New Petitions

Thank you for giving us the opportunity to appear before the committee. I will hand over to Professor Alex Davison to make the opening statement, if that is okay.

Thank you for affording us the opportunity to emphasise the points that we considered important when we formulated our petition.The geography and demography of Scotland provide a challenge to the provision of an effective health service and it is likely that there will be no single solution that is applicable to all areas. The service needs to accommodate the requirements of the two large conurbations, the numerous smaller cities and the rural areas. There is a clear need for centralised hospitals with high-technology facilities that are capable of achieving the highest standards in both diagnosis and treatment. Although we recognise the need for centres of excellence, not all diagnostic and treatment facilities can be provided in all hospitals. There is a need not just for large academic hospitals, but for a network of district general hospitals and smaller community hospitals. Our petition deals with the latter.In the rural areas of the Highlands and the Scottish Borders, the distances involved and the density of the population create difficulties for health care. In general, rural areas tend to have a greater proportion of elderly people, many of whom live alone. In the Scottish Borders, for example, almost 22 per cent of the population are of pensionable age and 9 per cent are aged 75 or over. The corresponding national figures are lower.There will always be a need for patients in such rural areas to attend, on occasion, both district general hospitals and centralised centres of excellence, depending on the level of expertise that is required to diagnose and treat specific conditions. Although we recognise and welcome the current trend to provide more care in the community and to keep as many people as possible in their own homes for as long as possible, that does not diminish the need for community hospitals, because not all patients can be managed at home. With elderly and chronically ill patients, there is often a need for a level of care to be provided that is lower than the level of care that is provided by the district general hospital, but higher than that which can be provided in the patient's home. In addition, we have concerns about the number of staff who are required to provide such a service in rural areas, in view of the amount of time that they spend travelling. Throughout Scotland, there are many small, community-based hospitals that provide valuable services to their local communities. We acknowledge that there are difficulties in maintaining such hospitals, as many are old and in need of refurbishment, and we are aware of the staffing problems that the working time directive presents. Nevertheless, we are convinced that small community hospitals provide a service to local communities that is not only required, but very much appreciated.A recent report from the British Medical Association found that health policies that are "developed in towns do not work in rural areas and that older people are disproportionately affected." Community hospitals have many benefits. Patients and their relatives do not have to travel far, which is a particular benefit for the elderly. Patients can receive rehabilitation following procedures in larger, more remote hospitals, thereby freeing up beds in the larger institutions. Respite care can be provided for elderly people and for people with chronic illnesses, with the added advantage that such patients will probably know the nursing and auxiliary staff and therefore be at less risk of incidental delirium, which can arise when people are admitted to unfamiliar and remote facilities. In addition, terminal care can be provided for people with illnesses such as cancer and other progressive debilitating conditions. Finally, communities are frequently proud and very supportive of their local cottage and community hospitals.The demography of rural areas presents a particular problem for the care of the elderly. Respite care and terminal care are more frequently required for that group of patients and it is not appropriate for such care to be provided in district general hospitals or larger institutions. The facilities that community hospitals provide thus support and complement the facilities that the larger hospitals provide.There is an opportunity to review the provision of patient care throughout the community, in particular the place of local hospitals in supporting the health care needs of people who live in rural areas. There is an opportunity to develop such hospitals to include the primary health care team, community nurses, social services support staff, health care educationists and all who are involved in caring for people. The existing network of community hospitals could be developed as community resource centres that would not only provide health care, but meet social services needs. If the existing facilities are abandoned, it will be difficult and expensive to reinstate them. It is recognised that local provision has many advantages over a centralised service and the opportunity to review provision and develop a novel solution to the 21st century health care needs of a rural population is an opportunity not to be missed.We sincerely hope that the Scottish Parliament will urge the Executive to introduce a moratorium on the closure of community hospitals, to enable a review to be undertaken to determine the most appropriate way of providing an integrated health service that takes account of the geography and demography of the country and of the care needs of given populations. We believe that there is an opportunity to develop a novel and effective solution that meets the specific needs of the Scottish population.

