HC Deb 12 March 2003 vol 401 cc128-36WH

4 pm

Matthew Taylor (Truro and St. Austell)

Mr. Chairman, I welcome—

Mr. Deputy Speaker (Mr. Frank Cook)

Order. I would be failing in my duties were I not to remind hon. Members that when the House took the decision to hold these sittings it stipulated that occupants of the Chair in Westminster Hall debates should be addressed as Mr. Deputy Speaker.

Matthew Taylor

Thank you, Mr. Deputy Speaker.

I welcome this opportunity to debate health services in Cornwall. I gave the Minister notice of some of the issues that I want to raise because I hope to get her support for some important developments. Some positive things are happening in the health service in Cornwall because of the investment that the Government are making as a result of the relatively small tax increases that allow significant extra funding to take place, which the Liberal Democrats support even if the Conservatives do not. We argued for it for many years; it is the sort of investment that we said was necessary, and it makes a real difference.

First, I shall mention some of the excellent things that are happening in the county as the public want to know what difference the investment is making and whether the health community in Cornwall is responding to the existing opportunities. I reassure the Minister that the health community in Cornwall is working positively as a team; it is a good example to other parts of the country that the three primary care trusts and the two hospital trusts have been working together and building social services in the wider community into their plans.

The Royal Cornwall NHS hospital trust recently went from two-star to one-star status, but there is a lot of good news and the staff do a great deal of hard work. The trust is actively working to meet the key targets. The basis of the star rating assessment is somewhat crude because a small change can make the difference between pass and fail. One hospital trust went from no stars to two stars in nine months as it had been just under its target and then managed just to get over them. Cornwall is not far off most of its targets, with one exception, which I will mention later.

The trust will be reducing the number of in-patients waiting more than 12 months from 238 in April 2002 to none at the end of March 2003. It is on course to meet the target. It is reducing the number of out-patients waiting more than 21 weeks from 385 in April 2002 to none by the end of March 2003. Again, it is on course to meet the key target. It opened a new clinical decision unit at the beginning of March for medical emergency admissions crucially to free up a significant amount of time for the accident and emergency department. Accident and emergency is making big improvements in meeting the target of 90 per cent. of all A and E patients being seen and discharged within four hours. That has been done despite a 9 per cent. increase in the number of people attending A and E in the first quarter of 2002–03 when compared with the equivalent period in 2001–02. Emergency admissions have been running substantially above funded levels. The trust has also had to contend with a 20 per cent. increase in out-of-area treatments over the past five years in accident and emergency for which it is paid in arrears. It is part of the explanation for the financial deficit, which is the one key issue that it has had to grapple with over a longer period of time. I will return to that.

I should add that the trust also met the target for two-week urgent cancer referrals for all patients since September. That is good news. It is working successfully to meet the Government's key targets. In addition, we have the welcome investments of the Well Cornwall project and the Knowledge Spa, a £14 million development in the Royal Cornwall hospital to create a new centre of excellence for education and training and research. It will be a centre of excellence that will benefit patients directly with more high quality staff at the Royal Cornwall hospital trust with the incorporation of the Peninsula medical school as well as the Institute of Health Studies, which will be used for nurse training. That will be a headquarters for research and development and national vocational qualification training. It will be an integrated training centre for all staff.

Additional wards are also coming in. The hospital does very well on some ratings. The latest Department of Health patient environment action team inspection was a great success. The trust was awarded "green light" status, which has only been given to one in six hospitals in England. It is the gold standard, which reflects on the high quality of some of the lowest paid staff within the hospital system. It is not only at RCHT. Cornwall Partnership NHS trust, for example, has been working hard to integrate health and social care services for people with mental health problems. It recognises that as many as one in four households will need those support services, and its work to provide them is very welcome.

I do not want the Minister to get the impression that we do not acknowledge that things are going well. We acknowledge that staff in Cornwall are working extremely hard, still with limited resources and under a great deal of pressure from rising numbers to deliver the goods. One of the greatest pressures on hospitals, and one of the reasons why they struggle—not only in Cornwall, although our figures are particularly high—is the increase in accident and emergency admissions and referrals to hospitals. These have consistently run above the projections, even though they were considered in great detail by experts in line with Department of Health guidelines.

I have one suggestion for the Minister. Will she consider helping to fund some specific research on this issue, linked with the development of the research and education base in Cornwall? Cornwall is particularly appropriate for such a study: first, the problem is quite high and secondly, because it is surrounded on three sides by sea, patients do not come in from surrounding areas. This may be a patient-choice issue as people choose one hospital rather than another. As the Government themselves are trying to work out what is going on, and this is clearly key to the ability to improve treatment times and outcomes and deliver the quality of care that we all want to see with the investment, there is a good case for considering Cornwall for a funded study.

