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11 Jan 2005 : Column 57WH—continued

GP Services (Exmoor)

3.30 pm

Mr. Adrian Flook (Taunton) (Con): I am extremely grateful for the opportunity to raise an important issue for the people of Exmoor that also resonates in every sparsely populated area of England. As the south-west region is the most rural of England's regions, the debate is relevant to counties other than Somerset and the part of Devon to which Exmoor extends.

I am sure that the Minister has boned up on his knowledge of my constituency and no doubt he knows that there are two very distinct geographical parts to it: Taunton Deane, which has 80,000 electors, and Exmoor, which has nearly 4,000—a much smaller number. The matter is best illustrated by my saying that although Taunton Deane is not overcrowded, the 3,900 electors of Exmoor live in an area roughly the same size as the whole of Taunton Deane.

I share Exmoor with my hon. Friend the Member for Bridgwater (Mr. Liddell-Grainger) and the hon. Member for North Devon (Nick Harvey), so together we represent one of the most remote areas of England. It is worth pointing out that, compared with the national average, Exmoor has a significantly greater proportion of households with individuals suffering from limiting long-term illnesses. Due to the nature of farming communities, families will be left to look after those who are ill.

On Exmoor, there is also a greater proportion of individuals caring for the ill or the elderly and a greater number of people living in medical and care establishments run by housing associations. Contrary to how some people regard Exmoor, it is not a very wealthy area across the piece. It is also well accepted that Exmoor has an ageing population, which is easy to understand when one considers that many people aspire to retire there. In turn, a higher than average proportion of people provide unpaid care in farming families, and a consequent proportion of the elderly live alone after the husband or wife has passed away.

It is also worth pointing out that Exmoor is unusual in having no traditional nursing homes, which creates extra problems for the GP surgery I shall mention in a few moments.

There are two particular issues that I want to bring to the Minister's attention. The first is the sparsity of the area that I represent, along with my hon. Friend the Member for Bridgwater, and the manner in which primary services are struggling to match those in the towns of Taunton and Bridgwater, as well as those elsewhere in England. Secondly, there is the particular problem of the Dulverton medical practice which is based at Trumpington House surgery in the town of Dulverton. Even to the Minister, hon. Member for South Thanet (Dr. Ladyman), whose constituency is hardly a conurbation, Exmoor must be really rural and Dulverton, although a town, not much more than a large village. It is the gateway to Exmoor and one of Britain's most beautiful areas, yet it is only a small town.

I am grateful for the information that has been provided by the partners of the surgery and Mrs. Pam Poole, the practice manager. Everyone who works for the surgery is held in high esteem by people throughout
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Exmoor. I am also grateful to Mr. Bernard Smith, chairman of the Dulverton medical practice patient group, which has a good relationship with the doctors at the surgery.

The practice covers an enormous area of 300 square miles and is based right in the centre of the town. That is the good news. The bad news is that the town is old and the practice based in extremely cramped conditions in an old house. There are 4,000 patients—a very steady number held over the past 20 years—with three whole-time equivalent doctors, of whom Dr. Lee Burton is the only full-timer. Some will say that 4,000 patients for three full-time doctors does not seem like a particularly burdensome load, but I am about to come to the crux of the issue, which is sparsity. Given that they have to cover 300 square miles, three full-time GPs working between 8 am and 6.30 pm five days a week do not have much time for house calls as well as surgery appointments, even on a good day. The doctors are, as in every doctor's surgery in the country, extremely pressed for time.

The patient group has emphasised the rurality of Exmoor to Somerset Coast primary care trust. Coupled with the lack of public transport, those from all the isolated communities must travel long distances to the community hospitals at Minehead, Williton, Tiverton, Taunton and, in some cases, Wellington. The round-trip can take several hours.

The patients' group is concerned that the outreach surgeries continue. They are in demand and began in response to local need. I know the village halls well, and will visit three of the outreach surgeries with Dr. Burton on Friday morning. I will be honest and admit that it would be fair to say that they lack professional amenities. No doubt Dr. Burton and his colleagues offer good medical care, but those village halls, which are at times cold, are not as well equipped as they ought to be. I am sure that the Minister appreciates that that is not the best way to deliver primary care in the 21st century.

The Minister will be aware of the issue of out-of-hours care. In a sparsely populated, rural area such as Exmoor, it is the main concern of the practice group. Patients are not happy with the out-of-hours service that has been afforded to them by Somerset Coast PCT. Thanks to the distance, emergency GP attention often takes several hours to arrive. Doctors are dispatched from Taunton, sometimes via Bridgwater, to get to the heart of the moor. Even with the most sophisticated navigation equipment available, local knowledge is immensely important.

