§ 4 pm
§ Tom Brake (Carshalton and Wallington)
I welcome the opportunity for such a timely debate. Much is happening in the national health service economy locally, and I know that my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) will seek to catch your eye, Mr. Cook—provided that I do not speak for too long.
First, I would like to raise the subject of the review of Epsom and St. Helier trust hospital services in Sutton and Epsom. I support much of what is proposed; the modernisation of hospitals and a new approach to delivering health care within the community is welcome, provided that it is properly funded and does not lead to the loss of essential services. The trust would like to make changes; it does not want hospitals that are too full, that often treat patients who would be better cared for outside the hospital or closer to home; nor does it want long waiting times, operations being cancelled and so on—things that I and my hon. Friend, too, would like changed.
A key element in the proposal is for there to be significant investment in primary care—that is care provided in the community by GPs, health visitors, district nurses and so on. That, too, I wholeheartedly support. It would lead to many more services that are traditionally hospital-based being delivered locally through other services such as care centres, community hospitals, or whatever one chooses to call them.
I assume that that proposal is in line with Government policy. The Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears) nods her head. If that is so, I would be interested to know how capital will be raised for the project and what guarantees the Government will give the project as it develops over the next seven to 10 years. I hope that authorisation will be quickly forthcoming at each decision-making point. I would also like the Minister to explain a little of the process that will be used to rank that proposal against the myriad of other proposals that will be seeking access to private funds—or Government funds, should any be available.
Finally, I wonder whether the proposals will be put at risk or jeopardised by the current financial position of the trust, as it has an overspend of f 1.6 million. Will that affect the proposals?
The most visible impact of the proposals, should they come to fruition, will be the reorganisation of hospitals, the provision of cottage hospitals or community hospitals and—this is highly likely—the provision of a single acute centre. My family and I live in my constituency. Both my children were born at St. Helier hospital. We have made regular use of its children's accident and emergency department; and we were very happy with the level care provided on every occasion. My personal preference would clearly be for the acute hospital to be built on the site of St. Helier's. Although the building has served its purpose, it is not ideal in this day and age. However, it is important that arguments about where the acute hospital will be rebuilt do not detract from the priority that must be given to providing the best-quality patient care. Clearly, that will include 127WH several factors, not just accessibility but also the experience of medical and other staff, the availability of consultants, doctors, nurses and so on.
So far, there has been reasonable consultation involving different organisations and I am satisfied that the process is moving forward in an organised and acceptable fashion. That contrasts with some concerns that I will raise shortly about at least one other local health care organisation that needs to be more open in the way it operates. Whether we are considering these plans or primary care trusts, it is important that the local authority is in a position to perform the scrutiny role. I understand that to recruit one health policy officer would cost in the region of £35,000, something that my local authority and others who will want to do the job of scrutiny properly will find it difficult to fund. Will the Minister use this opportunity to confirm that any funds that will be available as a result of disbanding community health councils will be passed to local authorities so that they can perform that role effectively?
I highlighted the longer-term plans for the Epsom and St. Helier trust, but there is a shorter-term matter that causes concern: the possibility of cuts within the trust. The budget of the Sutton and Merton primary care trust, the local PCT, will rise by 30 per cent. between now and 2006. Although the headline figure is good, compared to other PCTs the picture is less rosy, especially as the Epsom and St. Helier trust is recovering from a poor report from the Commission for Health Improvement and poor star ratings, which have improved in the most recent league table but need to carry on moving in the right direction. I want the Minister to explain what safeguards, if any, are in place to ensure that if the pendulum swings very far in the other direction in terms of the shift to primary care, the acute services do not suffer as a result.
There is one local difficulty in relation to the Epsom and St. Helier trust—the fact that one of the Surrey primary care trusts is not pulling its weight in terms of the financial contribution that it is expected to make; there is a shortfall of a couple of million pounds. Can the Minister say who should play an arbitration role in such disputes, if one PCT says that it will not provide funding but the others will? Someone needs to be able to step in and sort out the mess.
I come now to the openness of the decision-making process in respect of the Sutton and Merton primary care trust. The community health council has been talking with the PCT for several years about the need to be more open, particularly after the Nelson and West Merton PCT was set up. However, there has been a backward step in terms of accountability and openness, as the executive board of the PCT meets in private without any lay people or representatives of the CHC being present. Locality committees, which operate at a lower level, are responsible for drawing up a local development plan, but I understand that the CHC is not involved and apparently NHS solicitors have been asked to consider the matter. Will the Minister comment on the apparent lack of openness and accountability and say whether she supports action to ensure that the PCT is opened up to greater scrutiny?
