Health Authorities (Norfolk) (Hansard, 16 January 1998)

§ Dr. George Turner (North-West Norfolk)

In his introduction of what I believe was a landmark White Paper on the national health service, my right hon. Friend the Secretary of State declared that it was a step to

break down the Berlin wall between health and social care, so that patients get swift access to care and treatment rather than being passed from pillar to post."—[Official Report, 9 December 1997; Vol. 302, c. 796.] The motivation behind my debate today is that, in my part of the country, in north-west Norfolk, we need to break down not only a Berlin wall but, possibly—to fit in with this morning's debate—Hadrian's wall and Offa's dyke, originally intended to keep the Scots and Welsh out. Certainly, there is not only one wall involved in the provision of health services in north-west Norfolk.

The Berlin wall I would liken to the wall that stands between Norfolk county council and the health authorities with which it has to deal, of which there are two rather than the normal one. The North West Anglia Commission, the health authority in which my constituency finds itself, has a Hadrian's wall between it and the county of Cambridgeshire, while Offa's dyke is now being constructed as Peterborough moves into one unitary authority.

I should like the Minister to encourage those of us in my part of Norfolk to break down the walls. The White Paper provides good reasons to do that in terms of the operation of the health service and the provision of better care at the front end. At the same time, in the process of encouraging us to demolish those walls, my hon. Friend should allow us to move £2 million from bureaucracy into the front-line provision of patient care.

As I looked into the details of what is happening in my constituency, I was struck by the fact that the problem occurs not only in Norfolk. If, in Norfolk, there is £2 million that is now being spent on administration that could be spent on patient care, there are similar sums to be found in Kent, Lancashire, Hertordshire, Surrey, Devon, Hampshire and Cheshire. I have named but a few other counties where the boundaries of the health service are not coterminous with the boundaries of the county council and the provision of the main services, particularly social services, within which the White Paper envisages the development of further co-operation and partnership.

My constituency falls within a health authority that crosses the boundary of two counties. Only two counties in the region—the county of Norfolk and the county of Cambridgeshire—are so divided. As a member of the local authority of Norfolk, I was a vigorous opponent of that. As chairman of the education committee, I was well aware of the inefficiencies of such provision.

The original boundaries that were implemented in 1990 were for district authorities. Even at that time, with a different health structure, those boundaries did not make 664 sense because they did not encourage the partnership that the Government have recognised must be central to progress in the health service. When, in 1995, the Act abolishing the district health authorities considered the introduction of area health authorities as we now know them, there was quite a strong voice of protest at the confirmation of essentially the same boundaries in the move to the new areas.

Much can be said against those boundaries. First, it is difficult for the public to know in which health authority they live. If I tell the House what the boundaries are, hon. Members might understand the problem. Part of the health authority in which my constituency finds itself is in the county of Cambridgeshire, although even that is not easy to define. It is the city of Peterborough and the district of Fenland. In the district of Huntingdonshire, it is the wards of Elton, Farcet, Stilton and Yaxley. If one crosses the boundary into Norfolk, it includes the whole of the borough of King's Lynn and West Norfolk, of which my constituency forms part, but includes also part of the district authority of Breckland. Even then, it includes not all of Breckland but only parts—the wards of Conifer, Hermitage, Launditch, Mid-Forest, Nar Valley and Necton, Swaffham, Weeting and Wissey.

People have to know not only the ward in which they live but, in some cases, their parish before knowing which health authority serves them. People in the ward of Taverner must know whether they are in the parish of Colkirk, Horningtoft or Whissonsett. Those who live in the district of North Norfolk may happen to be in the one ward—that of Raynhams—that is in my health authority.

It is a nightmare for public perception, openness and communication with the public, and for public understanding of the health service. People feel that, to an extent, their democratic rights are being removed by the continuation of such false bureaucracy. I need not, in the presence of the Minister, spell out the detail of the White Paper and the case for review. The case for ensuring proper partnership with local government, particularly with the providers of social services, is now well understood. I looked through the debate in Committee that led to those boundaries and noted that Labour Members spoke vigorously in favour of coterminous boundaries with social services providers. It was therefore no surprise to see that the White Paper points out that it is important to encourage partnership. It is recognised that that means review and, in many cases, a reduction in the number of health authorities.

I know from many years on Norfolk county council that the management of social services would benefit considerably if, instead of Norfolk having to discuss matters with two different authorities, it could discuss them with just one. The same applies, albeit to a lesser extent, to the service that I knew best as a former chairman of education. There were certainly no advantages in having to deal with two health authorities within the county.

Practical campaigning issues and the role of the local authorities that the health service White Paper envisages in seeking partnership in health improvement programmes are complicated if we have two health improvement 665 programmes in different parts of the county. There is no advantage to splitting the participation of the district council. Voluntary organisations in the county are disadvantaged, which is why they were among those who protested when the present boundaries were introduced. Family doctors are disadvantaged by the split. The registration of residents in the health authority in which my constituency is located is still carried out by East Norfolk health authority. What a name—East Norfolk. Those who live in Yarmouth know that they live in east Norfolk, but those who live in Thetford or Norwich do not regard themselves as being in east Norfolk. The name and the structure of the health service that we have inherited is inappropriate and has many disadvantages. Whether one is concerned with family doctor services, drug action teams or public understanding, there is no logic in the continuation of the present division of health services.

