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Westminster Hall

Tuesday 10 February 2004

[Miss Anne Begg in the Chair]

Health Funding (Buckinghamshire)

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Ainger.]

9.30 am

Mrs. Cheryl Gillan (Chesham and Amersham) (Con): I am delighted to have obtained, through the Speaker's good offices, the opportunity to raise the funding of health services in Buckinghamshire. I extend a warm welcome to the Minister. His office telephoned me last week to ask me exactly what subject I wanted to raise. I am afraid that I told it that I wanted him to come to the House with an apology and a cheque book for the people of Chesham and Amersham. I hope that, by the time I have finished, my constituents will get both, but forgive me if my expectation is not high.

I am joined today by my hon. Friends the Members for Wycombe (Mr. Goodman) and for Beaconsfield (Mr. Grieve), and bring apologies from my hon. Friends the Members for Aylesbury (Mr. Lidington), who has been forced to attend to his duties in Northern Ireland, and for Buckingham (Mr. Bercow), who is returning from a mission abroad in connection with his international development portfolio. The five of us had hoped to participate in the debate, but I am glad that three of the five have made it, as I am sure is the Minister.

We are in trouble in Buckinghamshire because, with the approach of the new financial year, virtually every aspect of our health service will be in the red. Whether we look at the mental health trust, the acute trust or the primary care trust, we face a problem. As the Minister knows from his recent visit to the National Society for Epilepsy, even it—one of our country's leading specialist facilities—faces bitter options simply to maintain its facilities and research. About the only success story in health funding in my constituency at present is the wonderful achievement of Amersham plc, which is in the process of being acquired by General Electric. It leads the world in health science and will continue to do so from its headquarters in Amersham, something of which we are rightly proud.

I shall deal with four subjects in turn but, first, I want to place on record my admiration for the hard work and dedication of everyone who works in our local health services. Their morale, to put it mildly, is not great at the moment and I hope that the Minister will appreciate that the problems arise despite the best endeavours of our staff and managers, who do sterling work and stand in the firing line when it comes to bringing bad news to patients and front-line staff alike. The Minister goes back to his office surrounded by civil servants. The local health service officials must face the public, as I saw only recently at a meeting on Chesham hospital, in a way that perhaps he does not.

The first thing that I want to consider is the mental health trust. Since my election in 1992, I have been only too well aware of the issues surrounding mental health

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in my constituency. At that time, a facility was opened at Debenham house in the Chalfonts, and I was given a crash course in the fear and misunderstanding that can occur with regard to mental illness. However, in the 1990s I did not see large numbers being failed by the mental health system. Over the past couple of years, I have noticed that an increasing number of constituents who consult me at surgery have mental health issues. At the sharp end, it is becoming obvious that our resources are insufficient and stretched to breaking point.

By the end of the financial year, even with the most favourable out-turns, our mental health trust will have a £3.6 million hole in its finances. The reasons for the deficit range from an underlying structural problem inherited when the trust was established to the high costs of agency and locum staff, and from an overspend of about £500,000 on drugs to out-of-service placements or extra-contractual referrals, for which the current overspend exceeds £1 million. In addition, it looks as if there will be an overspend of nearly £750,000 on learning disability services.

I am the first to admit that the restructuring announced last week presents a partial way forward. The acting chief executive, Mrs. Jill Cox, whom we have all met, has done a tremendous job. By staying in post much longer than she or anybody expected, she has now negotiated an arrangement with the Oxfordshire mental health trust whereby Julie Waldron will run both trusts side by side. This is not a merger, but it may well provide economies of scale in management. It will not, however, alleviate the deficit or solve the continuing problems, such as the shortage of psychiatrists and nursing staff, and the problems with facilities, such as the Haleacre unit at Amersham general hospital in my constituency, which are in desperate need of improvement and which I believe will close. It will not prevent the possible closure of the brand new paediatric intensive care unit or provide the extra resources to help sick people who are unsupported in our communities when they are most vulnerable.

The Buckinghamshire hospitals acute trust covers three hospitals: Stoke Mandeville, Wycombe and Amersham in my constituency. The accident and emergency units are based at Stoke Mandeville and Wycombe, which, with Amersham, serve about 750,000 people. Amersham was a private finance initiative project initiated by the previous Conservative Government but built and executed under the Labour Government. It is an almost brand new facility, but we are already facing the possible closure of one of its wards—the Misbourne ward.

We have an enormous problem with the recruitment and retention of staff—a problem that will be exacerbated by the restrictions on working hours caused by the European working time directive. Again, agency costs have blown a large hole of about £5 million in the budget. Last year, I tabled questions to the Minister about the cost of the working time directive. His colleague, the Minister of State, the hon. Member for Doncaster, Central (Ms Winterton), gave answers that, frankly, were quite unsatisfactory and did not address my questions at all.

In fact, the total deficit to the acute trust will be upwards of £6 million despite the financial support of £4 million of extra resources from the Thames Valley strategic health authority. My hon. Friend the Member

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for Aylesbury has similar problems. He asked me to make the point to the Minister that a date has still not been given for the commencement of the new buildings at the Stoke Mandeville hospital. Apparently, parts of the hospital were built in the 1940s and are literally falling down. Back in April 2001, plans were confirmed to bring in private investment to improve the facilities. The Government initially delayed the development by gerrymandering in respect of the rules by which the hospital can gain private funding. Despite all the plans made, the Government have still not given the final go-ahead for building to begin. My hon. Friend wants to know when they will give a date and would like the Minister to give one now so that essential work can start on the hospital.

A consultation document has been published entitled, "Shaping the future of your local health services". The deadline for consultation is June 2004, but set against burgeoning financial difficulties, I am convinced that it is driven by concerns about cost and not about patients. My hon. Friend believes that there will be change and that the demands placed on the health service by population changes should be reflected in responses to the paper. He also believes, however, that the document gives few figures and little costing of any changes. As a result, he and I have real fears that there will be a reduction in services. What is particularly striking is that the document gives no cost of the implementation of the working time directive. Recently, however, the trust has been performing well. The reference costs published last week show that we have, and get, excellent value for money. As the Minister knows, however, the problem is that we do not have enough money—a point to which I shall return.

The PCT has been working overtime. This year, one hopes, it will break even, thanks to dedicated staff and really good management across the board. However, it has come at a price to my community. Appleyard, a much needed physical disability respite unit, has had to close. The older citizens' day hospital now opens only four days a week instead of five. Chesham hospital faces possible closure and its beds being moved to Amersham if the acute trust decides that it cannot keep the Misbourne ward open and offers it to the PCT. I suppose that there is also some good news in that the PCT plans to develop new health care facilities in Chesham. It may or may not be possible to build those facilities with beds if the Chesham hospital closes.