128WH Dental health care locally and the number of five-year-olds with decayed, missing and filled teeth are an issue. The figures are going in the wrong direction: the number of children suffering from dental decay has increased at a time when the targets for access to dentistry have apparently been met. I hope that the Minister will comment on how that can be the case.
The transfer of the renal transplant unit is also an issue. There are proposals to move some services from St. Helier to St. George's, but I understand that it has recently been shown that the cost of the upgrade that is needed at St. George's to accommodate the transferred service has increased significantly. I wonder whether that means that the plans have been put on hold or whether it is more likely that the service at St. Helier will be retained and the services at St. George's possibly moved there.
Bed-blocking is another issue. My hon. Friend the Member for Sutton and Cheam may have time to raise the local authority's concerns about the impact that the charges will have on the relationship between the PCT, the Epsom and St. Helier trust, and other health organisations. It is good, but could be affected by the charges.
I hope that the Minister can provide clarification on those points, either now, or shortly in writing.
§ Mr. Paul Burstow (Sutton and Cheam)
I congratulate my hon. Friend the Member for Carshalton and Wallington (Tom Brake) on securing the debate and selecting this topic. It is a timely debate on the important issue of health care provision in our constituencies and, indeed, in those of a number of other hon. Members present.
I declare a personal interest in that my family has used and benefited from the accident and emergency department for children and the maternity facilities at St. Helier. I therefore have direct experience of them and pay a warm tribute to the hard work that the staff do on behalf of the public, not only in the acute trust, but across the whole health economy in Sutton.
I welcome the increased funding that has been made available for the next three years. It provides a basis for stability of planning. There will always be questions as to whether the funding is adequate, and inevitably I make the point that it is one of the lower increases, but there is extra investment, which is one of the measures that I voted for in the Budget last year.
That said, we must place in a financial context the proposed clinical strategy that the acute trust has been working out with others, not least because at month six the Epsom and St. Helier trust reported that its financial position was an overspend forecast at £1.639 million. I have spoken to the trust more recently to get a fix on the current estimates for the overspend by the end of the financial year, and the figure is about £2 million. That is a serious, ongoing problem for the trust.
As my hon. Friend said, an additional problem is caused by the East Elmbridge and Mid-Surrey primary care trust not picking up all its responsibilities and obligations in terms of the money that it should be paying to the acute trust. That gives an additional financial problem of £2.15 million to the director of finance at that trust in balancing the books and making everything add up.
129WH Those very real pressures make delivery of the trust's clinical services strategy more difficult, particularly the transition that is inevitably involved in the document, in that there is a move from what is in a way a centralised system, under which most care is provided within the acute trust's main buildings, to a more decentralised approach and the use of care centres. That will involve questions such as whether there is dual running of services while we move to the new system and build confidence in it. Where will the money for that come from, given that the trust has to recover its financial position and deal with the £2 million overspend plus the funding difficulties relating to the PCT? It will prove difficult for me, as a Member who last year voted for the tax increases to fund the investment to the NHS, to have to explain to my constituents why later this year my acute trust may have to make cuts in its services to bring its budget back into line. That will be a rather difficult story to tell, but I hope that the Minister will be able to help by providing some answers that I can give to my constituents.
My hon. Friend the Member for Carshalton and Wallington raised the question of accountability and the transparency of governance of the Sutton and Merton PCT, and I strongly endorse his comments. However, I want to raise briefly the development of systems for new patient and public involvement in the NHS, in particular the Commission for Patient and Public Involvement in Health, which has been told by the Department of Health that it will have only one office in each strategic health authority. How on earth will that one office support all the patients forums in an area? Will the Minister tell us how that will work? Furthermore, why are community health council staff not being transferred to the new structure under TUPE, and why has no budget been announced for the work of that important local body? Why does it appear that local CHC members are being left out in the cold in the development of the new structures? Surely their experience, expertise and knowledge should not be lost to the new structures. It should be garnered and used to ensure that they work.