On your first question, I deliberately did not mention Jedburgh hospital, because we are considering not one particular issue but rural areas in general. However, in thinking about Jedburgh—which we could couple with Coldstream—it seems to us that the health boards are acting in a hotch-potch fashion and not in a co-ordinated way, with health boards considering their own little patch and saying, "This is what we think we should do and how we should redesign and reconfigure the service." A more generic solution should be considered for Scotland. Small communities such as Jedburgh require a local service, but we could say the same about 200 other small towns and communities throughout Scotland.The second issue is that we are aware that a review is being undertaken. The review group will visit the Borders on 17 February. The committee can be reassured that at least three people—and some more—will attend that meeting. We believe that it is vital to get levels of care that are appropriate for the community that is being served. We are not looking for a royal infirmary in Jedburgh; we are looking to get people into the most appropriate beds that their care demands.

Primary care services and all the other support services that patients need were fragmented. There is now much greater opportunity for partnership working between social services and health care services. There is an opportunity to develop facilities, including primary care and the services that are provided by the community nurses who go out. That would perhaps also include an element of health care education and preventive strategies, combined with social services, so that the service is much more integrated. Therefore, when people had a problem—for the elderly, many of their problems are multiple problems—they could go to one place and get the various elements of their problem sorted out. That model could be dropped into Comrie, for example, or places in the south-west of Scotland. It is not about providing one solution for one place; we must find a solution that is much more imaginative and much more inclusive for the person with a problem, as their problem often has different ramifications.

No. The acute and primary sectors need to be integrated, because people need to receive different levels of care. They need to go to the acute hospital when they have an acute problem. Often hospitals can deal with the acute problem, but that is followed by a period of rehabilitation, which should be done locally. The patient does not need to be in an expensive, whatever-it-costs-a-day bed to be rehabilitated. If we remove our community hospitals, that facility will be lost. That means that a backlog will build up at the centres of excellence, which should deal with the difficult problems, sort them out and pass the patient on to an appropriate service nearer their home.

The Sister Margaret cottage hospital in Jedburgh has nine beds for a populace of some 6,000, so it is a small number of beds in proportion to the population and we need to extend the hospital rather than close it.To answer Jackie Baillie's earlier question, one of the drivers behind the proposed closure—it is only proposed at the moment—is economic: the NHS board needs to save money and the Sister Margaret cottage hospital, being a small unit, represents a useful saving. If the European working time directive is applied, we need to employ two full members of staff at night, rather than one, so the unit would become much more costly if it retains only nine beds. Perhaps a solution would be to extend the hospital and the primary care services that it can provide in conjunction with other primary care facilities in Jedburgh. That could be a model not only for Jedburgh, but for many other small hospitals throughout Scotland.

At the moment, the Borders area does not have a hospice, and it would be ideal for the community hospitals to work with, for example, Macmillan Cancer Relief to provide hospice care, rather than have separate hospices.

John Farquhar Munro asked what the health boards could do. We must not consider Jedburgh alone, but we can take it as an example. The suggestion for reconfiguring the services in the Borders was entirely finance driven. When the health board was asked whether any needs assessment had been carried out to find out what the need in the community was before it decided how to reconfigure the services, its answer was no. If the health board was a commercial organisation, the first thing it would do would be to find out the requirement for the service, and health boards should be instructed to do that first. If the population is older and in need of services such as care for the elderly and hospice care, we should consider that and ask how best we can provide for that need. We should not be asking how we can provide a service with the money that we have. I am not saying that money is unimportant; we know that there is no bottomless pit. However, the service should be led by what patients require in a particular area.