The hospital has a history going back 100 years and it is a much-loved institution. I admit that it has passed its sell-by date, as all things do, and that it does not offer state-of-the-art facilities, but we must not underestimate our community's emotional needs. The hospital's place at the emotional and physical heart of the community gives it protected status among my constituents. New beds at a modern facility in Chesham may be acceptable, but a journey to Amersham would be less so. However, I appreciate that that might be the outcome and I cannot prejudge the choices that we shall face as a result of uncertainties at the acute trust.

The situation in Aylesbury is lamentable. The Vale of Aylesbury primary care trust has forecast an overspend of nearly £1.8 million, as my hon. Friend the Member for Aylesbury and many others predicted. Central

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Government's relentless setting of targets has driven health care managers to distraction. With so many compulsory targets, the money needed to implement them is, effectively, ring-fenced, which prevents managers from responding to the needs of the local environment. As a result, many essential services have been sidelined and are not funded adequately enough to respond to local need.

My hon. Friend wanted me to mention the speech and occupational therapy services in Aylesbury, which are woefully underfunded. Similarly, special educational needs are not being met. Such inadequate support might lead to patients requiring more care than they might otherwise have needed.

I cannot predict what my hon. Friend the Member for Wycombe will say about the PCT in his area, but it is in much the same situation as those in my area and that of my hon. Friend the Member for Aylesbury. However, I can predict with certainty that the PCT in my area will face growing demand next year and that it will have a hard time staying out of the red.

The calls on the PCT's funds are growing and underfunding has had a knock-on effect in one final regard. The National Society for Epilepsy has 258 places in residential and nursing homes on the Chalfonts site, as well as 26 assessment beds, which see a throughput of about 270 in-patients and 2,000 out-patients a year. The NSE operates under a service agreement with the National Hospital for Neurology and Neurosurgery. It has the UK's only magnetic resonance imaging scanner dedicated solely to epilepsy, which was paid for entirely out of charitable moneys. The same is true of the 3 tesla machine, which, incidentally, will come from General Electric and will be installed later this year at a cost of more than £1.5 million.

The Government's national care standards requirements mean that all the residential units will have to be updated at an astronomical cost, which will run into millions, but the fees paid by local authorities do not cover the costs of the residential care remit. Funding for the health care of residents falls to the PCTs and the costs are currently well over £800,000 a year, but the NSE receives only £116,000. Assessments are being carried out on the residents and 50 have been completed. The balance is expected to reveal that 29 more residents will meet the criteria for 100 per cent. health care funding. I assume that I do not have to spell out the implications of that to the Minister. No systems have been established to meet the assessed health care costs of those residents and there is an ongoing dispute, but the money will have to be found from somewhere and it will come from the NSE's charitable funds.

Thames Valley strategic health authority says that the PCT in which the resident lived immediately before coming to the NSE should be the funding authority. However, the Department of Health's guidance on responsible commissioners says that where a patient moves away from the area served by their registered GP, the responsible PCT should be determined as the PCT in the area in which the patient has become resident. Matters have still not been resolved, which is adding to the NSE's financial burdens.

In addition, there are immediate therapy needs. The NSE has only one full-time equivalent occupational therapist, one full-time equivalent physiotherapist and

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no speech therapist for a population of 225 residents. That is not good for an institution that is recognised as a centre of excellence by the World Health Organisation.

In practice, the lack of funding has forced the NSE to apply for planning permission for a housing development on part of its site as the only way to plug the gap in funding. The problem is that such a development would breach the green belt, which the Government now favour but which I and my constituents do not. The proposals have aroused much genuine concern among the NSE's neighbours, for whom I have a great deal of sympathy. The Secretary of State has refused funding, which is required largely because of the effects of his regulations. I also have sympathy for the NSE. We do not want to lose the facility, which benefits my constituency and those who suffer epilepsy throughout the United Kingdom and even the world.

The Minister saw the NSE for himself the other day, so I wonder what he would suggest. Will he encourage it to apply for planning permission and to breach the green belt or will he find the funding for that first-class organisation? I hope that he will not duck the question and that he will give us and the NSE the benefit of his advice.

There is a major problem with the finances in almost every aspect of our health service—I promised to return to the underlying problem. Despite all the hard work, carried out across the board, to build so-called recovery plans; despite all the economies and restructuring; despite the closure of facilities and the slimming down of others, to the detriment of my constituents and others in Buckinghamshire; and despite the so-called extra moneys that I am sure the Minister will fall back on in his speech, the truth is that we are underfunded and disadvantaged by a formula that is robbing my people in Chesham and Amersham of their rights.

Thames Valley receives 18 per cent. less money per head than the national average and Chiltern and South Bucks PCT receives less per head than the English average, by £150 or more. That is a scandal. The referral rates in Bucks are really low and the reference costs show that the acute trust is below the average at both sites. It could not be more efficient if it tried and the high cost of living means that the below-average funding is harsh to say the least. That is confined not to my area alone, but almost exclusively to the south.

The Health Service Journal confirms that half the English acute trusts are not confident of hitting their year-end financial targets and one in six rated themselves "very unconfident". London and the south-east accounted for all but one of the "very unconfident" finance ratings and—surprise, surprise—those in the north-west were the most confident about their financial out-turns. The Health Service Journal goes on to reveal that the Thames Valley area will have an enormous deficit of £18.1 million, which is on top of the £24 million NHS bank support. Most interesting are the comments of Noel Plumridge, a former finance director, who says that the financial results suggest that there is a problem throughout the south.

Thames Valley has done well in the circumstances, but the consistency of the deficits suggests that the problem is in the south rather than, as Noel Plumridge

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puts it, restricted to the usual culprits. The greater restrictions on the trusts' ability to delay capital spending is storing up problems for the long term, and backdating the consultant contract and the other factors that I mentioned all contribute to the picture. The problem is that those deficits are likely to be increased next year and even the severest of short-term measures is unlikely to remedy the situation. Indeed, what out-turn does the Minister forecast for my health trusts for next year—£36 million or £40 million? He must have a figure in his files and I should like him to share it with us.

I am sure that the Minister will argue that the standard of health is better in the south than it is in the north, and hence that the deprivation factors used by the Department justify the underspend in my area. That is not a valid justification. The needs of the north are not better served by levelling down those in the south. Surely we should be advancing medical services so that those improvements and advancements can be passed to other areas of the country rather than being used to penalise us for having different health requirements.

