HC Deb 08 April 1998 vol 310 cc319-25

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Mr. Llew Smith (Blaenau Gwent)

I hope that the consultations proposed by the Minister on the reconfiguration of health trusts in Gwent will put both sides of the argument, and that the conclusion that is reached will be based on an option that is supported by the local community and also reflects the health needs of north Gwent. It would be sad if that did not happen, especially in Blaenau Gwent, which, as we all know, is the birthplace of the national health service. There—and, indeed, throughout north Gwent—the Minister's proposals are opposed by the community, local authorities and, perhaps more important, doctors, including consultants. About 50 doctors had the courage to make a public statement opposing the proposals.

I have mentioned the importance of consultation because the Minister has agreed to set up a project board to plan for the one-trust option. I know the Minister well enough to be aware that, although he has anticipated the result in some respects, he is still open-minded enough to recognise that we are in the business of real consultation. I know that he will listen, and will reach conclusions based on the evidence given to him.

My constituency, is part of north Gwent. This subject is important to the community there. Unfortunately, Blaenau Gwent is near the top of the league in terms of health deprivation. I am thinking of heart and respiratory problems, cancers, mental health problems, disability and long-term sickness, infant and standard mortality rates, and babies with a low birth weight. As the Government have recognised, deprivation is linked to those problems; indeed, it is a causal factor. Deprivation exists in abundance in Blaenau Gwent, however it is measured—in terms of low pay, high unemployment, bad housing or even low levels of car ownership.

On the one hand, the Minister seems to consider that the proposed trust areas should not break up local authority areas; on the other hand, he has given trust status to the Cynon valley. We do not oppose that decision. In fact, we applaud it, and we now ask the Minister to apply the same logic that he applied to the Rhondda-Cynon-Taff local authority area when it comes to north Gwent. If he can accept the split in the Rhondda-Cynon-Taff area, surely he can accept it in some of the Blaenau Gwent local authorities.

Mr. Allan Rogers (Rhondda)

My hon. Friend has made an important point about the conterminosity of health services and local authority services, and the resultant linking of primary and community health services with general health provision. We are afraid that, following the integration of trusts, resources for community and primary care will be sucked into the acute sector.

Mr. Smith

I agree. I must admit that I do not normally use such big words as "conterminosity", but I shall attempt it a little later.

The Minister will probably argue that the Cynon valley was given trust status before his recent proposals for reconfiguration. He is right, but, in our view, that argument is irrelevant. The point is that, in terms of the Cynon valley, the Minister has recognised the importance of splitting up a local authority. Trust status will enable the Cynon valley to respond effectively to local health problems. Blaenau Gwent and the Cynon valley are similar, in that they are two of the poorest communities in Wales, with some of the worst health problems.

My hon. Friend the Member for Rhondda (Mr. Rogers) mentioned conterminosity. How important is that from a trust's point of view? In practice, patients go to the areas where they think they will be treated best. Currently, patients in Nevill Hall hospital come from all five local authority areas. It will never be possible to achieve a perfect fit between the area served by a trust and the local authority boundary.

For example, Caerphilly local health group would buy services from the Royal Gwent hospital, but in the north of the valley most patients go to Prince Charles hospital in Merthyr, while some go to University of Wales hospital in Cardiff, which is outside the area of the Gwent trust and health authority. Powys GPs often refer patients to Nevill Hall, Hereford, Prince Charles or Royal Gwent. Again, local health groups would have to deal with those trusts.

Conterminosity is relevant to the planning of services by health authorities in association with GPs and social services, but it is not relevant to the planning of delivery of those services. The GPs will dictate that.

Whether we have one trust or two, the Minister should examine the formula that determines the amount of health service provision. The present funding formula works against communities such as Blaenau Gwent, which has high levels of health deprivation and contains many people who need long-term care. The Minister should develop a system that responds to health deprivation and the need for long-term care. He should adopt a new philosophy—a philosophy in line with the socialist principles that have attracted not only the Minister but generations of people to the Labour movement.

Under the present system, all Gwent bodies fail dismally to respond to Blaenau Gwent's health problems. Let me give two examples. As the Minister will know, a couple of years ago, the Gwent community health trusts decided to reorganise mental health provision in the area—which obviously included Blaenau Gwent. A public meeting was held to protest about the plans for Blaenau Gwent. It was attended mainly by mentally ill people and their families.

