§ Dr. Richard Taylor (Wyre Forest)
I greatly enjoy debates in this Chamber, because there is a seat for me, bang in the middle between the two warring factions. I am particularly delighted to see the Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), because the document that has sparked off this debate, "Keeping the NHS local—a new direction of travel", reflects something she wrote in September 2001 that I often quote. As I am sure she remembers, she wrote:The culture within the NHS needs to change so that the views of patients and citizens are not only valued but listened to and acted upon as well.I had been rather sceptical about that, but now we have a document that provides strong evidence that the Government are listening and are prepared to act on the views of citizens. I would go so far as to say that some of us could have written the document almost as well as the Department of Health has.
In the time available, I will touch on three topics: the key messages from the document, with reactions from some groups; an outline of some of the difficulties the Government will face as the champion of the people, to whom the NHS belongs and who pay the staff salaries; and a brief mention of local situations. I hope to finish two or three minutes early to allow another hon. Member to speak—with your permission, Mr. Deputy Speaker.
Mr. Deputy Speaker
I am grateful to the hon. Gentleman for mentioning that another hon. Member wishes to speak. In a personal debate, it is normally the form that any additional hon. Member wishing to take part in the debate should not only get the permission of the owner of the debate—in this case, the hon. Gentleman—but that of the Minister and the occupant of the Chair. I have made the point.
§ Dr. Taylor
Thank you, Mr. Deputy Speaker. I apologise.
I can pick out only a few key messages. First, the document recognises that patients want more, not fewer, local services. It encourages the NHS to workin a new stronger partnership with the public and staff to find high quality, sustainable solutions for local services, and deliver the agenda for reform.The document describes what consultation should be, stating that consultationwith patients and the public, and with staff, needs to begin right at the outset— before minds have been made up about how services could or should change.That makes a delightful change from some of the mockeries of consultation that we have seen.
One of the core patient principles—the word is patient, not NHS or staff principles—isdeveloping options for change with people, not for them".The document also recognises that patients will accept the need to travel for high-powered specialist services, but not for bread-and-butter services relating to common emergencies. That fact was picked up by the Nuffield Trust in its 2001 publication, "Local medical 53WH emergency units". Referring to Downe hospital in Northern Ireland, which was due to be drastically downgraded, it acknowledged that people would not budge from their resistance to the removal of basic local emergency services. A pilot involving Downe hospital and hospitals in Belfast, which is intended to work out a partnership arrangement that will work, is mentioned in the document.
There are major messages about changes in the roles of clinical staff, involving teamwork within hospitals, networking with other hospitals, the information technology necessary for communication, different ways of covering night work, balancing generalist and specialist work and, most important, integrating primary and secondary care. I have time to mention only two reactions. The Royal College of Physicians has made a brief comment, prior to making a much more detailed one, that welcomes the challenge of improving the NHS and looks forward to responding to the document in detail. It pleases me by stating that the document recognises the need to balance three carefully chosen concepts: convenience, humanity and safety. Those words say an awful lot. The Royal College of Physicians also points to the difficulties, which I will deal with later.
The only contrary view of which I am aware was expressed in a letter to The Times on 18 February. The chair of the junior doctors committee of the British Medical Association obviously fears that the document is politically inspired and will be to the detriment of hospital services. I do not take it that way at all. The document is a very definite example of the Government listening to people. If it was inspired by the ballot box, so be it—perhaps that is the function of the ballot box.
The first difficulty is medical staffing and the European working time directive, which cuts junior doctors' hours dramatically. I cannot help wondering how continental European countries will cope. Will they be bound by the directive as tightly as it seems we plan to be, or will they turn a blind eye to some of it? At one of the public meetings of the Select Committee on Health not that long ago, we were talking about the European working time directive and a senior civil servant said that there was "a plurality of solutions." He did not give details of that plurality, but the document mentions some of the solutions. I hope that the Minister will tell us a little about them and say whether the pilot schemes are compatible.
A crucial difficulty in relation to the European working time directive is the way in which we cover continuity of care. In its initial comment, the Royal College of Physicians stated:Continuity of care will be one of the greatest challenges for the new NHS.It is easy to reminisce about the time, relatively few years ago, when people worked with their own teams and continuity of care was natural. I realise that that has gone and is impossible to recreate, but I hope that it might be a little more possible in some of the small units that are to come.
The second big difficulty is financial. Despite the extra money that the Government are putting into the NHS, primary care trusts will have little, if any, money for development, and both overspending and underfunding will be a problem. The primary care trusts are also 54WH overstretched managerially. I hope that the Minister will tell us whether the GP contract, if it is accepted, will help the smaller hospitals by making it more possible for GPs to cover some of the night-time work.