My constituents are hard working and pay enormous amounts of tax. They are articulate and knowledgeable about what they require in terms of health care. Their voices, too, deserve to be heard. Instead, they are vulnerable to a Government who have decided that they are worth less per head in terms of health care spending than people in other parts of the country. That includes some deprived areas in our constituencies in Buckinghamshire, which the Minister never seems to take into consideration.

I said that I wanted an apology and I think that even the Minister would acknowledge that our people deserve it. However, I also want him to get his cheque book out. It would make a difference if he were even to bring my constituents up to the national average. That might mean that they would not have to wait 13 months to get a hearing aid; that we do not have a bitter battle in my community over projected plans to build at the NSE to meet the Government's requirements; that the Misbourne ward does not have to close; that mentally ill people get the support they need; that we can give patients the therapies that they require; and that we attract and retain the staff we need to serve our community. After all, the community pays for and rightly expects that service.

The Minister will have a long list of successes and figures that show that much more money is going in than ever before. Well, it is not going into my backyard. After all, I am only asking for equality of treatment and a chance to face the new financial year without the inevitable cuts and reductions in service for the most vulnerable in any society, certainly in my experience—the sick. I hope he can give us the hope that we need in Chesham and Amersham and in Buckinghamshire.

Miss Anne Begg (in the Chair): I intend to call the first winding-up speech at half-past 10, so I would be grateful if the two remaining hon. Members divided the time equally, if possible.

9.52 am

Mr. Paul Goodman (Wycombe) (Con): It is a great pleasure to see you in the Chair, Miss Begg.

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I congratulate my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan) on securing this important debate and on covering the ground so thoroughly. Like her, I pay tribute to the 50,000 or so NHS staff who work in Bucks, and in particular those who work in the PCT, the acute trust and the mental health trust in my constituency.

As my hon. Friend has said, an image of Bucks tends to linger—it may even linger in the Minister's mind—of a rich, lush, wealthy, well-off county. However, the reality in my constituency is somewhat different.

I want to share some figures with the Chamber. The Minister will be familiar with the Government's indices of ward deprivation, which measure some 8,414 wards in England. I want to cite some of those figures relating to wards in my constituency. For child poverty, Booker and Castlefield comes in just outside the top 1,000, at 1,006. For education, the same ward comes in at 886. The housing figures are quite striking. Cressex and Frogmore is at 929, Green Hill and Totteridge at 772, Bowerdean and Daws Hill at 573, Booker and Castlefield at 529 and Marsh and Mickelfield, incredibly, at 256.

It might be hard for some hon. Members who are not familiar with Buckinghamshire to believe that such pockets of poverty and deprivation can exist in the south, but they do. The district has a 12.14 per cent. ethnic minority population, who are disproportionately represented in those poor wards. Many are originally from Kashmir and Pakistan, and do not always speak English as a first language. They have acute health needs.

We know from the census that 8 per cent. of the local population said in 1991 that they had limiting long-term illness. By 2001, that proportion had risen to 12.6 per cent. In 2001, no less than 14,700 people were providing unpaid care to their family, friends and neighbours. That is in the context of rapid population growth in the Thames Valley area.

We have a picture of complex health need, and of a small but important deprived group who lose out when other areas are better funded. Living in pockets of poverty, they are often little better off than others in areas that are, in general, poorer. However, our constituents also have a rising demand for health care. Like my hon. Friend, I am struck by how many of my surgery cases relate to mental health—they might involve a girl who harms herself or has anorexia, or a child with a problem in attending school. The number of such cases is increasing, and they are difficult and expensive to treat.

Returning to the figures that my hon. Friend cited, although funding in Wycombe district is almost £150 a head below the English average, and Thames Valley spending is some 18 per cent. below the English average, I have no evidence that demand in my area is 18 per cent. below the English average. If anything, I suspect that it is average or above.

That brings me to the first of three themes that I want to explore: the effect on funding of the star rating system for hospitals and targets. In the last but one set of ratings, Wycombe hospital was near the top of the list. However, last year its rating fell from three stars to one.

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I doubt whether the average patient admitted to that hospital for successive operations during those two successive years would have come out of the second operation believing that the hospital had declined from being excellent to one that was regarded by the star system as poor, but that was the effect of the trust's missing Government targets relating to finance, cancer, and accident and emergency.

Missing targets is extremely demoralising for staff. I know that, because I was admitted to A and E in the hospital last year for a minor operation, and I had the chance to talk to staff. It has a knock-on effect, which was referred to by my hon. Friend, and it is not happening in a financial vacuum. Buckinghamshire Hospitals NHS trust forecasts an overspend of £4.7 million and the mental health trust an overspend of £3.6 million. The total overspend in the county could be almost £14 million, when the acute trust has to restructure and all hospitals are having to cope with the impact of the working time directive.

Hospital trusts, mental health trusts and PCTs have an obligation to manage their budgets efficiently and effectively. However, the star system and the target regime make things worse rather than better because of their inflexibility. As a knock-on, the PCT is affected if the trust misses targets and therefore loses stars. For example, Wycombe PCT has targets relating to smoking cessation and to acute care. That seems reasonable. However, the targets are given the same weight—the PCT can incur serious financial loss if it misses the smoking cessation target—and it is less obvious why that should be so.

It is not just Conservative Members or Buckinghamshire MPs who think that the star system is too rigid. Oliver Wright, health correspondent of The Times, had an article published on Monday headed "Hospital star ratings to be scrapped". It said:

We are used to reading Government announcements in the newspapers before we hear about them in the House, but I would be grateful if the Minister either confirmed or denied that story, which appears to be extremely well briefed. Hon. Members might share my view that it would be pleasant to learn of any such changes from Ministers directly, rather than from the columns of The Times.

My second theme relates to what my hon. Friend said about Haleacre. There is concern about movement of services in my area, with its particular needs, to the

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centre and north of the county. Marlow day hospital was a facility in which a day nurse gave rehabilitation treatment to patients over 60. Recently, it closed. The patients are to be transferred to the Hayward unit in Wycombe hospital and to the Drake day hospital, which is based in Amersham hospital. I acknowledge that slots in Marlow day hospital were under-used and that all health organisations now want to provide more flexible care. I also acknowledge that the number of patients who, for one reason or another, do not want to avail themselves of transport to High Wycombe or Amersham is small to date. However, it is striking that no notice was given. That caused great stress and upset to my constituents in Marlow. No audit of social benefits provided by the hospital took place. As my hon. Friend said, people in Buckinghamshire—people everywhere—feel emotion about their local health institutions and want to be sure that their feelings are taken into account.

