Dr Julian Lewis: I am particularly pleased to see the Minister on the Front Bench tonight. I know of his care and compassion on the topic of mental health. Woodhaven Hospital is a state-of-the-art mental health unit set in a therapeutic, semi-rural but easily accessible location in my constituency. Its acute Winsor Ward has, unusually, en suite facilities for all 24 in-patients and other top-of-the-range features. It was a proud and happy moment for me when I cut the ribbon to open the new hospital just eight short years ago. Now, to the immense distress of service users and their carers, Woodhaven is threatened with closure.
Currently, 165 acute in-patient mental health beds are available to the Southern Health NHS Foundation Trust. They are in six units throughout Hampshire, as follows: 50 beds at Antelope House in Southampton, 25 each for men and for women; 20 beds at Elmleigh in East Hampshire, 10 each for men and for women; 24 beds at The Meadows in Fareham, 10 each for men and for women and 4 more, known as flexible beds, which can be used for either; 23 beds at Melbury Lodge in Winchester, 13 for men and 10 for women; 24 beds at Parklands in Basingstoke, 7 for men and 16 for women, plus 1 flexible bed; and finally, the 24 beds at Woodhaven in my New Forest East constituency, 10 each for men and for women, plus 4 flexible beds.
The Foundation Trust proposes to close Woodhaven, which is virtually brand new, and The Meadows, which is also quite modern. That would reduce the total available beds in the region from 165 to 117. However, of the 50 beds at Antelope House that have been available for acute cases up to the present, 10 are to be allocated to long-term, challenging in-patients, effectively reducing the total number of acute in-patient beds that will be available in future to only 107. The Foundation Trust has suggested that some of the future occupants of the 10 beds might come from other acute beds out of the 165 total, but it seems much more likely that the 10 beds at Antelope House will be allocated to residents from Abbotts Lodge, a different kind of unit that is not included in the 165-bed total and will be shut. For that reason, the real reduction in available acute in-patient beds will be from 165 to only 107.
Those 107 acute beds will contain two distinct categories of in-patient: those who are voluntary and those who have been detained. On what I believe to have been a typical day in mid-October, and on a similar day this month, when 153 beds were in use across the whole Trust area, no fewer than 88 were occupied by in-patients detained under the Mental Health Act. That constitutes 53% – just over half – of the existing 165 available acute beds. With only 107 beds available in future, that 53% figure will rise to approximately 82%. Conversely, the proportion for voluntary in-patients who are acutely mentally ill will fall from about 47% to just 18%. In practice, there will be only about 19 beds left for the whole of the Trust area in Hampshire for acutely mentally ill people who voluntarily go into hospital.
That will have a huge and negative effect on patient choice. There will be little chance of choosing or obtaining an acute in-patient bed, as four-fifths of them will be occupied by people who have had to be detained because they will not voluntarily agree to admission. Indeed, someone who desperately wants an in-patient bed would be well advised to create sufficient mayhem in order to be sectioned, if they are to have a reasonable chance of gaining admission. Once admitted, the voluntary in-patients will find that the effect of the greatly increased preponderance of detained in-patients in each of the four remaining units in Hampshire will be to make their wards significantly less therapeutic. Should the Trust be thinking of such a huge reduction in bed totals at all?
I should say at this point that there is no fundamental philosophical disagreement between me and the representatives of the District and County Councils on the one hand, and the management of the Trust on the other. The Trust’s spokesmen consistently agree that some acute in-patient beds will always be needed. For our part, my colleagues and I have no doubt of the value of strong Community, Assertive Outreach, Crisis Resolution and Early Intervention services at home.
The key question that must be resolved – I hope that it will be resolved as a result of this debate – is simply: what is the correct number of acute in-patient beds in Hampshire? Naturally, the Trust maintains that by investing in extra services at home some people will be prevented from deteriorating to the point where they need to occupy acute in-patient beds, but I believe that stripping out more than one-third of the existing beds, as the Trust proposes, cannot possibly be justified.
Of course, the Trust ought to make efficiency savings. It states that closing two out of six acute in-patient units in the area will save £4.4 million, £1.5 million of which is intended to be invested in what was previously described as a ‘virtual ward’ but is now more sensibly described as a ‘hospital-at-home’ service. The remaining £2.9 million is, of course, an easy way to make a significant annual saving, but it is not an efficient way, especially when one considers that, according to an Audit Commission survey, Hampshire already has the highest number of staff per 1,000 of the population in Community Mental Health Teams out of 46 Trusts examined.