One of the two members of the Gwent body who had drawn up the plans admitted that he knew nothing about Blaenau Gwent, and had not even tried to consult patients, families, friends, doctors, nurses, social services departments, Members of Parliament or anyone else with an interest in health provision in our community. People were treated with disdain. At that rowdy public meeting, the chairman of the community health trust, Bob Hudson, said to mentally ill people, "Well, folks, you've lost out." We would have lost out but for the courage of those mentally ill people, who stood up and made their voices heard. That is one example of people being treated with disdain by Gwent.

The second example arises from the recognition by Gwent health authority of health deprivation in the area. What was its response? A couple of years ago, it withdrew one of the doctors from Cwm. Once again, the local community had to raise hell to force a return to the status quo, but as with most promises by the health authority, two years later we are still waiting for that doctor. The Gwent bodies have not understood or responded to our problems.

Under Gwent trust, which will employ approximately 10,000 people, the situation will get worse. It will be centred in Newport, in the south of the county, and will be unable to develop closer links between the providers of community care, acute care, primary care, and social services and others. In planning patient discharge, general practitioners will have great difficulty in obtaining the co-operation that they need on hospital services. If they fail to get a response at local level, they will become involved in what is historically and always will be an unresponsive bureaucracy in the south of the county, where most of the population is concentrated and where all the money goes.

I am sure that the Minister recognises that services are becoming increasingly specialised. Some are provided regionally, and as there will be limited scope for administrative savings, the main target will be the rationalisation of patient care. To deliver savings, it is likely that specialised provision will be centred on the main population centres in the south of the county. As the Minister has said, that will be a gradual process, because Nevill Hall will continue as a district hospital. Such a hospital needs a minimum critical level of special provision, including intensive therapy, pathology, radiology and back-up provision for the main treatment programmes. That involves high investment in changing methods and technology.

With such decisions in the hands of a single trust, investment in Nevill Hall will gradually be eroded. As elements of the specialist services disappear, the front-line accident and emergency provision will not be viable, because emergency facilities will be centralised, and people in the most deprived communities, such as those in Blaenau Gwent, will have further to travel.

Mr. Richard Livsey (Brecon and Radnorshire)

I entirely agree with the hon. Gentleman. Does he agree that there will also be an impact on the people of Powys and on the GPs who refer them to hospital? That is a vital issue. I agree that Nevill Hall has high-quality facilities and that there must not be any reduction in its status.

Mr. Smith

I have already said that many GPs in south Powys refer patients to Nevill Hall. We are debating a matter that is relevant not just to the heads of the valley, to north Gwent, because its relevance extends over the border, if I may use that term, to south Powys. The distance that a patient must travel for treatment is crucial to success. Nevill Hall caters for people in south Powys, but it also provides substantial acute and community health care for local people in the six community hospitals. They extend from Tredegar, the birthplace of the national health service, to Monmouth.

In the past four years, much to the credit of Nevill Hall hospital, the number of consultants has increased from 32 to 45, and that has brought a wide range of specialties to the community. Since 1994, Nevill Hall has recruited almost as many consultants as it was allowed to recruit in the 20 years before that. It is a success story. The hospital has also successfully provided services that people in north Gwent and south Powys need, and that is what the debate is all about. It is not about creating structures but is about responding to health needs. If we fail to do that, we shall fail dismally as a Government.

Mr. Huw Edwards (Monmouth)

Does my hon. Friend agree that one of the key reasons for keeping the north Gwent trust is to maintain the integrity of Nevill Hall as a district general hospital and so attract and retain the specialist staff who are attracted to it because at the moment it is a specialist centre? Does he further agree that the debate will become important in the next few months? Will the Minister be able to meet again those of us who came to see him in the Welsh Office recently to discuss the matter?

Mr. Smith

My hon. Friend makes a fair point. Nevill Hall is currently an attractive hospital. Many consultants are attracted to it, partly because of the area, of which we are all justifiably proud, but we should not assume that all consultants wish to work in hospitals with 800 or 1,000 beds. Some people take a different view. A senior member of Nevill Hall told me some days ago that job interviews had been conducted with consultants, and that the one who had been invited to accept the job told the chair of the interviewing committee that he intended to withdraw his application because of the possibility of one trust serving the whole of Gwent. He did not find that an attractive proposition.