Above all, we cannot be sure that vulnerable people in need of treatment will not simply slip through any gaps in the system. As the director of operations at Wycombe hospital said:

so we return to the point about the shortage of money in the area.

There is a similar problem at Riversdale hospital, which until recently had a respite unit to care for patients with early-onset dementia. That has now closed. I acknowledge that not all the patients who used Riversdale came from Buckinghamshire and that there were long-running staffing problems at Riversdale. Again, I also acknowledge that all health organisations now want to provide more flexible care. However, once again no notice was given. Patients were not consulted until after the decision had been made and we cannot be sure that vulnerable people in need of treatment will not simply slip away without getting the treatment that would have been available to them previously.

That is an especially serious problem for carers. I know from consulting South Bucks Carers Association—to whose work I pay tribute—that one of the most pressing needs that carers have is simply that for a break from time to time. Caring for someone full-time, no matter how much one loves them, can grind even the most dedicated carer down. Once again, we are faced with a problem in the Wycombe area, in the south of the county, where relatively immobile and vulnerable people have to go to the centre or north of the county for treatment.

I do not intend to repeat everything that my hon. Friend said about the possible closure of Haleacre. There is the possibility that patients will be sent to the Tindal unit in Aylesbury or to an entirely new mental hospital at Stoke Mandeville, which will deal with the needs of the entire county. Again, we have the problem of a relatively vulnerable section of the population having to go to the centre of the county, from the rest of the county, for treatment. The fact remains that a large number of patients with mental health needs will be from Wycombe, which is the biggest conurbation in the county outside Milton Keynes. There is a strong case for keeping Haleacre open, or even siting a new facility in Wycombe.

When my hon. Friends and I recently spoke with representatives of the mental health trust, I was struck by the fact that, right from the moment when the

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curtains were rolled back at the start to reveal the trust, it was in deficit. No one can claim that the trust is in deficit because it has managed its finances badly or maladroitly—there has been a problem from the start, which is why we are looking to the Government to provide a solution.

My hon. Friend the Member for Chesham and Amersham said that she was hoping for the Minister to apologise and take out his cheque book. I am not absolutely confident that we will get an apology but, although I cannot speak for her, I would be willing to pass that up if I was absolutely sure that the cheque book would come out. Now that she and I have painted a convincing picture, backed up by fact, of the health needs in Buckinghamshire—I am sure my hon. Friend the Member for Beaconsfield (Mr. Grieve) will do the same—I cannot see any reason why our funding should continue to be 18 per cent. below the average, given that our demand is not. We look to the Minister for some answers.

10.7 am

Mr. Dominic Grieve (Beaconsfield) (Con): I am very pleased that my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan) was able to secure this debate, which raises a number of important issues, and I am delighted to participate in it. I hope to amplify some points that have been made without necessarily simply repeating what has already been said. I heard nothing from either her or my hon. Friend the Member for Wycombe (Mr. Goodman) with which I disagree.

Members of Parliament are of course in a rather strange position. Unless we make them our specialist area of study, the impression we tend to form of health services is in large measure dictated by those who come to see us with health care problems. I am the first to accept that this can sometimes be misleading. I am quite satisfied that in many areas a very high standard and quality of service is maintained in south Buckinghamshire. The chairman of my Conservative association, having suffered injury and spent some time in Wycombe hospital, came out with nothing but praise for the quality and standard of care that he received. Although the national papers may frequently comment on problems within the NHS, I have very little doubt that, once one is into the system and receiving care, the standard is very good indeed.

However, there remains a problem: there are plenty of examples from my constituents that, certainly in south Buckinghamshire, some people are unable to get the care for considerable periods, and sometimes simply do not get it at all. I will give the Minister some illustrations. A family came to see me with a young child who was showing clear signs of serious psychological problems. He was no longer able to attend school. This was not just a question of truancy or bad behaviour—there was clearly a serious issue. I was horrified by the fact that he was unable to go back to school at the start of the term in January, having missed a great deal of school the previous term, and by July, when his desperate parents came to see me, notwithstanding the fact that they consulted their GP at an early stage, he had still been unable to obtain the full services of the Amersham family and adolescent unit. This was not because the unit had thought their case unworthy of

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attention, but because it was short-staffed. One of the consultants was off sick and there were no substitutes or replacements who could be brought in. By the time I wrote to the Minister to point out my concerns, a child was in a situation that urgently needed intervention, but there had been no intervention for one whole school year. That was at a critical time in that child's life. I am sure that the Minister will agree that that is neither a happy nor an acceptable state of affairs.

We must face up to the fact that, in primary care terms, the local community's perception is that the standard of services is declining. Until two years ago, one of the surgeries in Iver provided a wide range of services, such as physiotherapy, in addition to its GP service. Just before the primary care trust was set up, it was decided that it would no longer be possible to continue with those additional services. I received a letter on the matter, which illustrates the problem:

I made inquiries, but I could not track anyone who felt that any other surgery in the area had benefited from that levelling-down process. Instead, a centre of excellence that had previously been a fundholding practice had its services reduced. The public perception in the locality was not that anyone local had benefited elsewhere.

In addition to those two examples, I face another local problem: my constituency lies at the very bottom of the county, so it is necessary that some of my constituents cross into other health authority areas for treatment from time to time, one of which is Berkshire, which is part of the new strategic health authority. Notwithstanding that fact, we continue to have what I can only describe as the reverse of a turf war: it is no longer, "Get off my turf," but, "Please come on to my turf and take over the services, which I have difficulty supplying." We see the same thing—the Minister smiles—between the county council and the NHS over the provision of social services. All those examples illustrate the serious underfunding that pervades the entire system.

I have another letter about the provision of adequate mental health care in the area. I do not wish to repeat my hon. Friends' comments on that, but the shortfall in funding in Buckinghamshire, and the problems related to that, mean that mental health is of particular concern to us. The letter concerns a family with a young adult son who has serious mental health problems. He has tried to commit suicide several times, and he clearly has psychotic delusions and needs careful management. Because he lives right down on the border with

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Berkshire, the family must get those services from Berkshire, but no one has the money to pay for them.

The letter illustrates the problem:

The letter, of August last year, continues:

the following is highlighted—

That letter was from the director of strategic planning of Buckinghamshire NHS trust. That is an unsatisfactory state of affairs. Repeatedly, everyone is ducking and diving, inevitably trying to find ways to turn a circle into a square, when that is simply not possible. Ultimately, the background problem is that the funding is not available.