In short, what is needed is funding for more doctors to cover the area at any one time. That issue, I am sure, will be evolving in many rural areas throughout the country. The problem is that, when the unknown GP arrives in the middle of the night, he has few, if any, patient records. That is always a cause for concern for patients and for the patients' group.

It appears that, since the system came into being at the beginning of April, none of that has been able to take place until the patient has telephoned the emergency contact number, been subjected to a host of questions—sometimes repeated by more than one operative—and been told that a doctor will be phoning. That call could come up to three hours later due to excessive demand for
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the service. That comment is what electors of mine—patients of the service—are hearing all too often, so, of course, confidence in the system is low.

The alternative is to call 999 immediately, rather than go through the NHS Direct system, but 999 calls mean an in-built expense to the NHS that we would prefer not to be placed on it. However, that is what a large number of people are beginning to do. When 999 is called and an ambulance arrives, the response time is well outside what is expected. That is understandable because Taunton, the location of the nearest major ambulance station, is at least 25 miles away.

So, the issues are out-of-hours service, the continuation of outreach services and sparsity. The availability of physiotherapy also needs to be improved. Farming is the mainstay of Exmoor and farmers go through physical work and exertion much more systematically than many of us, who seem to have desk jobs. It therefore becomes an imperative that people receive physiotherapy much more smoothly and efficiently, or they could end up prematurely chronically disabled and unable to work. That would undermine their whole lifestyle. Mental health care is common in rural areas, but the service and support for psychotic or affective disorders is sparse on Exmoor.

Mr. Ian Liddell-Grainger (Bridgwater) (Con): My hon. Friend and I share Exmoor almost exclusively. He makes an eloquent case, but perhaps I may tease out this point a little further. Domiciliary care in our local hospital in Minehead, not the main one in Taunton, has been cut even since we began to represent the area—not because the hospital wants it cut, but because the resource has been moved to Taunton. Does he agree that we must try to encourage more domiciliary care such as physiotherapy back on to the moor?

Mr. Flook : It would be extremely useful if the services being offered in Minehead were also offered in Dulverton. I wait to hear the Minister's response. In the spirit of trying to be helpful to one another, I informed his office of the issues that I intended to address this afternoon.

The minor injury unit represents an important issue, but one that I hope is being resolved. The Minister may be aware that it has been a slight local cause célèbre. Following 1 April and a new GP contract, the PCT saw no value in continuing to fund the minor injury unit. The sum involved is fairly small—just a few thousand pounds—and the unit offers local people an opportunity to be seen quickly by a health professional. However, the doctors thought that that decision was wrong and, despite local medical committee guidelines, which advise against offering services not funded by the PCT, they have continued to offer the facility.

Even the people in Bridgwater, where the PCT is based, did not grasp the issues of rurality and sparsity faced by those living on Exmoor. The 80 patients treated every year are grateful that the doctors have continued the facility. Where else could they go? Wherever they live—it could be Simonsbath—to go to Dulverton is a detour. If they found that the minor injuries unit was not open, they would have to go on to Taunton. Therefore, a small detour to Dulverton could mean another 25   miles to the accident and emergency department at Taunton or going back across the moor to Minehead.
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In response to my hon. Friend's comment on Minehead, there is, I am told, no medical cover, by which I mean a doctor's cover, for the minor injury unit between 11 at night and 8 in the morning. That creates further concern and pushes people the longer distance to Taunton, instead of the slightly shorter distance to Minehead.

The patients' group remonstrated with the PCT successfully, and following a personal meeting with Alan Carpenter, chief executive officer of the PCT, a dialogue is taking place. I hope the problem will be resolved

I hope also that the Minister has been able to follow closely my depiction of the difficulties in delivering primary health care on Exmoor. The matter is made more problematic by the situation in which doctors find themselves with their own surgery premises. The building, which is in the centre of Dulverton, is outdated and restrictive. It was converted in the 1960s from a house, when the doctor, who had a single consulting room, moved next door. The number of consulting rooms is now too few for the number of doctors. The nursing area is equally cramped. The corridors are not wide enough for wheelchair or stretcher access and there is a lack of space in the treatment rooms.

In view of the geographical isolation and the distance even to the community hospitals of Minehead and Tiverton, the surgery needs to be able, and is just about able, to offer dietician's advice, community nursing and midwifery, a health visitor service and—not that the doctors are being paid for it—the minor injury service, but all in cramped and unsuitable surroundings. When I visited the surgery in December, I was introduced to a number of staff who are based in what are effectively broom cupboards. They make the facilities that some of us still endure in the House of Commons look quite palatial.

