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§ Mr. David Chidgey (Eastleigh)
The Minister will be aware that Eastleigh is at the centre of various conflicting proposals for primary care trust configuration in south Hampshire. I have advised her office in advance of the main thrust of my concerns. I have also have provided to her details of a particular constituent's case that shows, among other things, the importance of getting primary care trust configuration right.
The local health authority recommendations on the preferred option for primary care trusts will reach the Minister later this month. I accept that she cannot pre-judge the approval process, but I should like to draw her attention to some key factors that should be considered. They include the particular characteristics of my constituency in the context of health and social care, the primary care trust options on offer, the application of Government policy guidelines in judging the options—when they reach her—and the specific issues that Eastleigh primary care trusts must address. Additional factors relate to the provision of national health service dentistry and an appalling case of postcode prescription.
I shall deal first with the particular characteristics of Eastleigh in the context of social and health care. Eastleigh has a population of approximately 120,000, which is settled in the old railway town at the centre, in the suburban northern edge, which contains many London commuters, and in scattered villages to the south, such as Hedge End, Botley and West End. These villages also include Hamble, Bursledon and Netley, which are situated in a rather isolated position on the Hamble peninsula and have particular concerns about health care provision.
Eastleigh's character has changed dramatically over the years, through massive speculative development that resulted in the construction of more than 10,000 extra houses since the 1980s. We are now promised—perhaps I should say threatened with—another 5,000 houses in the next decade. In terms of health care provision, Eastleigh has the problem of lying across two health authority boundaries. Nearly half the population live in the southern parishes and are served by the Southampton and South West Hampshire health authority. The rest live in the north and are served by the North and Mid Hampshire health authority. The 5,000 new houses that are to be developed over the next decade are likely to be sited on the boundary between the two health authority areas. It could be argued that that will make matters somewhat worse.
A comparison with other agency arrangements shows that there is an anomaly in our services. Hampshire county council social services division and the Hampshire constabulary division both embrace all of Eastleigh and Romsey. Eastleigh borough council embraces all of the parliamentary constituency up to the boundary of the Southampton city unitary authority. All the major agencies serving Eastleigh, including central and local government representation, are broadly coterminous, with the exception of health care. That is a key factor in determining primary care trust configuration.
95WH Within Eastleigh's present divided health care provision, there are significant pockets of health care deprivation in what is otherwise a relatively prosperous area. These include Bursledon, out on the Hamble peninsula, and the centre of the old town of Eastleigh. We need to bear in mind that inequality of health care when we consider the primary care trust configurations that are on offer. The Minister will know that the health authority has reduced the number of options to a shortlist of two. I should like to place those options on record. The first is to create four new primary care trusts: New Forest, with a population of 185,000; Southampton city, with a population of 231,000; Eastleigh and Romsey, with a population of 152,000; and mid-Hampshire, with a population 169,000. Option two would create three new primary care trusts: New Forest plus Romsey, with a population of 221,000; Southampton city plus Eastleigh, south, with a population of 277,000; and Eastleigh, north plus mid-Hampshire, with a population of 239,000.
One of the arguments advanced in support of option two, which involves only three trusts, is that it would reduce health care management costs, but, as the Minister knows, those costs are marginal in the overall sense, and in any event management costs do not come out of funds allocated for clinical services. Creating trusts with populations of 250,000 or more hardly squares with a policy of bringing health care decisions closer to the people. How will Government policy and the Department's guidelines be applied to the two options?
As I understand it, the three main functions of primary care trusts are to be: removing inequalities and improving the health of the local community; developing health services through investment to improve quality of care and the integration of services; and commissioning secondary services. A key aim is to reduce the variation in quality of primary care provision.
