17 March 2006
Up to 80 cottage hospitals in England are threatened with closure – and yet NHS community hospitals are meant to be the next big thing. Tash Shifrin investigates
The pretty Suffolk town of Sudbury is set in the picturesque countryside portrayed by its most famous resident, the painter Thomas Gainsborough. Its timber-framed buildings date back five centuries, ducks quack on the nearby river Stour and the town's ancient common lands are still a haven of tranquillity.
Yet appearances can be deceptive, for Sudbury is a battleground. The town's Walnuttree Hospital is threatened with closure, and local residents are up in arms. There have been protests and petitions signed by thousands of locals determined to save the much-loved community hospital and its 30 inpatient beds. Windows sport stickers for the campaign against Suffolk West Primary Care Trust's closure plans.
A similar scene has been repeated up and down the country. Between 60 and 80 of the 360 cottage hospitals face closure as the National Health Service seeks a way out of the financial crisis that this month led to Sir Nigel Crisp's decision to retire as NHS chief executive.
The community hospitals are predominantly in rural areas and, in a peculiar reversal of the 1980s, campaigners to save them have won backing mainly from Conservative MPs keen to paint Labour as the party of hospital closures and bed cuts.
But the closures that PCTs are now planning fly in the face of the government's own health policy. In January, Health Secretary Patricia Hewitt's white paper, Our health, our care, our say, trumpeted a future for community hospitals as a key resource in treating patients closer to home and reducing admissions to acute hospitals.
Community hospital inpatient beds offer the sort of intermediate care that can, for example, prevent elderly people being admitted to acute hospitals and allow them to be transferred nearer home when they no longer need an acute bed. Many also include minor injuries units, outpatient departments, minor surgery and other facilities.
The white paper repeats a Labour manifesto pledge to 'create many new community hospitals', to offer increased day-case surgery, more outpatient services, diagnostic tests and 'pathways within primary care for dermatology, ear, nose and throat medicine, general surgery, orthopaedics, urology and gynaecology' – the polyclinic model. Details of tendering for this 'new generation' of community hospitals will be released in the summer.
But with the axe hanging over many existing hospitals, Hewitt ordered PCTs to review any closure plans in the light of the white paper. Closures could go ahead where facilities were 'clinically not viable' or where people did not wish to use them, but 'community facilities needed for the long term must not be lost in response to short-term budgetary pressures', she told MPs.
Conservative MP Graham Stuart, chair of the campaign umbrella group, Community Hospitals Acting Nationally Together (Chant), was delighted by the white paper. 'It's fantastic, it really did vindicate what we've been saying,' he enthuses. However, he adds: 'Back in the real world, PCTs are under enormous financial pressure, a large number are in deficit and they've been told in no uncertain terms they must balance their books and do it immediately.'
Hornsea Cottage Hospital, in Stuart's Yorkshire constituency of Beverley and Holderness, has already lost 12 of its 22 inpatient beds and faces the loss of its minor injuries unit – a move the MP fears is a step towards total closure. There is now a waiting list for beds at Hornsea, and some patients must make a 40-mile journey to go to hospital in Hull. But Yorkshire Wolds and Coast PCT is £11m in the red, Stuart says.
Richard Lewis, senior fellow at the King's Fund, says this is the rub. 'There are competing priorities between the white paper and financial balance. Clearly, those two things will be in tension.'
Nigel Edwards, policy director at the NHS Confederation, agrees. He adds that PCTs are struggling to 'square the financial circle' and wrestling with budget cuts in a financial system still tilted towards funding acute hospital care. 'The issue is that the payment by results regime at the moment incentivises care in hospital. Payment by results for long-term care needs some thought,' he warns.
But Edwards has other reasons to be cautious about the great white paper rescue. Many community hospitals were originally built as war memorials just after the First World War so not all are suited to providing modern health care services, or will remain fit for purpose in future, he says. 'You can't automatically assume that a community hospital is in the right place, built in the right style or the appropriate form for the type of services likely to merge from the white paper.'