The Minister will know that much more is being asked of primary care and that Trumpington House has no opportunity to match what many GP surgeries can offer elsewhere in my constituency. The minor surgery service could even be extended. There could and should be mental health support. It would be good to see occupational health services for rural workers based there and even visiting GPs with special interests being allowed to go to the surgery.

Access for the elderly, infirm and disabled is real issue. There is an inadequate drop-off point on a narrow street, which always blocks the traffic and is a problem for blue-light emergencies and for the air ambulance if it ever has to pick someone up from the surgery. I noticed, because it is all too clear, that the dispensary is too small. Of the 4,000 patients, 75 per cent. get their prescriptions from the doctor and get a poor service—not because the pharmacy is inadequate, but because people have to queue so close to each other that everyone knows what everyone else's prescription is. That cannot be right. Overall, in the words of the chairman of the patients' group, Trumpington House

There is a solution. A site for a new medical centre has been found in grounds currently occupied by the dentist in the town. It is well located, easily accessible to everyone in the community and, as my hon. Friend the Member for Bridgwater and I know, even has the
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blessing of local planners, who are fairly picky. Funding, as I am sure the Minister would expect me to say, is the key to solving the problem.

The PCT acknowledges the difficulties, knows that there is a solution and, depending on the yardstick used, says that the surgery is its No. 1 or No. 2 priority. It has given everyone the impression that it wants to be helpful, but says that there are genuine restrictions on finding suitable capital funding to help the GPs to move their practice. It appears that the PCT's budget to help doctors to improve their facilities throughout all its surgeries on the Somerset coast amounts to about £600 per surgery. That may or may not include the extra £108 million for helping doctors to improve their premises, which was announced by the Government at the end of July, but it works out to an extra £100,000 per PCT and an extra £150,000 next year, which is not a lot. I hope the Minister appreciates that there are problems of sparsity on Exmoor and even the local PCT is slowly working out that it has not quite grasped what that means in terms of how services need to be delivered.

I believe that my comments are helpful and I hope that they have been received as such. We are looking for help and for understanding of sparsity and its impact on how doctors are trying to keep up with what is expected of primary care elsewhere in our country. In trying to improve the health of their patients, it appears to me as a layman that they have to struggle more than others. They are at the end of the queue in more ways than one: they tend to have smaller patient lists, which means that funding is more difficult, and they are geographically more removed from the centre, which means not only that their patients have to travel much further, but that the money seems to travel more slowly to them.

3.48 pm

The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman) : I am grateful to the hon. Member for Taunton (Mr. Flook) for the interest that he takes in his local health services and I congratulate him on raising the issues today. However, for the very reasons that he outlined, I hope he will understand that much of what he has said pertains to matters that have to be addressed locally.

The hon. Gentleman correctly said that, although my constituency of South Thanet contains significant rural areas, it is very different from Exmoor. I have no knowledge of the detail of how life on Exmoor works; I cannot possibly know. I have enough to do to ensure that I understand how life in South Thanet works. That is why it is right that we have a policy of shifting the balance of power, sending money for the national health service to local areas and making local primary care trusts the focal point for local decision making, with people who know the area making decisions that are relevant to it.

Although I will deal with some issues that the hon. Gentleman raised and tell him what is being done about them, the response must come from his local PCT and local health professionals who understand the area. They have been given the resources, the opportunity and responsibility to address those issues locally. I hope that he and his colleague, the hon. Member for Bridgwater (Mr. Liddell-Grainger), engage with their local PCT to ensure that their views are fed in. I am also happy to say
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that, because that local PCT has a duty to ensure it understands the views of local people, it organised a series of consultation events last autumn to enable it better to comprehend the needs of the local health community. Those events have informed the capital programme, including primary care services; helped to ensure that resources are going to the right places; and helped the PCT to create a strategic services development plan, which will no doubt address many of the issues that the hon. Member for Taunton raised.

Mr. Liddell-Grainger : The Minister has made the most elegant points. One problem with Somerset Coast PCT—most of which is in my constituency—is that one goes from an industrial town to a very large seaside conurbation to a huge rural area. We have four hospitals of which only one would meet Government standards. The PCT is good, and the Minister is absolutely right: it is undertaking a phenomenal consultation process, in which I, my hon. Friend the Member for Taunton (Mr. Flook) and my right hon. Friend the Member for Wells (Mr. Heathcoat-Amory) have been involved. However, it is finding it very difficult to obtain the capital receipts to be able to do what it would like to do.

