Patients admitted to the new Accident and Emergency Department who require further specialist treatment will transfer within the Barnet complex to relevant units quickly and safely. This contrasts with the present situation where some admissions through A&E have to be transferred between the Edgware and Barnet sites to receive appropriate treatment. That is a situation which we could not allow to continue.
I listened very carefully to the noble Lord's anxieties about the apparent reduction in capacity. It is true that eventually there will be fewer beds than at present within the Wellhouse Trust, although precise numbers are still not clear and will be affected by decisions yet to be taken. However, your Lordships will be aware that bed numbers are only part of the picture. Developments in medical procedures and greater investment in community and primary services are changing the nature of healthcare provision across the country, not only in North London.
The noble Baroness mentioned the increase in emergency admissions. We recognise that that is the case. It occurs not only in London but is a countrywide situation. The NHS is coping very well with that pressure. However, the department is looking at what may lie behind the rise in emergency admissions. We have recently established four pilot studies in different parts of the country to inform decisions on the assessment of the rise in admissions and how that can be addressed through the commissioning process.
That brings me to the relevance of primary care in the overall plans for the area. That is of course an essential feature of the services. As the Edgware hospital changes its role and becomes more of a local hospital so will local primary services need to adapt to the changed circumstances.
We fully acknowledge that local GPs will need time to develop human and financial resources to manage the shift from secondary to primary care. They will need to be closely involved in the development of community services on the Edgware site. Taking this into account, I should inform your Lordships that through Barnet's primary healthcare development fund an investment of £17 million over a five-year period will be made to improve local services.
Projects at present under way include the extension of nursing for terminally ill people at home, improvements in GP surgeries and an outreach ophthalmology clinic. Projects planned for the future include increases in community nursing staff, a new GP surgery in the Burnt Oak area, further training of GPs to carry out minor surgery and the introduction of community physiotherapy. We believe that all of these developments will provide a framework in which the new Edgware hospital will succeed and prosper.
I have listened carefully to the concerns expressed tonight by the noble Lord, Lord Rea, about transport provision. Of course I acknowledge that travelling will be more difficult for some patients coming from the Edgware area. However, the majority of the services currently provided at Edgware will remain.
Where services are being concentrated at the Barnet site, patients will continue to have access to a free NHS bus service operating between the two hospitals. Special arrangements will be made for elderly and infirm patients who are less mobile.
The noble Baroness raised a particular concern about the problems of transport in relation to accident and emergency provision. I can assure your Lordships that the health authority has taken careful account of the fears expressed about this. So far as concerns ambulance cover, the health authority intends to provide additional investment over and above the significant increase already agreed this year. Two additional ambulances and crews will be funded at an extra cost of £320,000.
We appreciate the deeply held views on this issue. However, we remain convinced that the proposals already approved and those in the making will lead to improved services for the local community in both Barnet and Edgware. The plans have been long in the making, and have been determined only after lengthy consideration and consultation.
Lord Rea: My Lords, before the noble Baroness sits down could she develop the short statement she made that GPs will be involved in the proposed new local hospital? What is envisaged? Will there be a primary healthcare unit inside the hospital? Will GPs be associated with the minor accident and treatment service? How far have plans developed and is the health authority in touch with local GPs about that proposal?
Baroness Cumberlege: My Lords, we recognise that any provisions or changes that are made need to involve local GPs. The details are being worked out at the moment. There will be further consultation by the health authority, and it would be wrong of me at this moment to pre-empt that consultation.
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