Peter Holden, a GP in Matlock, Derbyshire, and the British Medical Association's spokesman on community hospitals, believes money lies behind the closure threats. 'The noise in the white paper is to use them [community hospitals], but the trouble is, they're seen as a soft target for broke PCTs.'
The community hospitals act as a safety valve, preventing 'red alert' bed crises at acute hospitals in the area by providing intermediate care, Holden says.
But he believes that financial clout lies with the acute trusts, particularly the foundation trusts, which snap up the entire admission fee for patients, even if they are later transferred back to community hospital beds. 'High Peak and Dales PCT is £3m in the red because of this,' Holden says.
He is scathing of the 'middle-class view' that the community hospital could be replaced by services in patients' homes. 'There are some houses where you can't put things down. Many people live in considerable overcrowding; they simply do not have the room,' he says. And regarding the travelling time this would involve for GPs, he poses the question: 'Do you want me to treat patients or drive?'
Peter Morgan, of AMPM Research and Consulting, has acted as consultant to several campaigns against community hospital closures, including Walnuttree. 'Every one we've looked at has been primarily financially driven. It's not surprising if you draw up the top 20 PCT deficits,' he says, adding that the largest deficits are in rural areas.
Morgan puts the 'alleged savings' from closure of up to 80 community hospitals at around £150m but stresses that the NHS is being 'over-optimistic' on how much money would actually be saved.
Services to replace inpatient beds will still cost money – which has to come from somewhere, whether these are provided in people's own homes or through purchasing private nursing home places, he says. He points out that some alternatives would push the bill on to local authority social services or, where social services charges apply, on to users themselves.
But in a climate of straitened finances, there are fears that promised replacement services might never arrive. Stuart compares the risk to that of Care in the Community, an allusion to the policy responsible for the closure of Britain's long-stay psychiatric hospitals in the 1980s and 1990s. Progressive in theory, Care in the Community became a byword for a lack of care as resources to support patients in the community failed to materialise, leaving many vulnerable people on the streets.
Is there a danger that a similar gap could open up where community hospitals are closed? It is 'a hazard', the NHS Confederation's Nigel Edwards admits.
Morgan echoes the warning: 'A lot of the plans are going to cause problems because the increases in community services as an alternative to the community hospitals are so low that admissions to acute hospitals are going to go up. It's inevitable.'
It is unclear how many cottage hospitals will win a reprieve. In a move that has cheered the Sudbury campaigners, plans to close two community hospitals in the neighbouring East Suffolk PCT area have been referred to the health secretary in the wake of the white paper.
But West Wiltshire PCT – with a £9.5m deficit forecast – is pressing ahead with plans to close Bradford-on-Avon Hospital. It has already closed the inpatient unit at Westbury Community Hospital ahead of schedule, removing patients at less than a week's notice because of staff shortages as nurses found jobs elsewhere.
Despite earlier PCT statements attributing the closures to a 'parlous financial position', the trust's planning and partnerships director Nicholas Gillard says the closure decision is borne out by the white paper. 'Nearly all of our existing community hospitals are not fit for purpose, and would not enable us to carry out this new national policy and switch from secondary to primary care delivery as indicated in the white paper.'
Not all PCTs are clawing back money by shutting cottage hospitals. At Sussex Downs and Weald, operations manager Rosemary Diggins says that despite a £1m-plus PCT deficit, the four local hospitals are 'a valuable asset' and 'much loved by their local populations'. They have social services rehabilitation teams on site and offer minor surgery more cost effectively than the nearby acute trusts, she says.
Her words would be music to the ears of campaigners in other parts of the country. But considering the situation of the more stricken trusts, Lewis at the King's Fund says: 'In reality, health service managers are going to struggle quite considerably to achieve financial balance. I don't think that environment lends itself to subtle cost-effectiveness analyses.'