Sutton needs its own commission office to ensure access for patients and the public. I hope that the Minister will be able to respond to my points and those made by my hon. Friend the Member for Carshalton and Wallington.
§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I am delighted to respond to the debate and I congratulate the hon. Member for Carshalton and Wallington (Tom Brake) on his openness in welcoming the process that has been undertaken in drawing up the clinical services strategy. I can reassure him that the process has been designed to build on the views of patients, the public and the people who use the services in his community.
I have explored the matter with some of the officials responsible and am heartened that the process has been worked from the bottom up—by asking people what the service should look like in the future and then trying to design the service around their views. That contrasts with the previous process, which took place a couple of years ago and started from the bricks and mortar. It examined the hospitals and institutions that were 130WH already in place and the physical location and then tried to design a service from the top down. This process has been different, and there has been a genuine attempt to involve all local stakeholders, including primary care trusts, patients and local authorities, in designing the service. It is at the beginning and is about setting a vision. As both hon. Members have said, it is designed to be developed during the next seven to 10 years, so there is a long way to go in the practical implementation.
The process has been something of a revolution, as the service contemplates many more local care centres rather than the dominance of a large acute sector in the health economy. Much of the health service will move to a situation in which local centres cater for between 50,000 and 100,000 local people and provide a much wider range of services than have previously been available in primary care. We anticipate that GPs and other primary care workers will be doing much of the work that has traditionally taken place inside acute inpatient hospitals, and different ways of working, new skills, more investment and equipment, and much more flexibility in the staff who are employed in the local care centres and their skills will be required to bring about the change. The area in question will be a trailblazer, frontrunner and pioneer of a new way of approaching the design of health care services and their implementation. I would like to place on record my congratulations both to the clinical staff and to the health organisation staff on the imagination and creativity that they brought to bear in the process.
It is important that we try to change the way in which services are delivered for two reasons: first, to relieve the undoubted pressure on acute care and secondly, and equally important, to provide patients with the kind of services that they want in the 21st century. That means trying to give them the right care, in the right place, at the right time. That has not always happened. In future, patients will be more demanding. They will want services provided more quickly. They will want higher standards and they will want to choose which services are provided in their areas. That is exactly what the changes are designed to achieve.
The services in this area are the responsibility of Sutton and Merton PCT. The hon. Member for Sutton and Cheam (Mr. Burstow) was gracious enough to welcome the massive increase in investment that is going into the PCT. It is something like 30 per cent. over the next three years—a significant increase amounting to approximately £87.5 million. Although there are still pressures on the service, it will give real space for innovative thinking and new ways of delivering services for the PCT to put into place.
The PCT predicts that it will achieve financial balance in the next year, which is a significant improvement over where it was just a few months ago. As the increases in expenditure begin to feed through, it will be in a much more advantageous position. It is also meeting many of its targets. In some cases it is ahead of its targets. It is doing extremely well. The local hospital, which has gone from zero stars to two stars in the last 12 months, again under a new leadership team, is real evidence that progress can be made. In this Chamber today we are debating optimism, rather than some of the pessimism that may be being debated elsewhere in the House. We can see evidence of progress.
131WH Both hon. Gentlemen raised other important issues. I will do my best to attend to them. I should like to deal first with the two issues raised by the hon. Member for Carshalton and Wallington. He expressed concern about renal services. At present they are not under threat. The new approach that is envisaged is that out-patient and rehabilitation care will continue to be provided locally, as close to patients as possible, because that is where it is most appropriate. People do not want to have to travel miles for their out-patient care. They want rehabilitation if possible at home or in local centres.
Certainly the renal transplantation service will continue to be at St. George's. That is because it is a regional service. This service is not just for the hon. Gentleman's constituents, but for the whole of the south-east. It is therefore important that those transplantation services are looked at in the context of regional services as a whole, rather than this strategy, which looks at services for the people of Sutton and Cheam. That is why the renal transplantation service is not part of the clinical services strategy review.
The hon. Gentleman's second specific concern was the openness of the PCT in his area. That is an important matter. The Government are committed to trying to engage and involve as many local people as we can in decisions about the shaping and development of services and their priorities. Openness is a key factor. I understand that the PCT holds its board meetings in public and the community health council has been fully involved in all the discussions that have led to the drawing up of the clinical services strategy. They are supportive of the strategy and they have had a real opportunity to be involved.