Nevill Hall has a fine record for day care, and for community hospital and other services in which it excels. That is evident from the amount of support for the north Gwent trust. One of the most important factors in patient recovery and care is the distance between a patient's home and where he is being cared for. If Nevill Hall's facilities are gradually eroded, its reason for existence, which is to serve the community, will also be eroded.

The Minister will say that my scenario is unrealistic because decisions about north Gwent will be made by the local health group. Such groups will consist of health authority officers, general practitioners, and people from social services and the local community. We are told that they will have a strategic role. However, it will be some years before local health groups have any real influence or money to spend on buying the services that they need. By that time, the services in Nevill Hall could have been whittled away, so that when the local health groups have any clout, they could face an irreversible pattern of provision.

In Gwent, the local health groups may have influence, but they will not have real power. For that they would need sanctions, such as buying services from another hospital trust, but the creation of a single trust would eliminate choice for the people of north Gwent and, as the hon. Member for Brecon and Radnorshire (Mr. Livsey) said, for those in south Powys. The health groups would have to buy what the single trust made available for patients, who might have to travel for miles to Hereford, to the Prince Charles hospital in Merthyr or even to Gloucester. The establishment of a single trust in Gwent would create a monopoly, and that is not good.

Above all, the submission by Gwent health authority ignored the fundamental criteria that the Minister has laid down, and I am sure that he will wish to respond to that. One of them was patient choice for access to local specialist services, but the authority document does not even mention that all-important matter. My hon. Friends and I would like to say much more, but we are running out of time and it is important to give the Minister time to respond. In the fine traditions of not only the Minister but the Labour movement, I am sure that he will respond positively.

1.18 pm
The Parliamentary Under-Secretary of State for Wales (Mr. Win Griffiths)

I congratulate my hon. Friend the Member for Blaenau Gwent (Mr. Smith) on securing the debate. I hope that I shall be able to respond positively, because the debate is important.

We are dealing with the complex issue of health deprivation, and I certainly understand and share my hon. Friend's concerns about health deprivation in Blaenau Gwent and, indeed, throughout Wales. He will be aware—his speech testifies to it—that there is much to do in redressing the legacy that the Government inherited. The path to success will not always be easy, as there are difficult problems to be faced and dealt with en route, but the Government are determined to improve the health of the nation and, in particular, to deal with current inequalities in health status. They have already set in train some important measures and actions to tackle the situation, both within the health service and more broadly. Of course, there are many more in the pipeline.

As the House knows, our White Paper "Putting Patients First" sets out a programme of long-term reform and improvement for health services in Wales. In coming years, the excesses of the internal market will be progressively replaced by new programmes of co-operative activity between the health service and others, particularly local authorities. Bureaucracy will be reduced and the quality of care improved. The programmes will be reinforced by a strategy for the nation's health, details of which I shall announce shortly in a Green Paper.

We inherited a haphazard pattern of NHS trusts, which were poorly placed to respond to challenges. The trusts in Wales had been created as a result of local applications to support a market-based philosophy and to compete with each other in an attempt to drive efficiency into the system, but competition spawned unnecessary conflict and tension. It created unnecessary bureaucracy, paper chasing and haggling over minute details, rather than giving proper attention to what mattered: high-quality health services, money targeted to improve access to services, more doctors and nurses, better hospitals and modern equipment. We are determined to put right the problems of the past. A substantial reduction in the number of NHS trusts will be a significant contribution to that aim.

The decisions that I announced last week were not taken lightly. The proposal for a single trust in Gwent was based on the following reasons. First, I was keen to maintain, wherever possible—and, as my hon. Friend the Member for Blaenau Gwent has pointed out, it was not possible to do it throughout Wales—conterminosity of health service provision with services provided by local authorities, particularly their social services departments.

Mr. Edwards

I am grateful for the way in which my hon. Friend received the recent delegation from Monmouthshire and Blaenau Gwent, but does he acknowledge that local authorities that made representations to him did not make conterminosity the overriding principle, as he seems to do? Although we all agree with his wish to see more effective collaboration between health authorities, trusts and social services, the boundary should not be the overriding principle.