Cutting front-line services and making efficiency savings are two very different things.
Twenty-six acute beds per 100,000 people is the current average among the 46 mental health Trusts surveyed. The Southern Health NHS Foundation Trust has 28 beds per 100,000 and expects that figure to go down to 21 if the two units, including Woodhaven Hospital, are closed. I believe that the actual total would be just under 20 beds per 100,000 people. At the moment, with 28 beds, we are in the top 19 of the 46 Trusts. Whether we go down to 21 acute beds per 100,000 or to just 20, we shall be in the bottom six, and that is an immense gamble to take with the welfare of people who, almost by definition, are at risk of losing their lives.
Every day, the Trust files a record of how many beds were vacant out of the total of 165, and at my request it has provided a print-out for the past three months. This shows, beyond any doubt, that bed occupancy levels are consistently high. Let us remember that we are considering 165 beds, spread over almost all of Hampshire and serving hundreds of thousands of people. The Trust’s tables give a breakdown of the numbers of male and female beds vacant each day, and the numbers of so-called ‘leave’ beds temporarily empty. Leave beds are those that have already been allocated to in-patients, but that are not being used for short periods, because their occupants are spending typically one, two or three nights at home.
Even when leave beds are counted together with genuinely vacant beds, the total number of empty beds throughout the area is low – often, indeed, in single figures. Thus, from 21 September to 6 October this year, the overall daily totals were respectively 9, 7, 5, 5, 7, 3, 3, 3, 4, 11, 9, 9, 8, 9, 7 and 6 empty beds out of 165. When one excludes the leave beds, however, as one should because they have not been genuinely vacated, one is left with numerous instances of 100% acute bed occupancy for the whole region. For example, there were no vacant male beds at all on 2, 7, 10, 11, 17, 18, 20 to 24 and 26 September; in the same month, there were no vacant female beds on 7, 10, 11, 16 to 18, 20, 23, 24, and 26 to 29; and on September 3, 4 and 25, gender information not being available for those three dates, there was either only one male and no female acute beds available, or only one female and no male beds available in the entire Trust area in Hampshire.
Of course, one can debate how much use can safely and regularly be made of at least some of the leave beds that are temporarily vacant.
Mr Charles Walker: My hon. Friend will know from previous debates that one can have occupancy rates above 100% because sometimes, in emergencies, leave beds are drafted into use.
Dr Lewis: I am extremely grateful to my hon. Friend for making that important point, as I am for him being here to support me tonight. I know of his great interest in the subject.
Using the Trust’s own figures, I have calculated the average acute in-patient bed occupancy over the three months from August to October. Even if all the leave beds are counted as available – which they are not – bed occupancy was 91.9%, and the figure would be higher if weekends were excluded, given the number of people who go home for short periods at those times. When only the genuinely vacant beds are considered, the average occupancy rate is seen to have been a remarkable 96.7%.
One of the most extraordinary assertions in the Consultation Document on the proposed changes is to be found on page 11, where it declares:
“The time that people are spending in our…hospitals is longer than the national average (our average length of stay is 51 days (including leave) compared to below 30 days (excluding leave) in other Trusts).”
That is an extraordinary manipulation of the data, as it contrasts the total of days spent on and off the wards in our Trust area with the total of days spent only on the wards in other Trust areas. A glimpse of the true situation is again to be found in the tables drawn up by the Audit Commission. In referring to all mental health admissions in the Hampshire PCT area, which is not quite the same as the Foundation Trust area but is a reasonable general guide, the Audit Commission states:
“Hampshire PCT is below the national average”
for length of stay. I do not know whether the Trust’s blatant and gross failure to compare like with like was deliberate, but the public, their local representatives and Ministers are surely entitled to ask what the average length of stay excluding leave is in Hampshire’s acute beds, and what the average length of stay including leave is in the acute beds of other Trusts, so that real rather than bogus comparisons can be made.
Time prevents a more detailed dissection of other dubious claims made by the Trust. Its spokesmen refer to the acutely mentally ill suffering ‘disempowerment’ as a result of spending what is usually a relatively short time on an in-patient ward. Most frequently, it insists that
“people have consistently told us they want to be at home”.