I want to consider how the primary care trust configuration would work in the context of the national health service plan. Page 1 of the NHS plan summary document clearly states:The purpose and vision of this NHS Plan is to give the people of Britain a health service fit for the 21st century: a health service designed around the patient.Page 2 says that the NHS suffers fromover-centralisation and disempowered patients…The NHS has to be redesigned around the needs of the patient.The Department's circular HSC 1999/167 deals in particular with the criteria that should be used for the assessment of primary care trust proposals. Page 12 states clearly that one should ensure that the proposed organisation hasrobust arrangements in place to ensure it can deliver the 3 key functions of Primary Care Trusts.The criteria will be established through the following questions:Does the proposed Primary Care Trust show evidence of knowledge and understanding of the health needs of local people, including the pattern of health inequalities, and of how to take effective action for change?…Has an effective relationship been developed with local authority organisations (as well as Social Services)…?96WH That is a key point in this particular analysis.
Having examined the Department's circulars and considered Government policy, one does not have to look too deeply to find that option one, which proposes a separate trust for Eastleigh-Romsey, would meet the criteria in full. That option builds on existing interagency relationships within coterminous boundaries and has the support of a wide range of agencies that are keen to work together to develop integrated health and social care provision for the area. Most importantly, it breaks down the boundary of two health authorities that run through the middle of Eastleigh and serve different parts of my constituency. It allows resources to be focused on removing inequalities in health care provision and targets the areas of health and social care deprivation.
I will compare option one with option two as guidance for the Minister, who may not be as familiar with the area as I am. Option two would put half of Eastleigh together with Southampton city; there is no doubt that a trust under that option would be based in Southampton city and would focus on the 250,000 Southampton residents. The 50,000 residents of Eastleigh's southern parishes would be out on a limb, tacked on to the coat tails of a big city. My constituents could be the losers in that relationship, as the priority would be to serve the mass of patients, or customers, that live in the city and are easily accessible for a city-based trust.
I will give an example to show that I am not talking about simple tribal warfare. Under our existing primary care group, in the south of my constituency, which serves south Eastleigh and east Southampton, we have made little progress in establishing a new local health centre in Bursledon to serve the villages. Local health centres for the Southampton city part of that group, however, are well advanced. Clearly, there is real reason for concern about configurations of that sort.
I draw the Minister's attention to a comparison of the unified funding allocations for 2000–01. She will be familiar with the concept of analysing distance from targets of funding; I want to show the effect that that would have on the trust options. Under option one, the parishes in southern Eastleigh down towards the Hamble peninsula would level up under an EastleighRomsey trust, but under option two, southern Eastleigh could level down to match Southampton city. That would not be good news for people in my southern parishes who are looking forward to a significant improvement in the level of available health care. As I said, I realise that the Minister cannot prejudge the situation but I hope that she will bear in mind my analysis, which is based on local knowledge, when considering the primary care trust configuration recommendations.
I turn to two specific issues that come within the framework of PCT options. The first is an appalling case of postcode prescription, about which I have already advised the Minister. It concerns a constituent whom I shall call Steven. I shall quote some letters from his GP that make it clear that we still have a big problem with postcode prescription. The GP said:I am writing to ask for your support in lodging an appeal with the Local Health Authority in Southampton against their decision not to pay for this patient's Clozaril. This is an extremely effective 97WH drug for the management of severe Schizophrenia. Without this treatment Steven would, almost certainly, be a long term hospital inpatient.Steven has multiple disabilities including Paraplegia, severe Schizophrenia. and has Insulin Dependent Diabetes. He is also an Amputee, having lost a leg in an accident… He is also an Epileptic…I recently managed to obtain a written guarantee from the Southampton South West Hampshire Health Authority under the continuing and Care and Community programme that Steven was eligible as a resident of their Health Authority Area for all the Services that are available to any other citizen of this country under the NHS free of charge.It seems to me to be grossly unfair that this most unfortunate individual should be victimised by the National Health Service in this way.It means that his mother—who manages his trust—has to pay £4,500 every year for the Clozaril, in addition to paying for the team of nurses, for his 24 hour round the clock care at their home.In a further letter, the doctor confirmed thatThe decision to force Steven to pay for his medication was apparently made by…a Consultant Psychiatrist at the Royal South Hants Hospital in Southampton. The reason given for this decision was that Steven's psychiatric care is supervised…at the Milbury Unit at the Royal Hampshire County Hospital in Winchester. Steven lives in Hedge End—in my constituency—which is in the catchment area of the South Hants Hospital…It is interesting that the Southampton and South West Hampshire Health Authority agree with my contention that Steven is being discriminated against because he has the wrong post code.The Manager in Primary Care at the Health Authority has confirmed in writing that Steven is entitled to all the facilities, services and medication available under the National Health Service. Unfortunately. the Health Authority no longer has any power to intervene in decisions made by individual Trusts.That is the important point to consider in deciding new boundaries and management processes for the provision of health care.