The third difficulty is information technology. The Royal College of Physicians puts it rather nicely. It says that the document reflectsperhaps an optimistic view of the benefits of the early application of information technology in the NHS.My plea is that we concentrate on IT that actually works. We know that digital X-ray services work. I would be very grateful to know the proportion of trusts that have such services, because they are by no means widespread.
§ Andrew George (St. Ives)
The hon. Gentleman is making a very important point. I congratulate the Government on putting £250,000 into the West Cornwall hospital pilot study on the reconfiguration of local services. I am a stakeholder member of the steering group for that project. To pursue the hon. Gentleman's point, does he agree that it is important that emergency services are as close to home as possible? If information technology services cannot provide back-up to small hospitals, we need a system whereby staff from larger hospitals are rotated to give smaller hospitals adequate staffing cover and to ensure that emergency services are properly supported.
§ Dr. Taylor
I do not mean to imply that information technology can wholly replace the presence of emergency services in a community. I am simply saying that the digital transmission of X-rays actually works.
My last point is about local situations. The sites of the pilots that have been set up—in Penzance, to which the hon. Member for St. Ives (Andrew George) referred, in Downe hospital, Northern Ireland, and in Bishop Auckland hospital—make me absolutely green with envy, because they are all so much better than what my poor constituents have. The document recognises that unsympathetic, drastic downgrading of an acute general hospital does not work. In a sentence that was excluded from the final version, a draft of the document acknowledged that, in some cases, local access to hospital care had suffered as a consequence. I am not surprised that the sentence has been left out.
Sadly, in Worcestershire, everything is happening as predicted. Waiting times are rising, ambulances are queuing more, stressed staff are walking away, there are insufficient staff and beds, and the elderly are frightened. Two and a half years after the downgrading, the flow of letters to me continues. However, hope has been rekindled for the rest of the country and even for Worcestershire by this document.
I conclude with two quotes from the document. The first is thatthe objective is to provide as a minimum a "first port of call" (a service able to receive and provide assessment, initial treatment and transfer where necessary)".That is described as a minimum. The pilot areas will have that minimum—that first port of call; other areas will not, but should have it. Secondly, the document is aboutworking with local communities and staff to rebuild local services around local needs.55WH I thank the Department of Health and the Minister for recognising that local people need local services, and for acting on behalf of citizens and the public to try to make an incredibly difficult compromise work.
Mr. Deputy Speaker
Before I call the hon. Gentleman to make his point of order, I wish to tell the hon. Member for Wyre Forest (Dr. Taylor) that I might have advised him incorrectly. If an hon. Member wishes to intervene during a half-hour Adjournment debate such as we are having, they may do so. Whether to give way is entirely up to the hon. Member who is speaking. It is only if an hon. Member wishes to participate in the debate that he or she must seek the permission of the Minister and the occupant of the Chair.
Uniquely, I shall allow the hon. Member for Cotswold to raise a point of order. I believe that hon. Members will understand why when he has given his short address.
§ Mr. Clifton-Brown
I apologise to you, Mr. Deputy Speaker, and to the House. I spoke in the debate on rural housing, but forgot to declare my interests before I spoke. I am a fellow of the Royal Institution of Chartered Surveyors and own rural property, although I do not believe that it will be affected by the debate. I should have declared my interest.
Mr. Deputy Speaker
The House is grateful to the hon. Member for Cotswold. He has proven himself to be a truly honourable Gentleman.
§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I genuinely congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this debate on reconfiguration of hospital services. I am aware of his keen interest in health matters, not only in his own constituency but across the wider canvas. From the quotation that he used to start the debate, I know that he is aware of my personal commitment to making sure that citizens, the public and patients have a real role in shaping their future health services.
I am delighted that the hon. Gentleman welcomes the publication of the guidance "Keeping the NHS local—a new direction of travel". He rightly highlighted that it challenges the "biggest is best" mindset in respect of hospitals and hospital services, which we in this country have perhaps suffered from for many years. We believe that the twin opportunities offered by technological change and changing workforce roles—including developments such as new equipment, new information technology, telemedicine and other new technologies that are coming on stream, alongside the changing work force roles and the new issues relating to the skills mix, whereby nurses are beginning to do things that only doctors did and doctors are doing things that only consultants did—will enable us to design services in a very different way in future. They also open up a new range of possibilities for smaller hospitals, which are dear to the hearts of many local communities.
56WH I must make it clear that the guidance is not a blueprint for hospital design. If it were, it would almost defeat its own object, because talking about keeping things local means that solutions must come from local communities themselves, so that people feel a real sense of ownership and that they are stakeholders in the design. What the guidance does is try to empower the NHS to work in partnership with local people and to decide together what range of services will meet the needs of that community.