Such claims fly in the face of what we hear from service users and especially from carers, who want the assurance that an acute bed will be available when it is needed. I have yet to discover what, if any, systematic survey was undertaken to arrive at that conclusion. Who carried it out? How many people were surveyed? What questions were asked? The Trust says that its soundings showed a desire for:
“Care within a community setting where possible, and avoiding going into hospital unless it is necessary.”
Well Amen to that. We can all sign up to that; but that is a very different proposition from wishing to see a more than one-third cut in available beds that have an average occupancy rate of between at least 91.9% and 96.7%.
Only 5 out of the 46 Trusts listed by the Audit Commission have 20 beds or fewer per 100,000 of the population. Southern Health NHS Foundation Trust wishes us to follow that example. Its Consultation says that that minority of Trusts
“deliver good or excellent standards of care”,
and it recently identified four of those five Trusts in a presentation to me and others. Although the overall ratings for those four Trusts are, indeed, good or excellent, the picture is different where in-patient services are concerned: none of the four is rated as ‘Excellent’, two are rated as ‘Good’, a third is rated only as ‘Fair’, and the fourth is rated as ‘Weak’.
At meetings with the Trust, I and my colleague, County Councillor Keith Mans – a former and distinguished Member of this House – have stressed the need for the new hospital-at-home model to be piloted before any of the six in-patient units is closed. If this exercise is really about ‘Improving Outcomes for Hampshire’s Adult Mental Health Services’ – as the Consultation Document is entitled – rather than about saving £2.9 million a year, then acute in-patient beds should not be discarded until pilot projects clearly show significant reductions in the current very high levels of acute bed occupancy.
We need a step-by-step approach that clearly rules out the present plan to remove not just one but two modern mental health units, including Woodhaven Hospital, right at the start. It is distinctly probable that the Overview and Scrutiny Committee of Hampshire County Council may decide to refer this matter to the Secretary of State. This evening, I look to the Minister for two assurances.
First, I want an assurance that Woodhaven Hospital, which is so valued by our community, will not be closed until objective and independent surveys have been carried out assessing whether there really are dozens of people in beds for the acutely ill in Hampshire who do not need to be there.
Secondly, I want an assurance that Woodhaven will remain open until a pilot scheme has demonstrated that the proposed hospital-at-home scheme is starting to reduce the current high levels of acute bed occupancy. It cannot be right that in-patient beds should be cut to 107 for the whole Trust area in Hampshire, so that we are left with a woefully inadequate total of about 19 for voluntary in-patients once all those detained under the Mental Health Act have been accommodated.
People’s lives are at stake.
[The Minister of State, Department of Health (Paul Burstow): I congratulate my hon. Friend the Member for New Forest East (Dr Lewis) on securing the debate and on being, as ever, so thorough and detailed in his exposition of the case that he puts before the House. I take this opportunity to pay tribute to the hard work of the staff who work within the NHS in his constituency.
I want to set out the current position, as I understand it from the briefings that I have had over the past few days, and to respond to several of my hon. Friend’s specific points. I assure him that under the proposals for adult mental health redesign set out by Southern Health NHS Foundation Trust, Woodhaven Hospital will not close but will change the nature of what is provided. I want to make it clear that there is a continuing NHS future for the facility, albeit not the one that he believes to be appropriate.
While the Trust recommends that the acute adult mental health ward is withdrawn from Woodhaven, the excellent hospital which my hon. Friend opened eight years ago and which the community should rightly be proud of will continue to offer specialist adult mental health services. The aim of these changes is to provide the right mix of community and bed-based care – this debate centres on what that balance is – and ultimately the best possible support for people in his constituency who use these services.
My hon. Friend will be aware that during the 18-month engagement with the public that took place prior to the statutory Consultation, the majority of patients consulted said – this is one of the areas that he challenges – that they wanted to be treated in the community. As a general principle in any field of health care, the more we can focus on prevention and on supporting people in their homes so that they retain their independence and stay connected with their communities, the better the outcomes we can achieve. The principles behind the Trust’s proposed redesign can therefore be pinned squarely to the views of local people, and this is where I want to reassure my hon. Friend a little further. I understand that, through the Consultation, the Trust has been told this on repeated occasions. I have a quote from one service user:
“I was unfortunate enough to need the services of the home treatment team over Christmas 2008 and New Year 2009, but due to the care I received from the team I didn’t need to be admitted to hospital and I was able to stay at home with my husband and son.”