Equally important—probably more important in the minds of the public—is the fact that, not only are we causing inconvenience to public bodies and those delivering the service by increasing their work load and by complicating the delivery of the health service; we are squandering public money. The Government are proposing legislation to ensure that we have formula funding, which I welcome.

If ever there were a reason to support the boundaries that we inherited, it was because of local squabbles and a fear—particularly during a period in which Norwich was looking for the provision of a major hospital—in some parts that their interests might be marginalised if they were linked with the rest of the county. There was a feeling—founded on fact—that, at one time, those who ran the health service in Norfolk were not fair in how they distributed resources between the east and west of the county compared to the provision for Norwich, the central and important county city.

The problem, which led to some people thinking that there was an advantage in the old arrangement, will be swept aside when we have fair funding which is dependent on population and need—as the Government propose. Whatever reasons there were will have gone away. I have estimated that some £2 million will be available for front-line care if the changes take place.

According to the figures that I have, some £13 million will be spent in the present financial year on administering the management costs for the authorities affected: the Cambridge and Huntingdon authority—including the portion of Cambridge not in the authority which I am in, which is North West Anglia—and the part of Norfolk which is not in the authority that serves my area, which is East Norfolk. The region distributes funding for management costs on the basis of a formula that, understandably, has some fixed costs and a portion that depends on the population served.

In the absence of a detailed investigation, my estimate is that, if we use the formula funding, the money saved by having two authorities rather than three amounts to well over £1 million. The costs to the East Norfolk authority of taking over the administration of the constituency which is my concern showed a saving of £1.7 million. It could well be higher if detailed investigations were done into the costs in Cambridgeshire.

Understandably, the Government will distribute money on a formula basis and not in terms of the boundaries and the amount of costs. There is considerable benefit in 666 moving to new boundaries. I have contacted the Norfolk Members of Parliament to ascertain their views and I have received positive responses from all Labour Members. My hon. Friend the Member for Great Yarmouth (Mr. Wright) wrote: It seems entirely logical and sensible for there to be a Health Authority covering the whole of Norfolk. It would bring us into line with others in the region and facilitate co-operation between key service providers. My hon. Friend the Member for Norwich, South (Mr. Clarke) said: This change would make a real difference to the quality of service people receive across Norfolk and I know it has the support of the community. My hon. Friend the Member for Norwich, North (Dr. Gibson) said:

Our manifesto promised we would cut red tape to put more money into patient care. This is a clear example which would benefit all of us in Norfolk. A change in the boundaries is entirely compatible with the drive to efficiency through a more rigorous approach to performance and by cutting bureaucracy, so that every pound in the national health service is spent to maximise patient care. The Government intend local decision making to be central to any changes that are introduced. When I initiated the debate, I was partly motivated by a leak from the region. According to the note leaked to me, the region was determined not to consult on the preferred option, if the preferred option was to do nothing. There would have to be consultation if change was proposed, but the region did not intend to consult if there was to be no change.

The matter should not be left to those directly involved in the region. The Government should take responsibility for ensuring that, not only in my part of Norfolk but in the nation as a whole, we address the issue of size of health authority. My investigations suggest that we should have larger health authorities. GPs, as providers of primary care, will be able to flex their muscles in the health service and should be given space to do so by avoiding conflict with small health authorities. There is a case for doubling up—for two county-wide health authorities.

There is also a case for ensuring that regional divisions are sensible. If we are to have proper regional government, should not health authorities in the regions also be examined? I shall be interested to hear the Minister's comments.

For the 50th birthday of the NHS, let us have a birthday card with a £2 million cheque attached, by ensuring that the change takes place speedily.

§ The Minister of State, Department of Health (Mr. Alan Milburn)

I am delighted to have the opportunity to respond to my hon. Friend the Member for North-West Norfolk (Dr. Turner). I congratulate him on securing time for a debate on a subject that concerns him and is important to his constituents.

Health services in Norfolk have already featured large in the Department of Health's business this year, which is the 50th anniversary year of the NHS. As my hon. Friend knows, only last week I was pleased to announce the go-ahead of the largest private finance initiative scheme so far in the history of the NHS—the £200 million development of the Norfolk and Norwich hospital.

667 This is one of the first debates of the new year, and the issue that my hon. Friend raises touches on much that is at the heart of the White Paper that we published last month. As he rightly said, the White Paper sets out a 10-year programme of modernisation for the NHS. The proposals in it provide an important context for the debate on the boundaries of the health authorities covering Norfolk.