The problem in a nutshell – Walnuttree Hospital
Overlooking the pastoral scene on the edge of Sudbury, an industrial-looking building stands out. A former Victorian workhouse, Walnuttree Hospital does not look like the cheeriest building.
'It's services we're fighting for, not the buildings at all,' says Michael Mitchell, Unison rep at the hospital and a member of the Walnuttree Hospital Action Committee. And inside the hospital, despite the narrow corridors and the top floor being closed off as a fire risk, the wards appear warm and friendly, sporting hand-knitted covers on the beds. There is a day hospital, outpatient department and physiotherapy service on site too.
The WHAC campaigners are keen to stress that they are not Luddites, wedded to their workhouse. An earlier, long-awaited plan to build a new health centre with inpatient beds and a range of services was welcomed by the town. 'It was all going to be on one site — ambulances, sheltered housing — like a one-stop-shop,' says Mitchell.
But Colin Spence, chair of WHAC and former vice-chair of Suffolk West PCT, says the plans were dropped last June. 'There was a big public meeting with the chief executive and he said the proposals put forward are not affordable now and it won't go ahead.' Spence resigned in protest. Now, the PCT — with a £13.5m forecast deficit, even after £9.1m savings this year — wants to shut the hospital ahead of any new development (which will have no beds). The campaigners want the beds, and believe if Walnuttree shuts before the replacement is built, they will never see a new health centre.
Chief executive Mike Stonard refused to answer Public Finance's questions before the PCT's board makes its final decision next month.
Community hospitals under threat, by strategic health authority
Avon, Gloucestershire and Wiltshire SHA
Bradford-on-Avon Hospital
Westbury Hospital
Melksham Community Hospital
Trowbridge Community Hospital
Devizes Community Hospital
Warminster Hospital
Malmesbury Community Hospital
Tetbury Hospital
Cossham Hospital
Moreton-In-Marsh Hospital
Moore Cottage Hospital, Bourton-on-the-Water
Fairford Hospital
Thornbury Hospital
Cumbria and Lancashire SHA
Alston Cottage Hospital
Cockermouth Hospital
Millom Hospital
Brampton War Memorial Community Hospital
Keswick Community Hospital
Maryport Hospital
Penrith Hospital
Workington Community Hospital
Pendle Community Hospital, Nelson
Hampshire and Isle of Wight SHA
Emsworth Hospital
Fordingbridge Hospital
Romsey Hospital
Milford War Memorial Hospital
Havant War Memorial Hospital
Alton Community Hospital
Andover War Memorial Hospital
Fenwick Hospital
Hythe Hospital
Norfolk, Suffolk and Cambridgeshire SHA
Hartismere Hospital
Aldeburgh and District Community Hospital
Felixstowe General Hospital
Bartlet Hospital
Newmarket Hospital
Walnuttree Hospital, Sudbury
St Leonard's Hospital, Sudbury
Doddington Hospital
Surrey and Sussex SHA
Weybridge Community Hospital
Cranleigh Community Village Hospital
Farnham Community Hospital
Dorking Hospital
Emberbrook Care Centre, Thames Ditton
North and East Yorkshire and Northern Lincolnshire SHA
Hornsea Cottage Hospital
Withernsea Community Hospital
Alfred Bean Hospital
Bridlington Hospital
Whitby Hospital
Trent SHA
Skegness Hospital
Newholme Hospital
Cavendish Hospital, Buxton
Shropshire and Staffordshire SHA
Ludlow Community Hospital
Bridgnorth Hospital
Whitchurch Hospital
South West Peninsula SHA
Moretonhampstead Hospital
Okehampton Community Hospital
Thames Valley SHA
Townlands Hospital, Henley
Bicester Community Hospital
Kent and Medway SHA
Sittingbourne Memorial Hospital
Edenbridge and District War Memorial Hospital
Dorset and Somerset SHA
Clevedon Hospital
South Petherton Hospital
West Midlands South SHA
Evesham Community Hospital
PFmar2006