To turn from those particular examples to more general points, which bear repeating, I would be grateful if the Minister clarified whether I am right in saying that per capita expenditure on health care in Buckinghamshire is £405 per annum. In Liverpool, the figure is £900 per annum, while in Scotland I think that the figure is £1,200 per annum, although you may know more about that than I do, Miss Begg. Those are pretty stark figures and they illustrate the absolutely central issue, which is why today's debate is taking place. We are faced with a system that has been devised over time by a Government who have decided that areas such as Buckinghamshire require much lower health expenditure than other areas. The figure for Scotland is distorted by the fact that, overall, Scotland gets a block grant, which it can spend as it likes, that is 24 per cent. higher than the total per capita in the rest of the United Kingdom. For Liverpool, however, the difference is due to a perfectly straightforward governmental choice.

The Minister will of course say that the difference is based on the Government's assessment of need. I do not disagree with that rationale. However, as every consultant in Buckinghamshire with whom I speak points out, need is not demand. Indeed, I understand that there is ample evidence—perhaps the Minister can confirm this—that there are high levels of demand in areas such as Buckinghamshire. That is not because my constituents have all suddenly become hypochondriacs who want either to clutter up their GPs' surgeries or to receive services that they ought not to try to obtain. Rather, the community is articulate.

As my hon. Friend the Member for Chesham and Amersham said, people there pay high levels of tax, they are pretty much aware of the medical services that ought

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to be available and they inquire after the availability of those services. Some people want beta interferon, because they suffer from multiple sclerosis, while others want to make use of more specialist services in the NHS. The principle behind the NHS—this has been the Government's ambition—is not that it is need-driven, but that it is demand-driven by all those who have a need. The Government are creating a situation in which there is a growing gap between the requirements created by the demand and the money that they are making available.

I have always accepted the principle that we cannot operate in a united country without the richer areas paying for the poorer. That is how every sovereign state operates, whether it be the United States, which sends huge sums from California to Arkansas, or the United Kingdom, which sends huge sums of public money from the pockets of the wealth producers in the south-east to disadvantaged areas.

However, we also have areas of disadvantage. My constituency has the 13th most deprived ward in the south-east, as well as the money. I am sure that my constituents are willing to dig into their pockets to raise standards and the level of service for others living in more disadvantaged conditions to the same as theirs, but I do not think that they see it as part of the deal that others should have a higher standard of service, which is what they are getting.

Some may slip off into the private health care system, and to some extent successive Governments have encouraged them to do so, although it is worth pointing out that when there was serious bed blocking at Wycombe hospital during the winter of 1998, the then chief executive said that he was satisfied that one of the reasons was that the Government had removed the incentive for the elderly to have private health care. That was an own goal of monumental proportions in terms of the crisis that it created.

There are other oddities, and I would be grateful to hear more about them from the Minister. It was pointed out to me at a recent meeting with consultants that some current funding measures operating within the NHS are bizarre. As diagnostic and treatment centres develop, the going rate of £262 will be paid for each case seen and diagnosis made. They range from a procedure such as a skin tag being taken, which takes 15 seconds, to a three-hour complete diagnostic assessment. One of the consequences of that bizarre funding system—I hope that the Minister will be able to respond to this—is that there will be cherry-picking as the centres develop, and inevitably hospitals will receive fewer and fewer resources and less income for carrying out the major procedures that others do not want to cherry-pick. By depriving the hospitals of volume, we shall create a system whereby the funding crisis for those that buy into services within hospital trusts will become more difficult.

I would be grateful for the Minister's response, because if that is the route that we pursue, the funding crisis that we are experiencing will get worse. What I want is not an apology, but to know what will happen next. I only have to look ahead to see that our problems will get worse. In the primary care trust allocations for Buckinghamshire, the percentage term increase for children in south Buckinghamshire at 29.2 per cent. is below the national average of 30.8 per cent., so the Government do not seem to have cottoned on to the fact

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that there are long-term funding difficulties, although I accept that in Wycombe the relevant figure is fractionally above the national average, as it is in the vale of Aylesbury, but that will not benefit my constituents.

I would also like to know from the Minister how he will deal with the problem of attracting suitably qualified staff. I realise that there is a problem, but he cannot get away from the fact that Buckinghamshire is a high-cost area. How will recruitment be done? Specialist consultants make the point again and again that the specialist nurses on whom they depend for providing services are leaving to live in London, where the weighting is better, or in lower-cost areas. That simply reflects a difficulty that we have had with virtually all forms of public service provision, including the police. Can he explain the Government's thinking in relation to tackling that problem?

Although each case concerns individual human beings, at the end of the day the issue relates to money. If the national average of overall expenditure were being received I have little doubt that the problems that beset each of the health trusts would simply disappear. I want the Minister to explain not just the short-term future but the Government's thinking in the longer term. We are getting to a point where public tolerance of such disparities will erode. Unless he heeds our comments, there will come a time in Buckinghamshire and other areas of the country when there will be growing resistance in respect of how people perceive themselves to be disadvantaged by the Government's funding formulae.

I am mindful of the Government's problems. They can examine areas of high need and decide that those are where the money should be targeted, but they should be mindful of the consequences for the people who provide the motor force for wealth generation, without whom the Government could not provide such services.

10.26 am

Sarah Teather (Brent, East) (LD): I, too, congratulate the hon. Member for Chesham and Amersham (Mrs. Gillan) on securing this important debate. I am pleased that she and the hon. Member for Wycombe (Mr. Goodman) made a point of paying tribute to NHS staff. When we consider such important issues, there is a danger that we overlook their hard work. This is my maiden speech in this place and my first outing as Liberal Democrat health spokesperson, so I am pleased that it concerns the issue of health funding.

Liberal Democrat colleagues on Milton Keynes council are concerned about health funding in Buckinghamshire. Milton Keynes has the fastest growing population anywhere in the country. Under the Deputy Prime Minister's communities plan, it will gain 34,000 new homes by 2016. Even without that growth, the Office for National Statistics seems to have grossly underestimated the population of Milton Keynes. My colleagues on Milton Keynes council have been working very hard with the PCT to redress that balance. Added to that problem is the question of how NHS funding is allocated. On a three-year basis, estimates based on the population in year one may be grossly out of proportion to the eventual population if there is dramatic population growth. There are existing pressures on that health service.

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The accident and emergency service in Milton Keynes was expected to serve 16,000 patients a year, but it treats 65,000. The PCT in Milton Keynes has a projected overspend of £1.8 million, but if that figure is combined with other factors, such as the projected deficit for Milton Keynes general hospital, it may be much higher. That creates real dangers for local services.