Rather more fundamentally on funding, I should like to raise the strategic outline case that Cornwall has put together involving all the health providers, including consultation with social services as well as the main players within the NHS delivery system. They have all worked hard with the strategic health authority and have had the support of all the county's Members of Parliament. I am glad to say that we received a very supportive response from the Minister in November 2001 when we met her and presented the case for expanding capacity and delivering patient care innovatively in a rural, dispersed county, moving away from all services being centred around Treliske. I am talking not about the community and community hospital services, but the great majority of other services that are centred around Treliske and the Royal Cornwall hospital trust. We are talking about using instead what I used to call intermediate hospitals. I am advised that that is the wrong term: they are diagnostic and treatment centres. That would enable patients to receive better care, delivered nearer to where they live, in a county where no town has more than 25,000 inhabitants.

At present, people have to travel very long distances to receive out-patient care and treatment at the Royal Cornwall hospital trust. The aim is to devolve acute care closer to patients' homes and, in the process, free up beds at Treliske for the more acute care that can be delivered only in a larger district general hospital.

The strategic health authority has before it the first two key bids in that process. One is for further new wards, theatre facilities and diagnosis and treatment equipment, which is very expensive, at Treliske. It is a £9 million proposal. Perhaps even more fundamental, as that is on the existing Treliske site, is the proposal for the first diagnostic and treatment centre at Bodmin. That would include outpatient clinics, diagnostic support, therapy services, day surgery, endoscopy and other primary, community and local care services.

That is preliminary to proposals for later developments on a similar basis at west Cornwall and, in the longer term although not quite on the same scale, proposals for St. Austell, Camborne and Redruth, Newquay and Helston. The proposals would create very good local services for people to receive treatments that currently are available by and large only at the Royal Cornwall hospital trust. They would allow the delivery of increased capacity and therefore the care that is so desperately needed.

I understand that there is as yet no decision on the proposals. There is concern that the decision may be held up because of the process of testing whether the private sector might be able to offer a provider. I am not here to get into a debate about who provides. In fact, Liberal Democrats believe that, providing that new systems of delivery are within the NHS and delivered free, they may be a good idea. It is hard to believe that the private sector is likely to want to cater for the sort of package of services that DTCs would deliver, but if it does, let us not allow that to delay a process that is key to tackling capacity problems in Cornwall and providing better patient care. I hope that the Minister can offer some reassurance about the speed with which the proposals can be decided on, so that we can meet the original timetable for rapid investment and rapid improvement.

The use of DTCs is highly innovative. It has existed in some urban areas, for rather different reasons, but not, I understand, previously in England for the delivery of rural services to meet the needs that we are discussing. I note that Cornwall is doing this with no great support for the extra costs of rural areas, which are perhaps reflected in the proposal. There is now a rural adjustment, which I welcome, bur even the biggest eneficiary—Herefordshire—receives only a 0.6 per cent. increase in the budget above the level that it would otherwise have. Cornwall has rather less.

The next issue that I want to raise briefly relates to the fact that, despite all the progress that I have talked about and the fact that the hospital trust now looks set to meet almost all the key targets, there are real concerns about star status for the hospital, on two grounds. First, perhaps the Minister could help by clarifying how progress to meet these targets will be treated in future assessments, because the Royal Cornwall hospital trust is now delivering 100 per cent. on a series of key targets on which it was previously short, and it therefore cannot go any further in delivering on them. There is obviously a backlog in terms of the history of the figures, which will show that the hospital has moved from not meeting the targets to meeting them. The question is how long it has to live with the backlog in the assessment. Is the fact that it is now meeting the targets sufficient for it to get a tick in the box in future assessments?

Secondly, there is the financial issue. The Minister will be aware that there is a substantial deficit, which is shared across the health community and is not a specific issue for the Royal Cornwall hospital trust. There is agreement in the health community on how to tackle the deficit. The RCHT has an excellent record on deficits: until last year, it had had no deficits in its nine-year history. The Minister will be aware that the deficit relates to the working through of the changes caused by the abolition of the old Cornwall health authority and the financial knock-on consequences for not only the RCHT but the primary care trusts. Nevertheless, the trust knows that it must tackle the deficit.

The trust has agreed a three-year plan, which would entail breaking even next year and paying back the accumulated historic deficit over the following two years. It thought that it would obtain a pass once the strategic health authority had agreed the plan because a plan was in place to tackle the problem. More recently, it has been told that under the resource accounting rules—I do not understand why this should be the case—it has to turn the deficit round in two years, not three. It is therefore set to continue to fail. That has had a significant effect on morale because the trust is doing everything that it has been asked to, is working to a plan—I hope that the plan will be agreed shortly, and should like reassurance on that from the Minister—and is meeting all its targets. It cannot hope to get three stars because of historic problems rather than because of what it is doing now.