The hon. Gentleman is asking for the professional executive committee meetings and the local management board committee meetings to be in public too. Clearly there is a debate about whether those are decision-making meetings that should transacted with the public, or whether they are management meetings and therefore less appropriate for that kind of public debate. We need to examine that matter to ensure that we get the right balance.
Clearly in any organisation, certain meetings where decisions are discussed will be internal management meetings. However, decisions should never be reached behind closed doors without dialogue with the public so that they can know what the criteria were, how the decisions were reached and what other options were on the table. I will certainly look at the issue that the hon. Gentleman has raised, but it is never as simple as saying that every meeting should be in public or every meeting should be closed. It is a matter of what business is being transacted and the appropriateness of those meetings.
On a similar matter, the hon. Member for Sutton and Cheam raised the important matter of public involvement. He said that the Commission for Patient and Public Involvement in Health would have one office for the whole strategic health authority, and he asked for a specific office for his local area. However, the idea behind the commission is that it is not simply about bricks and mortar—offices or shop fronts where people go to make their views known.
132WH The ethos behind the commission and the system for public and patient involvement is that it will go out to where people are. Again, that is a huge change for the national health service. In the past, we expected people to come and make their representations, which meant that we did not hear the voices of those who would not come to an organisation. Therefore, the commission staff have a specific brief as outreach workers to go out and interact with the local community, to work with the Citizens Advice Bureaux and all the local organisations to get their views. They will not be office based or static, but will be out working in the community. They will also be involved in all the different regeneration initiatives under which similar community development work is being carried out, and will feed views back into the NHS.
It cannot be good enough for the NHS public involvement work to be in a separate, parallel stream to all the other good public involvement work, in which the local authority will be greatly involved. Joining up all those views will be a key part of the commission's work. I ask hon. Gentlemen to be more creative and imaginative about the ways in which community development can work. It is certainly not the case that bricks and mortar offices and shop fronts are needed for people to come to.
The spending decisions with regard to the budget for the public involvement system have not yet been announced, but I can tell the hon. Member for Sutton and Cheam that from 1 January this year, the NHS has a statutory duty to involve the public not only when there is a significant variation in service—in other words, when the decision has been made—but from the very beginning in shaping and developing ideas. A good example of that is happening in the constituencies of the hon. Members for Carshalton and Wallington and for Sutton and Cheam. As they both agreed, the clinical services strategy was drawn up on that basis from the beginning, rather than coming up with a preferred option.
§ Mr. Burstow
Have patients and the public been consulted to ascertain their preferred way of getting access to the commission as part of the process of devising the outreach strategy to which the Minister referred?
§ Ms Blears
Presumably, the hon. Gentleman is in contact with all the organisations in his area that carry out community development work, whether they are the local authority, the CAB or the council for voluntary services. All those groups engage with a wide range of members of the public. There is overwhelming evidence that where public involvement is to be successful, organisations must be flexible and go to where people are, engaging with them in a way that makes them feel comfortable and that it is worth-while to give their time and energy to get decisions taken.
Anyone who has been involved in any community development work will realise that having a static organisation that simply expects people to come to it is not the sort of organisation that is the most successful or that gets the greatest number of people involved in their communities.
133WH The strategy is likely to take seven to 10 years. The hon. Member for Carshalton and Wallington, who initiated the debate, asked whether finance would be available throughout the process to make the proposals a reality. I am delighted that he believes that this Government will be in a position to make that clear in seven to 10 years' time when those proposals may well be realised.
The shift in the balance of power programme is to ensure that the primary care trusts, which will be spending 75 per cent. of the budget, will be taking those financial decisions in consultation with their local communities, and will decide such matters as whether to spend their money on local care centres and what the contents of those centres should be. That process will be on-going to ensure that the priorities of the community 134WH are reflected in the budgets. While the Government are in power, we have been able to invest a tremendous amount of extra finance into those budgets to try to ensure that the vision set out in the clinical strategy has a realistic chance of becoming a reality and providing much better services to people in this area.
The programme is extremely ambitious. I am delighted that it has the support of hon. Members as the representatives of their communities, and I hope that we will begin to see some flesh on the bones in the years to come to ensure that the services are health care in the right place at the right time for people in their local communities. I have no doubt that those services will be of extremely high quality and valued by local people.
§ It being half-past Four o'clock, the motion for the Adjournment elapsed, without Question put.