The guidance has three core principles that will in future underpin everything that we do in this field. The first principle is that options for change should be developed with patients not for them, and that before we even start to formulate preferred options, we have a sense of sitting down right at the outset to design what services should look like—their essential features—and where they should be. In the NHS in the past, a preferred option would emerge and people were presented with it almost as a fait accompli. Consultation was sometimes simply the expiry of a period of time, people would do the first thing that they had thought of, and the process was not altered by the involvement of the public. The first underlying principle is that we develop proposals for change in consultation with local communities and that we start at the outset to think about what service redesign should look like.
§ Mr. Peter Luff (Mid-Worcestershire)
My constituents will be encouraged to hear what the Minister has just said. Will the principles that the Minister has just underlined be expected to apply in the consultation at Evesham community hospital and in every circumstance, or is that an ideal approach that will not always apply? Do the Government expect it to apply to every consultation on hospital developments?
§ Ms Blears
If the hon. Gentleman listens as I develop the argument, he will see that they are core principles that underpin the whole thrust of our future policy development.
The second principle is that, where possible, services should be redesigned rather than relocated. That is a really important statement, because it means that we will look at services rather than at shifting them around the area. We will consider how services can be redesigned, and ways in which to get consultants to come out of hospitals to do things in local communities and the primary care sector rather than expect patients to travel to where the services are. It is a shift in the balance of power towards the people who use the service rather than the people who provide it. There are important constraints, which the hon. Member for Wyre Forest has mentioned, and I will try to deal with them.
The third principle takes a view of the whole system, not an isolated part, and looks at the networks between different institutions. To an increasing extent in areas such as cancer services, people receive services, including diagnostics, screening, treatment or palliative care, in as many as three or four different places. The aim is to look at the patient pathway across those different institutions rather than simply at the bricks and mortar of the institution that has provided care in the past. We want to take a whole systems view and look at genuine integration and joint planning to see who can bring what to the overall design of services.
57WH The first principle, involving patients and the public, is now underpinned by a new legal framework. Last year, I was delighted to introduce the new system for patient and public involvement. Despite being the former chair of a community health council, I am absolutely convinced that the new service will be more vigorous and vibrant and will get patients involved in service redesign. We now have a legal basis for that framework in section 11 of the Health and Social Care Act 2001, which places a duty on the NHS to make arrangements to involve and consult the public in everything that it does. Under that new statutory framework, the NHS has a duty to involve the public in planning and developing services and in making decisions about how services will operate.
That is a world away from the old system in which people were left with the options of complaining after the event or objecting to a proposed service redesign. It is difficult to get one's views heard when a decision has almost been made and one is on the outside saying, "This should not have happened." We all know how difficult that has been, whether the complaint has related to the process or to the merits of a proposal. If we can get people involved in designing services, community involvement should be vastly increased by the time we reach the decision-making stage.
§ Andrew George
Despite all that, what can the Minister say to reassure our constituents about the delivery of emergency services? Consultants have shown a tendency to retreat from local hospitals to a few large centres. What can the process she describes do to reverse that trend?
§ Ms Blears
I direct the hon. Gentleman to the document that we published last year, "Reforming Emergency Care", which emphasises the need to take a whole systems approach. Emergency care is not only about what happens in accident and emergency. About 40 per cent. of people who turn up at A and E could be better served in primary care, by community mental health teams, crisis teams or access outreach; and some of the capacity problems in A and E are the result of delayed discharges at the other end of the system.
Whole systems redesign is the third principle of "Keeping the NHS local". We must look at the patient pathway and find out which services are most appropriate for the person who needs emergency care, primary care, acute care, residential social care, outreach care or community care, then put those services in place around the patient. We should engage consultants in the whole systems redesign, rather than see them as part of the bricks and mortar of the A and E department and a separate part of the system. If the hon. Gentleman looks at that document in detail, he will see that the emergency care networks that are being established throughout the health service bring together primary, secondary and community care.
We are publishing guidance entitled "Strengthening Accountability" to put flesh on the bones of the section 11 duty. That guidance and the document "Keeping the NHS local" provide two powerful tools to ensure that the new way of working will be embedded in the NHS. The guidance contains some really good practical suggestions for people in the health service. It is all very well for the Government to say, "You must do this or 58WH that", but we also have a responsibility to give people good practice cases so that they can share good ideas about practical ways in which they can make a difference.
The Health and Social Care Act has given new powers to local authority overview and scrutiny committees. As the democratically elected representatives of communities, local authorities will have the opportunity to look at reconfigurations to see where there is conflict. I urge local authorities to become involved at the outset in the service redesign process so that we can minimise the occasions on which there is real conflict. In addition, there is the independent reconfiguration panel. On 14 February, we announced eight members of the panel and we expect to be in a position to make the final appointments shortly.