First, the White Paper ends the internal market in the health service. The internal market was divisive and costly, setting hospital against hospital and doctor against doctor. That system led to the creation of North West Anglia health authority. Part of the rationale for setting up the health authority in 1992, when Peterborough and King's Lynn were merged, was to ensure that it had two district general hospitals that could compete with each other. That is no longer a reason for determining health authority boundaries. With this Government, the needs of patients, not of institutions, come first.

Secondly, in the White Paper there is an emphasis on partnership. We need to break down the Berlin walls between health authorities and local authorities because whether those are Berlin walls, Hadrian's walls or Offa's dykes, they can hinder patient care. The White Paper sets out a range of measures to promote closer working between health and social care.

New local health improvement programmes will be drawn up by the health authority in conjunction with local authorities and other partners. Those will identify the most important health needs of the local population and how services should be developed to meet them, either directed by the NHS or, where appropriate, jointly with other organisations. We propose to strengthen the duty of partnership between all parts of the NHS and local authorities. All those steps should go some way to addressing the issues of partnership between health authorities and local authorities, regardless of where the boundaries lie.

Thirdly, the White Paper sets out a new role for health authorities. They will give strategic leadership on the ground to help overcome the fragmentation that characterised the internal market. One key task will be to support the development of primary care groups so that family doctors and community nurses can help shape services. We obviously want to work with health authorities to streamline their administrative functions so as to release time, effort and, perhaps most importantly, resources for higher priorities.

As my hon. Friend pointed out, that may provide scope for making economies of scale at the health authority level. We are certainly committed to cutting out unnecessary bureaucracy. That is why we are reducing the number of commissioners in the health service from something approaching 4,000 to more like 500. That will help free £1 billion within the health service for investment in the front line.

While there is an appetite for change in the NHS, there is no appetite for upheaval—and certainly not for upheaval imposed from the centre. We want to change the NHS for the better rather than introducing change for change's sake. We certainly envisage that there may be fewer, leaner health authorities in the future and that the type of merger proposed by my hon. Friend may be 668 the shape of the NHS in the next century. However, I should emphasise that there is no question of any change being imposed from here. We are clear that local decisions rather than national edicts should determine the shape of health authority boundaries.

That brings me to the specific question raised by my hon. Friend. North West Anglia health authority was created in 1992 and, as my hon. Friend said, serves the western part of Norfolk and the northern part of Cambridgeshire. This eastern end of the Anglia and Oxford health region is the only part of the region where the health authority boundaries are not coterminous with the county boundaries. Therefore, it is right and proper to raise the issue of its boundaries as the NHS begins to implement the White Paper.

I am pleased to say that the Anglia and Oxford regional office of the NHS executive is currently conducting a preliminary review of the boundaries not just of North West Anglia health authority but of East Norfolk and Cambridge and Huntingdon health authorities. That review will examine whether they are appropriate to serve best the needs of patients in Cambridgeshire and Norfolk—whether they live in Peterborough, Cambridge, Norwich or in the fens around Wisbech and King's Lynn. I emphasise that there is no suggestion that those health authorities have failed to provide effective health care or are badly managed. The review arises because of the issues of coterminosity with local boundaries raised by my hon. Friend.

The hon. Members who represent the people living in those areas—my hon. Friend quoted some of their comments—should have already received a letter inviting their views on the configuration that they believe would best serve their constituents' needs. In addition to the views of hon. Members, the regional office of the NHS executive will seek the opinions of NHS trusts, general practitioners, local authorities and community health councils to see whether they think that change should be explored at this moment. I emphasise that it is only a preliminary review at this stage: the aim is to investigate whether a full-scale review and public consultation are worth while or appropriate now.

I of course cannot pre-empt the outcome of those initial discussions. However, there will clearly be a number of important issues to consider. First, we must be entirely satisfied that any changes would benefit the people of Norfolk and Cambridgeshire. We want to ensure that the needs of patients and not institutions are put first. Secondly, we shall need to take account of future changes in the local authority boundaries as well as the existing boundaries.

From 1 April, Peterborough will become a unitary council, running its own social services department separate from Cambridgeshire county council. That means that, even if the health authorities reverted to the county boundaries, there would still not be coterminosity with social services departments. That is why it is so important that, at the same time as considering organisational changes and coterminosity issues, health and local authorities must look at how they can improve their working relationship, regardless of the boundary issue. Thirdly, we must be satisfied that any benefits arising from reconfiguring the health authority boundaries are not offset by the disruption caused in achieving that change.

669 Once the preliminary review is completed, a report will be made to the regional director of the Anglia and Oxford regional office of the NHS executive by the end of March. If there is a full review, my right hon. Friend the Secretary of State will have to make a decision in the summer, to allow the necessary changes to be in place for April 1999. In those circumstances, I shall have to be circumspect in commenting any further about any possible reconfiguration.

670 I can say that whatever the final decision, my hon. Friend can be assured that it will be taken in the best interests of the patients living in the area concerned. If there are specific proposals for change, there will be proper, open consultation, to which I am sure my hon. Friend will make a valuable contribution.