Mr. Griffiths

Obviously, the boundary issue is not the overriding principle, but it is important that we get these things right, particularly with regard to the important role that local authorities can have in developing and improving health care in conjunction with local health groups, new NHS trusts and, of course, the health authority.

Close collaboration is vital in providing the seamless service that patients deserve. I have to admit that I am excited about the prospects involved in the new co-operation between the NHS and local government. Joint management of a wide range of services, especially for vulnerable groups of people, will ensure that local authorities—again, wherever possible—do not have to get into business with more than one NHS trust. It is important to do that as far as possible.

Secondly, the single trust solution offers the potential for much greater sub-specialisation, so improving the delivery of specialist services for the people of Gwent. I know that my hon. Friend the Member for Blaenau Gwent is keen that that should happen at Nevill Hall. I want it to happen at Nevill Hall and at the Royal Gwent. I want the two hospitals to move forward together in improving services.

Thirdly, the integration of acute, community and mental health services throughout Gwent would remove artificial boundaries between health providers. Finally, the single trust solution appears to offer potential for greater savings from a reduction in unnecessary bureaucracy. As I have made clear throughout the exercise, trust reconfiguration is not primarily about saving money, but we must ensure that as much money as possible is channelled towards direct patient care, rather than paper chasing and detailed haggling about finances and contracts.

For all those reasons, I decided to accept the Gwent health authority proposal that we consult on the single trust option. There will be a period of consultation over the summer months. I am sure that my hon. Friend the Member for Blaenau Gwent will be heartened to know that the management board that is conducting the consultation and preparing the papers for the new trust in Gwent is headed by a councillor from Blaenau Gwent, Peter Law. I am sure that he will have every confidence that Peter Law will want to ensure that all the difficulties in health service provision that have been identified by my hon. Friend will be dealt with in bringing forward the project, which will be subject to consultation.

Mr. John Smith (Vale of Glamorgan)

Will the consultation genuinely listen to the user groups, in particular, and to those very local authorities and other elected bodies with which we want to work in partnership, to provide the best possible health care? Will my hon. Friend be prepared to listen to those views and, indeed, if need be, to change the recommendations that are before us?

Mr. Griffiths

I shall want to ensure that, as a result of the consultation, the new trusts that I am proposing come forward with proposals that show an identifiable gain in the delivery of health services in their areas. If they cannot show that, they will not be approved. If there is a need to change the proposals in any significant way, a completely new round of consultations will have to take place, but I want to make it absolutely clear to everyone that the merged trusts, the individual hospitals involved and the local populations will not see a diminution of health services that are currently provided.

Local health groups, to which my hon. Friend the Member for Blaenau Gwent alluded, will be vital in providing the service. They will work from a plan that has built into it improvements in health service delivery, so there will be no question of the groups facing a hospital that has lost services; that is not part of the plan.

We want to ensure that local general practitioners, social service representatives, other professionals in the health service and interested local health service bodies play a full part in ensuring that their nearest hospital is the one where services are provided for the people in their area, and that mental health and community services will be provided in a way that best meets the needs of local people. That is the whole purpose of carrying through the trust reconfiguration. Anything less would fly in the face of our commitments to put right the wrongs of the past and to improve health services.

On resource allocation, we are currently reviewing the allocation formula to ensure that it takes account of best practice elsewhere and of relevant data on health need. The working group has not yet reported its findings to me, but it may recommend changes to the current formula or the introduction of a new approach. At this stage, it is not possible to say exactly what will happen, but I believe that we could introduce a wider range of variables into the formulae that take account of particular health circumstances.

The future health service will be different. Local health groups will have a fundamental role in defining and commissioning primary, community and secondary care. They will commission local health care from the NHS trusts. The trusts will simply retain their existing responsibilities for providing services according to the commissioners' requirements. The doctors, health care professionals and local authority social services departments will decide what services they want from the trust.

Mr. Edwards

Will my hon. Friend give way?

Mr. Griffiths

Much as I would like to give way, I cannot, because I am in the last minute.

We shall soon publish a Green Paper focusing on the development of a public health strategy. We shall seek to improve the health of people in Wales—

Mr. Deputy Speaker (Sir Alan Haselhurst)

Order. The Minister will have to give way now, because we must move on to the next subject.