The panel, chaired by Dr. Peter Barrett, will offer another means by which the voice of the patient can be heard. The panel will use the two documents—"Keeping the NHS local" and "Strengthening Accountability"—as the basis for its considerations. It will look at how patients were consulted and local people were involved. It will ask whether that process was real—did patients have a good opportunity to participate, or was it a matter of two public meetings held on a Thursday night in a far-flung part of the area that nobody attended? The independent reconfiguration panel will take a pretty robust look at the involvement processes and will also set great store by "Keeping the NHS local".
The panel will look closely at whether NHS bodies and their partners have incorporated the three core principles that I have described. There is a series of checks and balances in the system to ensure that there is not merely a headline message, but permeation through every part of the service.
§ Matthew Green (Ludlow)
That is a welcome announcement, but for Kidderminster hospital, which serves about 15,000 of my constituents, it is six years too late. If only what the Minister describes had been in place six years ago. Is there anything in the document that might encourage health authorities and primary care trusts to consider bringing back some services that were wrongly taken away?
§ Ms Blears
I shall mention Kidderminster hospital al the conclusion of my remarks. There are great grounds for optimism, and I urge the hon. Gentleman to consider matters in a more positive light.
The process of redesign is near the top of the agenda for all primary care trusts. In their commissioning processes, they will look at how services can be redesigned. PCTs have 75 per cent. of the budget and are in the driving seat when it comes to asking what local services should look like. PCTs are increasingly developing their skills in process redesign, which is new for them. The best PCTs now have skilled people who are looking at the patient pathway and asking, "How can we redesign our services to have more things at primary care level than in the acute sector?" There is now the money to make those commissioning decisions a reality. Again, we have put in place not only the ideas but the tools to do the job.
Let me explain about the pilot projects. At West Cornwall hospital, people are looking together at the emergency services. Specialist medical staff from Truro 59WH are advising via a telemedicine link so that more people can be kept in the local area. Clinicians in Penzance and Truro will make the decisions together on whether someone needs further treatment, and then refer them without a further wait in A and E. The second pilot is at Bishop Auckland hospital, where emergency medical care and critical care is being looked at, but only in relation to elective surgery. Those involved have to depend on networking between the three neighbouring institutions—Bishop Auckland hospital, Darlington Memorial hospital and University Hospital of North Durham—and see how those networks develop. The third pilot is at Central Middlesex hospital, London. That hospital provides both emergency medicine and emergency surgery, and is strongly reliant on networking with neighbouring sites for critical cases. There are new series of networks there.
The pilots illustrate the whole systems approach to service redesign. We want to learn what the good things are and what the problems are. We recognise that the processes are not easy to go through. The hon. Member for Wyre Forest has mentioned three imperatives: the working time directive, continuity of care, and funding. Those are serious issues. We can learn from the pilots how to provide services in a smarter way, rather than sweat services more so they produce more. We have lessons to learn.
We are putting in place a major independent evaluation of the pilots. The NHS research and development programme has just advertised in respect of that evaluation. We are really keen to learn the lessons, and we want them to provoke discussion and debate across the health community to see what we can learn.
60WH The hon. Member for Wyre Forest and the hon. Member for Ludlow (Matthew Green) are concerned about Kidderminster hospital. The guidance does not say that we should go around unpicking decisions that have been made. The health service develops and thinking moves on all the time. We shall probably move on from the pilots as we develop the process. However, the decisions made on services at Kidderminster hospital have led to substantial new investment, including £13 million to develop a state-of-the-art diagnostic and treatment centre, an ambulatory care centre, a modern minor injuries unit, a primary care centre, outpatient clinics, operating theatres with 23-hour recovery facilities, and radiology facilities, including X-ray and a computerised tomography scanner.
Those services are not all in place yet, so I entirely understand why people do not feel as confident as they might do. I urge both hon. Gentlemen to help the new services at Kidderminster hospital to get established. Now is the time to start to work with those services and to look to the future. When the new facilities come on stream, both hon. Gentlemen can play a real part in encouraging the people in the local community to have confidence in their health services. They can continue the debate on service redesign so that we get services that meet the expectations and aspirations of that community. I know that both hon. Gentlemen want to lead on these issues in the local area, and I urge them to join me in ensuring that we help local people to make the most of the benefits on offer.
Mr. Deputy Speaker
I am grateful to the Minister for her reply. We now move to today's final debate in Westminster Hall, on a subject initiated by the hon. Member for Stafford (Mr. Kidney): the future of farming and food in Staffordshire. I welcome the Minister for Rural Affairs and Urban Quality of Life to Westminster Hall for the second time today.