That has a crucial impact on foundation hospital status. My concern with that status does not concern freedom for hospitals, which they should be given, or innovative new forms of finance—I am with the Secretary of State for Health on that point, if not the Chancellor. My concern is the potential for a two-tier service if some hospitals get foundation hospital status and some do not.

For this debate, I shall forget about the rest of the country. I am concerned about Cornwall not being eligible to get the benefits that may shortly go to Exeter. That will suck out staff because Exeter may have the discretion to increase pay and to improve terms and conditions. It will also be a visible symbol for people in Cornwall that patients in Exeter will get improvements, which are not available in Cornwall, because of bureaucratic rules rather than because of anything that the hospital, which meets the key objectives, is doing. The matter certainly has nothing to do with anything over which patients or the community in Cornwall have had control. I hope that the Minister can offer some reassurance on that serious issue.

Although I have gone slightly over time, I shall raise a final point. The financial problems relate not only to historic national funding issues in the health service but to the distribution formulae. I will not start a debate about why the formulae are not fair to Cornwall, but I will make one observation: all the other objective 1 areas are deemed to be areas of high social need and have received extra resources as a result. Cornwall is an objective 1 area, which contains the lowest incomes in the UK, high levels of older people and pockets of high deprivation.

We would not have objective 1 status if the community were not deprived, but Cornwall has not been defined in the health budget as such a priority social need area. That relates to the old-fashioned assessments of rural deprivation. Other Departments used to use such assessments, which they have now accepted were not right. The Administration in Scotland has put particular emphasis on extra funding for rural areas. If Cornwall received the same treatment as other objective 1 areas, it would get an extra £18 million. I appreciate that the issue is technical and that I was unable to raise it with the Minister in advance, and I should be happy if she addresses it in writing or in her reply.

4.19 pm
The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)

I genuinely congratulate the hon. Member for Truro and St. Austell (Matthew Taylor) on securing today's debate on important issues. I welcome his support for the new investment that is going into the national health service and the real and tangible benefits, some of which he outlined, that the people of Cornwall are seeing as a result of that investment.

The hon. Gentleman raised important matters relating to the unique nature of Cornwall, which have implications for the health system as a whole. I shall try to deal with each issue that he raised, particularly those concerning funding, the strategic outline case, constraints on capacity, the plans of the local health community as a whole to meet those challenges over the next few years and what the impact will be on the community.

I am delighted to confirm that, as the hon. Gentleman highlighted, all the primary care trusts and local authorities in the area are working tremendously well in partnership with the acute sector. All our ideas for shifting the balance of power, putting the money into PCTs and getting front-line clinicians involved have been illustrated in Cornwall with a real sense of people working together and looking to the future. I am delighted to place on record my congratulations to everyone in the NHS and social services in that area who is working to ensure that the community has joined-up and seamless services.

I shall deal first with the funding issues raised by the hon. Gentleman. He hears us say time and again that investment is crucial and that with reform we can achieve real results. He highlighted some improvements in the area, including a 6.2 per cent. real-terms increase for his local PCT—central Cornwall—this year and a 7 per cent. real-terms increase for next year.

I want to highlight a couple of matters to which the hon. Gentleman did not refer, including a new £5 million clinical oncology centre at Royal Cornwall hospital. I know that services in relation to cancer are still under pressure in the area, but the new oncology centre, which was opened last year, will be incredibly welcome. There has also been an £11 million development at Bodmin to provide a 15-bed centre for continuing mental health care. That area is not often highlighted when dealing with acute hospital sector provision, although mental health provision is equally important to local people. There has also been a £5 million development in Camborne to provide 67 beds for in-patient mental health care. We are not just aiming at targets and getting waiting lists down, but providing community-based facilities in important areas.

The hon. Gentleman referred to the formula and its impact on rural areas. We have tried to make it more sensitive to various measures of deprivation in this year's allocations. We are now using the indices of multiple deprivation of the Office of the Deputy Prime Minister, updated in our formula, which is a more sensitive measure. Such formulas are never perfect because of their complexity and we can all find cases in which they do not meet 100 per cent. of needs, but we are trying to ensure that rural issues are considered. For example, low car ownership is usually an indication of deprivation, but in rural areas where car ownership is more of a necessity because of lack of public transport, there is not necessarily the same direct correlation as in an urban area.