Clearly, my hon. Friend disputes the evidence that the Trust is putting forward about whether patients want to be treated at home, but it is for this reason that it is recommending the integrated model for mental health services in Hampshire and the reinvestment of savings from acute services into community services. However, I will ensure that he is supplied with further evidence on these points so that he can satisfy himself and his constituents that the Trust is basing its decisions on reasonable evidence.
Additional community services will ensure that patients receive flexible and bespoke care packages in their home wherever possible, even when acutely unwell. The intention of the proposals will mean that people are admitted to hospital only if it is clear that hospital is the best place for them to receive their treatment. The Trust tells me that treatment and care for patients will be provided in the most appropriate and therapeutic environment for the patient and that acute beds should be available for those who need them. However, when local Trusts propose changes to existing services, the public should be closely consulted. Again, my hon. Friend obviously feels that that is not what has happened. In the case of Southern Health NHS Foundation Trust, service user involvement projects and carers’ groups from across the county have worked closely with the Trust to develop the proposals for the redesign.
I want to deal with a couple of the specific statistical points that my hon. Friend set out so clearly. He has demonstrated something that does not always happen in these debates, in that someone has done a lot of detailed research to try to nail the issue that he is most concerned about. First, I want to deal with the proportion of people detained versus those in voluntary admission. He referred to two days’ worth of data that he had collected and his conclusion that 53% of people were detained in those circumstances. However, I understand that over the past six months, on average, 22% of people admitted to the Trust’s adult acute beds have been detained under the Mental Health Act. I have asked the Trust to write to my hon. Friend with those figures so that he can see more data.
Dr Lewis: The Trust did fax me some figures of that sort. However, they did not make sense because when they were added up, the total was way below the number of beds that had been occupied. I honestly think that the Trust is wrong on these proportions.
Mr Burstow: That is why I think it is right for the Trust, having read this debate, to follow it up by writing to my hon. Friend. I know that he has been engaging with it face-to-face as well, and I am sure that he will continue to do so.
My hon. Friend made a point about the Trust anticipating the effectiveness of the whole clinical pathway and about the focus on the most unwell reducing the number of people admitted under the Mental Health Act, in addition to reducing voluntary admissions.
My hon. Friend mentioned the issue of whether one counts leave beds. It is common for people who have been detained in hospital to have a period of leave from the ward before they are discharged. That can vary from a few days to several months. The beds for leave patients are not kept empty, but are made available for other acute admissions, as my hon. Friend the Member for Broxbourne (Mr Walker) said. It is therefore important to count leave beds when considering capacity. My hon. Friend the Member for New Forest East set out clearly his concern about bed occupancy and the impact of leave beds. I will make sure that the Trust considers this issue carefully as it draws together the feedback from the Consultation before its forthcoming discussion with the Hampshire Overview and Scrutiny Committee. I will ensure that his concerns about length of stay, which he set out so clearly, are put to it.
My hon. Friend made a request for a pilot. Although I will not go quite as far as he would like tonight, it might help if I provide him with some information about the process that the Trust has put in place to evaluate and assess the proposed changes. I understand that it has invited the Centre for Mental Health to do an independent review of the proposals, which is expected to be complete within a month. The Trust’s research and development department is also completing a thorough evaluation of proposals, comparing a range of quality measures at baseline and after implementation.
On the next steps, the Trust has been in discussions with the Hampshire Health Overview and Scrutiny Committee, and it has been agreed that the Trust will hold a number of stakeholder meetings. It is expected that the Trust will return to the Health Overview and Scrutiny Committee at the end of this month and present a written report that describes the themes from the Consultation feedback and the progress that has been made in those meetings. The Trust will then make suggestions on the next steps, which it will agree with the Health Overview and Scrutiny Committee, with a view to reaching final decisions in early 2012. As I understand it, any changes will be implemented by the Trust in a phased, transitional approach over a period of time, not as a big bang.
The Trust will, of course, keep my hon. Friend fully informed. I know that he has been diligent in pursuing the Trust with his concerns. I encourage him to carry on that dialogue. I again congratulate him on securing this debate and for clearly articulating his concerns on behalf of his constituents. I hope that I have been able to articulate some of the points that the Trust has put to me and I look forward to a conclusion of this matter in the New Year.]