Finally, I turn to the problem with dentistry in connection with the primary health care trust. As the Minister will know, under the NHS plan, the Government have committed themselves to making high-quality NHS dentistry available to all who want it by September 2001. The plan appears to rely on health authorities as the main drivers of NHS dentists working as part of primary care multi-disciplinary teams, but not within the PCTs, which I find strange. In the context of the options available to Eastleigh, a proposal is being developed to provide an NHS dental access centre in Southampton to serve my constituents in Hedge End, West End and Botley. That surely prejudges the primary care configuration options, within the trust and elsewhere. It is also woefully inadequate as a response to the Government's aim of making access to NHS dentistry available to all who want it. I would like the Minister to look at that in the round when assessing primary care trust recommendations.
I have tried to set out my concerns about the primary care trust configuration as it affects my constituency and I have highlighted an appalling case of postcode prescription. I have also shown that the proposals for NHS dentistry are inadequate. I look forward to hearing the Minister's response; if there is enough time, I may intervene.
§ The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)
It is a pleasure to be back in Westminster Hall after the summer recess; I had forgotten the joys of Adjournment debates. I congratulate the hon. Member for Eastleigh (Mr. Chidgey) on raising the issue of primary health care trusts. Before I respond generally, I shall deal with two specific points that he raised.
I am grateful to the hon. Gentleman for giving me prior notice of the case involving his constituent, Steven. My information is that it is not a case of postcode prescribing, but rather that the patient was originally a private patient at the practice, and subsequently changed to the NHS. It was then a question of the health authority assessing his case. I am informed that, after consideration by the health authority two weeks ago, it was agreed that he would be prescribed the drugs on the NHS. Steven is currently in hospital and on the drug. When he is discharged, he will continue to be prescribed Clozaril by the NHS for as long as it is clinically appropriate. I hope that that is good news.
§ Ms Stuart
I am glad to have cleared that up.
It is important to put on record the fact that NHS dentistry will remain the responsibility of health authorities. It is no part of PCTs. We recognise—as did my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) when he was Secretary of State—that considerable improvements are necessary in this sector. On a national basis, we have funded several projects. One is an £18 million commitment scheme, which rewards dentists for their greater commitment to the NHS. From 2001–02, £35 million will be available to modernise NHS dental practices. Additionally, in the current year, £4 million will go to help dental practitioners give treatment to patients. So far, the Southampton and South West Hampshire health authority has received £639,000 worth of investing-in-dentistry grants, which are intended to improve dental facilities. That has generated an extra 46,000 registrations.
I hope that the hon. Gentleman will be delighted that his area was chosen for one of the personal dental service pilot schemes, which bring together community and salaried dental services. By September 2001, we will ensure on a national basis that, wherever they live, people will be given information on obtaining NHS dentistry. There is still some way to go, but we have provided considerable investment.
The main subject of the debate is proposals on PCT configuration in the constituency of the hon. Member for Eastleigh and across Southampton and south-west Hampshire. I want to consider the proposals in the context of the Government's overall view of the role of primary care.