The hon. Member for Chesham and Amersham said that her area is funded at a level 18 per cent. lower than the national average. The hon. Member for Wycombe said that poverty levels in his constituency are unrecognised. Perhaps it is a case not so much of changing the formula, but of handing political control to local people. At the moment, the only accountability in the system is a change of Government. If we were to hand over political control and the ability to raise money for local services to local people, political control would exist at a level where people could see that they were making a difference. That would provide real flexibility. Changing the formula will always leave someone disadvantaged and unhappy.

Thames Valley strategic health authority is likely to have an overspend of £11.4 million by the end of the year, but it is not alone. Latest estimates predict that the North West London SHA—the SHA for my constituency—will have a projected overspend of £15.5 million, Hampshire and the Isle of Wight SHA will have an overspend of £27.9 million, and Surrey and Sussex SHA an overspend of £21 million, which is projected to double by the end of the year. There are severe problems throughout the south of England. As the hon. Member for Chesham and Amersham said, it appears that almost half of strategic health authorities in the south are very unconfident or quite unconfident about meeting their financial targets. That is a particular problem within acute trusts and mental health trusts. There is a difficulty with undiagnosed mental health problems. I have seen people in my own surgery with such problems. Not only is that not unique to Thames Valley SHA, but it is not new. That is what is most depressing.

Looking back to January 2003, I found an article in The Guardian, based on a leaked memo, saying that hospitals and clinics in the south-east of England would have to find savings of £60 million by the end of March. That included the SHA that covers Buckinghamshire. We are in the same position a year later. Each year we seem to go through the same cycle of bulimic funding and cutting. It is a nonsense and the enemy of sustainability. Worse, we do not know the extent of deficits within the national health service because there is no consistent reporting scale for financial deficits within the NHS.

The problem is about historic underfunding, and while I have no doubt about the sincerity of hon. Members, the Tories must take some responsibility for that, as must the Labour Government for sticking to the Tory spending plans. Each year we have the depressing cycle of fiddling figures and engaging in accounting sophistry to try to meet the end-of-year balance. The

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result is an NHS focused on meeting debt and political targets rather than on having the flexibility to innovate, which is what it really needs.

Mrs. Gillan : I think the hon. Lady will agree that the usual methods of tackling deficits are proving less successful this year than ever before. I know this is her first outing as health spokesperson, but surely six years after the Labour Government came into office, it is ridiculous to blame the underfunding in Buckinghamshire on the Conservative Governments of 1997 and earlier.

Sarah Teather : I thank the hon. Lady for her intervention, but part of the problem is that the Labour Government stuck to Tory spending plans, so both must share responsibility.

As we heard, five key issues are relevant to the financial pressures experienced by Thames Valley SHA this year. Recruitment and retention is a problem, particularly within the mental health trust in Buckinghamshire. Nationally, agency staff are predicted to cost the NHS £1.4 billion this year, which is £4 million a day—a tripling since Labour came to power. The Government's solution of an in-house agency seems to have had little effect. We need a long-term approach involving more flexible opportunities to pay more locally. That would allow extra payments for the cost-of-living factors within Buckinghamshire. We need to consider factors, such as inflexible shift patterns, which drive many people away from the NHS, as the Royal College of Nursing said.

Mr. Andrew Lansley (South Cambridgeshire) (Con): It is possible that the hon. Lady is still familiarising herself with her party's policies, but I had not understood that it was Liberal Democrat policy that local NHS bodies should have the discretion to pay outside the "Agenda for Change" flexibilities. Is she proposing that?

Sarah Teather : "Agenda for Change" does not come on line until later this year. It is our policy to have flexibility at a local level to pay more if circumstances allow.

Compensation payments, based on the ombudsman's ruling on continuing care, are also important but have not been mentioned. It is estimated that Thames Valley SHA could face a cost of £8 million. Would it not be much simpler to budget for care for the elderly in the first place and to pay for it rather than having this ridiculous fiasco now?

Another important factor is the drugs bill. About 70 per cent. of prescribing is done on a generic basis. I want the NHS to use its power as a major purchaser to drive down the cost of drugs within the NHS. There are interesting models in New Zealand, to do with reference pricing.

The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman) : Will the hon. Lady comment on the scale of the New Zealand pharmaceutical industry and how much it spends on research compared with the pharmaceutical industry in this country?

Sarah Teather : It is true that the New Zealand industry is much smaller, but that does not necessarily

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mean that the lessons learned there are not relevant here. A conservative estimate is that we could drive down the cost of drugs by 3 per cent., whereas New Zealand has driven them down by about 9 per cent.

Perhaps most worrying is that Thames Valley SHA has not taken into account a problem that has been identified as a major financial pressure—the delay in implementing the consultant contract, which may cost as much as £5 million. Even when the contract is implemented, it will still be difficult to assess its impact on the health service. At the moment, we count doctors' heads, not whole-time equivalents, so it will be difficult to judge whether the contract will drive down hours.

The last issue of concern is the increased use of accident and emergency facilities, which was mentioned in Milton Keynes. A spokesperson for the Milton Keynes General Hospital NHS Trust said that there was a straight choice between treating patients and meeting financial targets. Ironically, an article in the Health Service Journal last month said that the Government's attempt to make GPs more accessible had made the problem worse because the 48-hour access target had made it more, rather than less, difficult for people to book appointments with GPs.

Buckinghamshire has a variety of financial pressures as a result of historic underfunding and the inflexibility of the funding formula. It is time that we moved away from cyclical debates and considered methods of preventing disease, which would cut the cost of expensive hospital treatments. We should move health care closer to home and hand real control to local government. That would allow a radical integration of health, social services, housing and environment. We could then consider the real causes of ill health and have a national health service—not a national illness service—that would be responsive to local needs.

10.37 am

Mr. Andrew Lansley (South Cambridgeshire) (Con): I share in congratulating my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan) not only on securing this debate but on the manner in which she introduced it. She demonstrated her concern for her constituents and her awareness of their experience of the NHS, both positive and negative. I emphasise in particular the positive support that they give to those who work in the NHS in her constituency. We must understand not only what our constituents are experiencing, but the organisational and financial context in which NHS employees work. Indeed, my hon. Friends the Members for Wycombe (Mr. Goodman) and for Beaconsfield (Mr. Grieve) also addressed that issue, and I, too, wish to touch on it.