What you say is absolutely true. If we are talking about an elderly population, we must look at where they live, what sort of accommodation they live in and whether they live alone or are supported by relatives. Increasingly, elderly patients are being isolated in the community because they live alone. Such people require to go to all sorts of hospitals—some of them will require to go to centres of excellence. There is no way round that. However, greater attention should be paid to getting them back from centres of excellence to local district general hospitals. Once they are stabilised, they should go from there to community hospitals that are in their own towns.I alluded to incidental delirium. People go into hospitals where they are infrequently visited by their relatives and which are very strange surroundings for them. They do not know any of the staff and their local general practitioner cannot drop in to find out how they are progressing, because the patient is 40 or 50 miles away. Of course, that is exactly the problem in the Western Isles. People in those situations become disorientated and much more ill than they would be if they were in more familiar surroundings. That is not to criticise in any way the hospital staff, who are unquestionably excellent. It is just that patients whose mental faculties are diminishing find it very difficult to cope with and adjust to unfamiliar surroundings. We need patients to be back where all sorts of people, who might just be going down to the local shop, for example, can pop in and ask them how they are doing. That support still exists in small rural communities, but not necessarily in towns. I think that such support is very helpful because, by providing it, we are getting people back into their own homes much more quickly. Wendy Frost knows about that.

In a matter of three or four weeks in my local village, which is very small, three people were in need of respite care, which was provided in the cottage hospital. That must be happening in other communities as well. The respite care was desperately needed by the patient, but the carers also needed it. Another side that we should consider is that cottage hospitals also provide for the carers. Respite care and travelling affect the patient and the carer. In rural areas at the moment, carers are providing the vast majority of care in the community. That carer might be, and often is, an elderly spouse who either cannot drive or who finds public transport difficult or impossible to use, but who also needs breathing space so that they can continue to care and provide relief for the health service.

It would be good if I could give you a nice, concise answer, but I do not think that there is one. Our concern is that if we move patients into the community and provide community nurses, we will need more community nurses because of the travelling time. If the community nurses are based in the Borders general hospital at Melrose and have to travel to Jedburgh, they are going to have 40 minutes of travelling time in the day just to see one person. Therefore, I do not believe that just moving care from the small community hospitals into the patient's own home will help to solve staffing problems because that will create a need for more staff that are trained in a different way.One of the advantages that community hospitals might have over the big central hospitals is that they can often recruit people from the local area because there is local support for those hospitals. A highly qualified nurse might not be needed all the time and many nursing assistants and support workers could be involved. We could use a lot of people in the community and if we develop community hospitals into resource centres, other local people such as physiotherapists and occupational therapists will be able to help in the rehabilitation of patients.There is a staffing problem that will be aggravated if we move people who need to be cared for out into the community. By having people in local hospitals, we could improve levels of recruitment.

We are given to understand that, during a night shift, qualified members of staff are required to have 10 or 20 minutes' break. However, with only one qualified member of staff, that cannot be done.

I can speak personally about one or two European countries. Italy and Germany have different systems and provide much more community-oriented facilities for patients.

Yes, in some respects.

We have not done so, but we will follow that up.

You are absolutely right. After people are trained, they move and then find that they have to go 40 miles to work and pay for parking when they get there. They would be much happier if they could work locally.

We will certainly do that. We will have a bus load of people going with prepared questions. I wonder whether the Official Report of today's meeting will go to the advisory group.

That would help our case, but it would also help the advisory group by providing more evidence.

I very much agree. If patients are not released from the general hospital into the community hospital, they cause bed blocking in the general hospital. If they are released into the community too quickly, a burden is placed on the budgets of council social work departments—in our case, Scottish Borders Council, whose budget is already seriously stretched. By closing the community hospitals, we are moving problems about; we are giving ourselves more problems, including more financial problems.

I agree absolutely with what you say. It is absolutely right. I add that, because the medical team may have been looking after the patient for 50 or more years, they have a heritage of knowledge about the patient that staff in a remote facility will not have. The general practitioner can go to the local cottage hospital to visit their patients and see how they are progressing. The GP knows their patients' home background and can say, "Now is the time to get this person home", for example. The GP's knowledge base on the individual is so much greater.

I am sorry. That was not my intention.

Professor Davison referred to a community resource centre as being a good model. In fact, we have a model of that type of provision in Scotland. I believe that it is in Auchterarder. An integrated centre there provides social and medical care and advice as well as training for staff—all within the same centre. We have spoken to the centre's staff. Perhaps that model could be taken forward as the model of provision to replace in a local care setting what we have at the moment.

I thank the committee for giving us the time.