When we published the NHS plan last July, few of us had any doubt about what was at stake. Fifty years after the NHS was founded, it was under attack from many sides. Its delivery was under attack from patients—and from those within the NHS—who had seen the effects of years of under-investment, too few staff, outdated equipment and crumbling buildings.
99WH Underfunding has hampered the NHS, but so has the way in which the NHS operates—the way it is organised to make people wait; the barriers that prevent efficient use of staff; and the chasm that opens up between NHS and social care. The NHS needed money, but it also needed change. That is what the NHS plan is all about—investment and reform, money and modernisation. The money came at a price—the need to change the way in which the NHS operates.
The result was a plan that set out how the NHS needed to change if it was to make the best use of the new investment. More convenient access to primary care was necessary with more consultations, more tests, more diagnosis and more treatment in primary care settings. Proper priority needed to be given to the major killer diseases like cancer and coronary heart disease. There was a need to end postcode rationing for drugs and to secure better access to hi-tech equipment—the National Institute for Clinical Excellence has played a significant role in that. However, that change can come about only with the full involvement of everyone in primary care.
We have already allocated £54.5 million to primary care groups and trusts this year, to kick-start the expansion of primary care services. Further investment will follow. It is important that those funds are used strategically to develop new services and improve access to primary care. However, although primary care will receive ear-marked funds, those are not the only funds that will affect how services are delivered. More than £20 billion has been devolved to primary care groups and trusts to commission services. That money must be used responsibly.
The creation of primary care groups was a vital step in the biggest devolution of power and decision making ever seen in the NHS. It brought together doctors, nurses, community nurses, health visitors and local people, and put them in the driving seat when deciding how local patients are looked after and treated. We have set up a central programme of support and development to help manage the transition because, as the hon. Gentleman pointed out, the cultures of corporation and of management that have developed over the past 50 years were variable.
For starters—it is close to my heart because I have some responsibility for the use of IT—we have provided £50 million to help PCGs improve their IT infrastructure and data management, so that all the partners in the system can communicate effectively. The national primary care development team was set up to ensure that all PCGs have access to expert advice and support; we did not expect each group to reinvent the wheel but to learn from good practice. We have issued guidance to ensure that all PCGs have organisational development plans in place that are relevant to their needs. That has already made a real difference to patients. I shall give some examples from the hon. Gentleman's constituency.
Money allocated to the Eastleigh, North and the Southampton, East primary care trusts has gone towards training nurses and providing additional hours for triage services in GP practices; extending chiropody and podiatry services to reduce waiting times; and improving access to GPs and primary care professionals 100WH by ensuring that all practices are open 12 hours a day, because access is important. We have also developed a locality care centre to act as a one-stop centre for primary care services, a minor injuries unit and a patient information centre.
Those examples of good practice have been achieved by ensuring better working across boundaries and the development of robust links between primary and secondary care. That, and the more effective direction of resources, has meant improved services for patients, but we have taken it further.
The development of primary care groups into primary care trusts provides an unparalleled opportunity. It will allow local communities to determine the pace of change that is right for them. The system will allow local health professionals to control budgets, which will enable them to shape hospital and community services for patients in their area, and invest in improving the primary and community services provided by doctors, nurses and other local professionals. We must be careful not to talk only of doctors and nurses; we must not forget the important role of others in the chain of care. I am forcefully reminded that 60 per cent. of those working for the NHS are not doctors or nurses.
We want to develop more integrated services between general practice, community services and social services, and give patients better access to healthcare, by identifying which services most need developing. Again, the hon. Gentleman referred to historic inequalities, which must be identified; and some groups will need support to develop. Above all, decision-making must be placed closer to patients, and it must be shaped by the professionals who most often meet patients' needs.
Nationally, 40 PCTs are currently up and running and more than 130 PCGs have expressed an interest in becoming PCTs from 1 April 2001. That is a clear sign that primary care professionals recognise the benefits that becoming a PCT presents to them and to the development of the health economy. In reality, they realise that no other body has the same range of flexibility and opportunities to improve services, and we acknowledge the huge agenda they face.