A long time ago, and more recently, I became aware of the quality of service delivered by those who work in Buckinghamshire's health services. Nearly 20 years ago, during the winter of 1984, I stayed in Buckinghamshire for some months while Margaret and Norman Tebbit were in Stoke Mandeville hospital. At that time, after the Brighton bomb, we had every reason to be grateful for the remarkable work that the staff did, and continue to do, at that hospital. Three weeks ago, I visited Milton Keynes general hospital and primary care trust, which I shall return to in the context of what the hon. Member for Brent, East (Sarah Teather) said about Milton Keynes.

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My hon. Friend the Member for Chesham and Amersham set out an interesting context for the problems in Buckinghamshire. It is clear that there is red ink right across the Buckinghamshire trusts, from the Buckinghamshire Mental Health NHS Trust, to which she made particular reference, to Buckinghamshire hospitals in general. The Milton Keynes PCT and Milton Keynes general hospital forecast deficits. Something is going on and it is clear that much of it is to do with the relative formula spending share for Buckinghamshire as against need.

We do not need to look far for the solution. I suspect that my hon. Friend already knows that there is hope in our policies because, with respect to the hon. Member for Brent, East, converting the calculation of health spending to a local body and setting up local taxation is not the answer. Inevitably, resource allocation and equalisation measures will distort every effort to achieve that. Putting control in the hands of patients, as our patient's passport intends to do, is the only way to make a difference.

Sarah Teather : Do the Tories have a funding plan for the patient's passport? I believe that it will cost about £900 million in the beginning.

Mr. Lansley : The hon. Lady will have to be patient; she will have to wait only a few days for the plan to become clear.

The patient's passport will put control in the hands of patients, benefiting them through engagement—

Dr. Ladyman : Will the hon. Gentleman give way?

Mr. Lansley : I will when I have finished my sentence.

Patients themselves will be able to engage. The Wanless report says that the engagement of the public with their health care is very important. Such engagement also discloses need rather than relying on formula share, which is especially important where long-term medical conditions such as epilepsy or mental health are concerned.

My hon. Friend the Member for Wycombe mentioned the long-term illnesses experienced by some of the ethnic minority population in his constituency. Those conditions are precisely where direct payment and the ability to control one's health care can empower people. Resource allocation begins to replace formula allocations with disclosed need.

Dr. Ladyman : We cannot allow the hon. Gentleman to get away with fobbing off the question asked by the hon. Member for Brent, East. Whether the figure is £900 million, as she believes, or £2 billion, as I believe, is it not true that the hon. Gentleman's party will put that money, which could have gone into the national health service, into the private sector?

Mr. Lansley : The Minister will also have to be patient. His belief that the figure will be £2 billion is based on a complete misrepresentation of the patient passport. If the scheme has any impact on the resources allocated to the NHS and the private sector, it will simply be to allow what I imagine to be a reduced number of people in the long term to exercise choice outside the NHS in a way

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that does not incur additional costs to the NHS. He makes a different calculation based on the whole cost of the plan and on an exaggerated number of people involved. I will not go down that path.

Sarah Teather : Will the hon. Gentleman give way?

Mr. Lansley : No, because I want to say a few other things.

My hon. Friend the Member for Wycombe raised a couple of important issues. The Minister is keen on asking questions, but he will have to answer some. One question relates to star ratings. Depending on the newspaper that one reads, the Secretary of State is either about to confirm that star ratings will be abolished or about to defend them and announce that they will be maintained. He cannot do both, but it will be interesting to hear the Minister explain the position.

We have made it clear that star ratings should go because they are a crude measure that provides a partial reflection of the situation. It is clear that the loss of some star ratings reflects organisational and financial factors and has nothing to do with clinical quality. As the hon. Member for Milton Keynes, South-West (Dr. Starkey) made clear in the main Chamber, she does not believe that the star rating for Milton Keynes general hospital is an accurate reflection of its clinical quality.

I want to say a word about Milton Keynes, which I visited not so long ago, because its services are trying very hard. I am not sure to whom the hon. Member for Brent, East spoke, but when I talked to people in the accident and emergency department at Milton Keynes it was clear that they had taken exemplary measures over the past few months to deliver what the Government's targets require them to deliver. More to the point, however, they were delivering what they regarded as a better standard of health care for those entering accident and emergency. They did that by innovating. For example, they established a clinical decisions unit at Milton Keynes general hospital. If the staff have one point to get across, as the hon. Lady said, it is that their accident and emergency unit was designed for a fraction of the number of people who are now coming to it.

We cannot explain precisely why the increase in the number of accident and emergency referrals is rising so dramatically, but the capacity of the NHS in Milton Keynes especially—although it illustrates the situation for Buckinghamshire as a whole—in no sense reflects the population and the rising demand. In response to what I heard in Milton Keynes, I said that it is vital that we revisit the whole issue of formula spending shares and how they reflect not only disclosed need in the NHS, but also population changes and characteristics. Staff in Milton Keynes are deeply concerned that although it is possible to go to developers and use the planning system to get money for roads, schools and, to some extent, GPs' surgeries, very rarely does one get money for new hospitals and still less recurrent resources for hospitals. Also, the time lag involved in the work carried out on the 2001 census data means that places such as Milton Keynes are deeply in the red as they try to manage the capacity consequences of existing arrangements.

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My hon. Friends, in particular my hon. Friend the Member for Beaconsfield, who talked about patient experiences, have illustrated what my right hon. and learned Friend the Member for Folkestone and Hythe (Mr. Howard) said yesterday in a speech on the NHS: too often, first-rate medicine is trapped in a second-rate system. We see a lot of that in Buckinghamshire: a second-rate system that is not providing the resources, the capacity or the ability to respond to patients' health needs and disclosed wishes. This issue is not simply about being more efficient with the money available—it was made clear that reference costs, for example at the Royal Buckinghamshire hospital, are below average—but about the ability to reflect the needs of the population. In the short run, it is about that being part of the formula share. In the longer run, it is about shifting to a system, as we propose, that genuinely reflects need and some deprivation indicators when allocating public health budgets. In that way, we can move towards a system that is fairer across the country as a consequence.

I am very grateful to all my hon. Friends and their absent colleagues for their work. I am happy that we have also added something in respect of the problems as they relate to Milton Keynes.

10.48 am

The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman) : I congratulate the hon. Member for Chesham and Amersham (Mrs. Gillan) on securing this Adjournment debate. She and her hon. Friends who represent Buckinghamshire are doing what they ought to do by championing the cause of their constituencies. They make up in enthusiasm for what they lack in accuracy and perspective.

I congratulate the hon. Member for Brent, East (Sarah Teather) on her new Front-Bench responsibilities. I am not convinced that scrapping national pay bargaining and basing the pharmaceutical price regulation scheme on the New Zealand model will be vote winners for the Liberal Democrats, but if she believes that they will be, she is welcome to take that to the country any time she likes.