The same applies to the retention of senior staff in rural areas. Staff tend to work more on their own and to have more autonomy and skills, so usually they are better paid and more senior. They also tend to stay in post for longer, so they are entitled to increments, which is an extra pressure on the service. In a number of areas, formulas, no matter how sensitive, will not always meet the criteria, but we are trying to recognise in all our policies that sometimes there are pockets of deprivation in areas of affluence where they would not be expected. Drilling down to ensure that our resources go to the right places is important.

I am aware of the deficit facing the hon. Gentleman's health community over the next few years. It is significant, so I am delighted that everyone has come together to work out a financial recovery plan. I understand that there will be calls to wipe the slate clean and to start from scratch, but that is not realistic and I believe that people locally recognise that. I have asked officials in the regional office to work very closely with all the managers in the area to try to find the best way to tackle the challenging financial position that the community is facing.

A financial recovery plan is being drawn up, and I will be keeping a close watch on its implementation to ensure that we strike a balance on getting the organisations back into a good financial position, but not at the expense of plans to improve services for people in the area. This is about getting the balance right, and I give the hon. Gentleman an undertaking that I will continue to take a personal interest.

The strategic outline case has been built up to expand capacity, and the plans are extremely exciting and innovative. The strategic outline case is with the PCTs for approval. Obviously, as the PCTs have the budget, they must decide whether those plans are affordable in the context of the revenue streams that they will be able to provide to support them over the next few years. Once the PCTs are happy with it, they will have to take the case to the strategic health authority for approval. The hon. Gentleman will be anxious that there are no delays in the system, but he knows how important it is for every one of those players to buy in if the capacity expansion is going to work and be sustained for years to come.

The plans are exciting, and not just in respect of the diagnostic and treatment centre at Bodmin. I understand that it is part of a whole systems approach to have a series of DTCs in Penzance, Helston, Camborne, Redruth, Falmouth, Truro, Newquay and St. Austell, and Bodmin designing services very differently. Under our guidance, "Keeping it Local—A New Direction for the NHS", we are working with West Cornwall hospital on a pilot project. We have just commissioned an intensive evaluation programme through NHS research and development facilities, because we want to learn the lessons from that pilot. It will offer national lessons on new technology, telemedicine and joint assessment before transfer in respect of emergency services. It will also give reassurance to many communities up and down the country on doing things differently. The health community in Cornwall has not only good partnership, but good ideas, creativity and imagination. That is very welcome indeed.

I emphasise that the strategic outline case is not just about the acute sector. There are further initiatives to enhance primary care, with the development of the community hospitals to include intermediate care and rehabilitation facilities. Importantly, there is also the co-location of health and social services and voluntary sector services to support the development of integrated networks for seamless care so that people do not fall through the gaps. That has often been a real problem, especially for older people.

The plan seems to be well thought through, and it will help to ease pressure on the hospital and provide much better services at community level. It is with the PCTs for approval. It will then go to the strategic health authority, and it must find its way through the process. I will try to ensure that there is no undue delay in consideration of whether it can proceed.

I understand the hon. Gentleman's concerns about the position of the hospital and its star rating. Performance is looking extremely positive, and by the end of the month there will be no over-12-month wait for in-patient treatment and no over-21-month wait for out-patient treatment. Again, I congratulate everybody who has worked so hard to make that the case. Obviously, the next performance assessment and the star rating will depend on the exact date at which the figures are taken. I am not sure that that has been decided as yet, but I could write to the hon. Gentleman to set out the details of exactly what the process will be.

I do not want the performance rating to act as a disincentive to that health community, which is working so hard to ensure that it improves, but there will inevitably be a cut-off point and people will fall on one side of the line. I say that with feeling, as my local hospital lost one of its stars this year—it did not quite reach the 100 per cent. mark, although the staff worked incredibly hard locally to try to get back-up. I understand what that is like from a constituency Member's point of view, but the performance framework that we have established should act as an incentive for people to do well and improve their performance. It should not act as a disincentive when staff are trying to catch up with a backlog, as the hon. Gentleman outlined.

The hon. Gentleman briefly raised the situation in relation to foundation trusts. He does not want his hospital to be unable to apply. We are conscious of those concerns as many Members have raised them, which is why we have said that there will be no arbitrary cap on the number that can apply for foundation trust status. We envisage that, within four to five years, most, if not all, trusts could be up to that level.

We want to put more support into trusts—not trusts such as the hon. Gentleman's, but those with a zero or one-star rating, to ensure that we have a managed process to get them to the point where they can apply because we want as many people as possible to get the new freedoms and flexibilities to be able to do that. The transition phase is key for us. We want to ensure that a two-tier service does not develop, particularly in relation to pay and staff incentives. We are absolutely committed, in the way that the licence and the regulator will operate, to ensuring that that does not happen.

It being half-past Four o'clock, the motion for the Adjournment of the sitting lapsed, without Question put