Organisations such as the national patient access team and the national primary care development team have been set up to support them. They are working closely with PCGs and PCTs to encourage the appropriate management of demand and to enable primary care to play a full role in cutting waiting times. We have also developed a toolkit specifically designed for PCTs to ascertain how well they are doing with referrals, admission rates and lengths of stay and to determine whether that is good, bad or indifferent. Often, people in the health service had no means of comparing themselves with similar providers. Those tools will allow PCTs to measure their performance and compare it with that of others. The hidden message behind that is that, if they are not doing as well as others, they will be able to determine what they need to do to improve their standards.
With that level of support and the additional freedom and flexibility, PCTs will be the key vehicles to drive through our modernisation agenda. In general, PCTs of between 100,000 and 300,000 will be assumed to be of acceptable size. Those that are larger or smaller will 101WH need closer scrutiny. However, I must stress that that scrutiny will apply equally to all PCTs, regardless of size.
All PCTs must meet the same four basic criteria. The first involves a vision. They must be able to demonstrate the need to be a PCT and what will be achieved as a result of that. The second relates to support. They must show that the application has broad local support from all the stakeholders. Thirdly, they will need to show competency in clinical leadership, management capacity, technical systems and skills to manage large budgets and provide community services. The fourth concerns the fact that they must ensure that there will be no detrimental impact on other services or service providers within that health system.
PCTs must be able to balance local knowledge against the capacity to manage the provision of services and the management of resources necessary for delivery. We believe that that will best be achieved by responsive PCTs working effectively together to ensure a cohesive approach to health care across a locality, sharing management resources and requiring co-operation from other local providers to obtain the services required. The starting point for determining a PCT boundary should be the need to ensure a coherent and cogent focus on meeting the needs of all the people living in that community.
We have made it clear that PCTs should seek the best possible coterminosity with other bodies. In fact, while coterminosity is not a requirement to attain PCT status, we continue to encourage the move towards coterminosity between local authorities and all other administrative boundaries. It will be imperative for a PCT to forge effective links with county, district and borough councils in order to perform its health improvement functions.
Coterminosity with social services authorities may also be helpful in enabling the pooling of budgets, which will bring service delivery benefits to all those in the group. Although coterminous boundaries will certainly assist PCTs that wish to enter into pooled budget, lead commissioner or integrated provider arrangements with 102WH local authorities, they are not the only determinant of effective partnership working and should not halt progress in this vital area.
That leads me to events in the hon. Gentleman's constituency. As he said, there is currently one PCT in the area of the Southampton and South West Hampshire health authority—the Southampton, East PCT. It covers the east of the city of Southampton and the southern parishes of Eastleigh borough, which is within the area represented by the hon. Gentleman. It has been operational since April this year. That PCT and the Southampton, Central PCG have recently been the subject of a consultation on a proposal to come together to form a city-based PCT from April 2001.
The consultation exercise is a process designed to allow any interested individuals, groups or stakeholders to put forward their views on the proposals set out by local stakeholders. I am delighted that the hon. Gentleman has made some detailed proposals, which I read again this morning. The Southampton and South West Hampshire health authority will take into account the representations made and consider them carefully before making any decision. I am sure that the hon. Gentleman will have already taken the opportunity to take wider soundings. He made it clear in his letter that he was expressing not only his views, but those of a number of the stakeholders to whom he had spoken.
The proposals are now with the health authority and will be considered at its board meeting on Wednesday 15 November. At the meeting, the authority will also discuss wider plans for the development of PCTs in the remainder of the health authority area, including part of the hon. Gentleman's constituency.
The health authority's recommendations will then be received by the south east regional office of the NHS executive before being passed to my right hon. Friend the Secretary of State for a final decision. Until then, we must remain impartial and must not be seen to be influencing any decision. We must not, and will not, prejudge the outcome of any local consultation.
I am sure that we all share a common desire to ensure that the right services are available to all patients at the right time and in the right place.