Sarah Teather : I did not talk about scrapping pay bargaining; I said that there would have to be local flexibility.

Dr. Ladyman : That means scrapping national pay bargaining. That is the opposite of the argument that the hon. Lady and her colleagues deployed a few weeks ago when we debated foundation hospitals. Then, she said that foundation hospitals would pay more and create a two-tier service. She can either hunt with the hounds or run with the fox, but she needs to rethink that.

From the hon. Member for South Cambridgeshire (Mr. Lansley) we heard the first of the new Tory leadership's tax and spend commitments. Whichever way he paints it, the patient passport will transfer money from the national health service to the private sector. I

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assure him that the Government and the country will fight that tooth and nail, and we shall have some enjoyable debates.

Mr. Lansley : Are the Government therefore against spending NHS money in the private sector, at an average of 43 per cent. more than they pay the NHS for the same treatment?

Dr. Ladyman : The difference between the Government and the Opposition is that at all times we adhere to the principle that treatment in the national health service should be free at the point of need. We are perfectly happy for the national health service to buy advice services from the private sector to deliver to everybody in the community, but we are against the system that the hon. Gentleman would introduce, as a result of which many older people would have to spend thousands of pounds of their hard-earned money, with the help of a little extra from their patient passport, to get the treatment they need. If he wants to go down that route, we in the Government are delighted, because it clearly divides the two parties, and at the next election the public will know exactly what they are getting.

Before I focus on Buckinghamshire, I want to establish the general principle that we at the centre do not try to micro-manage the country's health economies. We pass the majority of national health service funding to primary care trusts, which we allow to decide how money is allocated in their areas and how services are commissioned. Therefore, local people are making decisions about the way in which services are configured and money is spent on the different aspects of service. That includes the commissioning of acute services and mental health services. If the balance in Buckinghamshire is wrong, it is in the hands of local people and local PCTs to put it right.

Mr. Grieve : I understand the Minister's point, but I hope that he will be able to deal with the funding disparities nationally, which undermine the argument that similar sums of money per head of population are handed to PCTs to spend as they wish.

Dr. Ladyman : I never implied that similar sums of money were handed to PCTs to spend as they wish. We allocate the money using what we believe is a fair formula. Let me give the hon. Gentleman some examples of the factors that the formula takes into account. If he wishes to intervene and tell me that he disagrees with any of them, he can do so.

The factors include the local population's health need and its level of deprivation; the number of people and the public sector costs in the area; and the rurality of the area, because services must be more disparate in rural areas. The impact on Buckinghamshire of the south-east effect is positive, too. All those factors are taken into account when we allocate funds, and have been when we have allocated funds to Buckinghamshire.

I notice that no Opposition Members are leaping up to say that any of that is wrong. However, the hon. Member for Beaconsfield (Mr. Grieve) had the unusual idea, which I should have thought the hon. Member for Brent, East would have screamed and shouted about, that somehow we should allocate money according not

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to need but demand; because his constituents are more eloquent and more motivated, and therefore demand more services, the Government should hand over more money to them.

Mr. Grieve : Will the Minister give way?

Dr. Ladyman : Let me finish, and then I will give way.

I suspect that the hon. Member for Brent, East has Bangladeshi communities in her constituency. Infant mortality rates in those communities will be nine times that in Buckinghamshire. Is the hon. Gentleman honestly suggesting that, because people in Buckinghamshire are demanding more services, we should be taking money away from deprived communities and giving it to their county? That is a preposterous notion.

Mr. Grieve : I note the tone of the Minister's remarks. I made it clear in an intervention that I fully understand what he says about the question of need. However, I suggest that the Government's formula on need may be missing the point. I have come to the conclusion that there is no correlation between need and demand. If we are not meeting the demand but there is a need for that demand, we will not meet the need in Buckinghamshire.

Dr. Ladyman : The hon. Gentleman makes the same point again. If he has objective reasons for disagreeing with the formula, he should cite them. The hon. Member for South Cambridgeshire, speaking on behalf of the Conservative party, should propose a new formula that could be used by a Conservative Government to distribute money around the country. We would be delighted to look at it—but if it does not take account of need, if it takes no account of poverty and if it does not recognise fairly that many areas have poor health outcomes, we will be delighted to point that out to the public at the next general election.

I shall put the health economy of Buckinghamshire into context. Of the wards in the Thames Valley area, 81 per cent. are in the fourth and fifth least deprived quintiles of the country. Wards in the area of the Wycombe PCT are rated 8,411 in the deprivation indices; the least deprived in the country is rated 8,414. I agree with the hon. Member for Wycombe (Mr. Goodman) that affluence can hide pockets of deprivation. Indeed, 4 per cent. of the wards in Wycombe are in the most deprived category. That is why we need to give the money to local PCTs, which can decide where the need is; they can then ensure that they target the needs of deprived communities.

Mrs. Gillan : I acknowledge the intellectual position from which the Minister approaches the argument. However, he is telling people in Buckinghamshire that they are worth less than half the spending on health care per head than people in Liverpool. I am sorry, but the people of Buckinghamshire are not going to accept that logic. Frankly, the Minister should be interested in levelling up the service, not levelling it down—which is what he is doing by depriving the people of Buckinghamshire of the money that should rightfully be spent on their health.

Dr. Ladyman : I am told that we should be levelling up, and that is exactly what the Government intend doing.

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That is what the formula will achieve. I point out to the Opposition that that is in the context of huge increases in spending in Buckinghamshire. Spending might not be increasing as fast as in some deprived areas, but it is increasing a heck of a lot faster than the Conservative Government would have allowed—and a heck of a lot faster than a prospective Conservative Government would allow.

As a result of the current spending round, Buckinghamshire will see a 30 per cent. increase in spending this year, next year and the following year. An extra £150 million will be going to Buckinghamshire as a result of the Government's spending plans. However the Opposition paint it, vastly more money per head is spent on health in Buckinghamshire now than in 1997.

Mrs. Gillan : It is obvious that the Minister is not going to deal with the detailed points that I and my hon. Friends have raised today. I ask him to read our speeches in Hansard and address each and every point that we and Members who are now absent have made, and to respond fully in writing.

Dr. Ladyman : I am happy to go through Hansard and answer the specific points raised by the Opposition. I am sorry that I have not had time to deal with them all in detail this morning, but—unfortunately—I was limited to 10 minutes.

The important principle that needs to be established is that Buckinghamshire's health economy is receiving huge extra investment. There is no doubt that the challenge is to decide how that funding is to be distributed and managed.

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