Dr. Ladyman : Later on, I hope to have good news about capital receipts for the hon. Gentleman. We have come up with a formula for ensuring that the capitation expenditure in each area reflects properly the needs of that area. Deprivation and rurality are two issues that are taken into account when determining the amount of money per head going into the health service in a particular area. It will take us some years to move fully to the use of that formula, but it already is and will continue to be an awful lot more generous to Exmoor than the formula for spreading out money in the national health service that it replaced. I hope it will help the PCT to address the issues mentioned in the long term.

I ought to say something about the problems of contracting and attracting GPs to an area such as Exmoor. Before I do that, with my Government hat on and to ensure a balanced debate, I am pleased to say that in December almost 100 per cent. of patients were offered an appointment with a GP within the national target of two working days and almost 100 per cent. of patients were able to gain access to a primary care practitioner within one working day. That is a considerable achievement by health professionals, and I congratulate them on their hard work and commitment.

Part of the modernisation of the national health service means that we must modernise the role of GPs and have the new general medical services contract, which came into existence in April, as an alternative to the personal medical services contract. It allows far more flexible working and increases UK expenditure on primary care from £6.1 billion in 2002–03 to £8 billion in 2005–06, which is an increase of 33 per cent. It is based on a series of quality indicators that will allow GPs to be paid more if they improve the quality of services to their patients and are able to reflect the needs of areas such as Exmoor.

The contract also provides new recruitment and retention possibilities to tackle shortages, which will be very important to areas such as Exmoor. For example,
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it allows for new benefits, including enhanced service payments if specialist services are delivered in a primary care setting; allows for resources to be allocated more fairly according to need; and benefits patients, giving them a far wider choice of high-quality services.

I hope that those services will be in the community, as the hon. Member for Bridgwater said in an intervention, rather than in a hospital. In an area such as Exmoor, it is vital that we provide more services in people's communities, rather than have them travel long distances to hospital.

All the surgeries in the west Somerset area, which includes Exmoor, have transferred to GMS contracts—only a few remain on the PMS contract. I have no doubt that they all recognise the benefits and that they can use them to improve services in their area.

The hon. Member for Taunton raised several issues, and I shall try to deal with them. First, the Trumpington House surgery in Dulverton faces several serious challenges. I do not minimise them for a second. Officials of the PCT have met regularly with the surgery to discuss options for developing integrated health facilities on an alternative site. I am pleased to say that, following acceptance of the new GMS contract, the PCT has invested more than £900,000 in Trumpington House surgery.

The news that I have for the hon. Gentleman—I am slightly surprised that he has not heard it already and that the PCT has not put it up in lights—is that the surgery has been awarded £250,000 for 2005–06 from the Dorset and Somerset funding. The money has been allocated for development of the modernisation project and has come from the new premises moneys released by the Government in 2004. It is for the local PCT and the surgery to work out how the £250,000 can best be used, but, if the provision of new services and facilities is as important as the hon. Gentleman suggests, I hope that they give serious consideration to using the money for that purpose.

The hon. Gentleman discussed out-of-hours services. He may be aware that the new GMS contract allows PCTs to take responsibility for such services. By
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1 January, all but seven PCTs had assumed responsibility for them. Indeed, the transfer of responsibilities for such services to PCTs means that in many areas much more effective out-of-hours services can be provided. The new contract also helps to retain and recruit GPs who otherwise would not be interested in providing an out-of-hours service.

Somerset Coast PCT has taken on this responsibility and has put in place a robust and integrated out-of-hours service. The service can be accessed by NHS Direct and is supported locally by treatment centres, minor injury units, community hospitals and community nursing teams. Out-of-hours services are available at Musgrove Park hospital in Taunton and at community hospitals in Bridgwater and Minehead. The services are supported by a county-wide strategic development group, which is chaired by the chief executive of Mendip PCT, the lead PCT for out-of-hours services in Somerset.

I am not saying that everything about that out-of-hours service is already working perfectly. Of course it is not. The service will have to be monitored and improved. The issues that the hon. Gentleman identified will have to be addressed as time goes on, but the local team has put in place a strong plan that can improve on and deliver a top-quality out-of-hours service to people on Exmoor in the long term. Although feedback will be necessary from patient groups, the hon. Gentleman and local people, I believe that the service will go from strength to strength.

It is important that we deal with resource allocation, at least briefly. As I said, because the old formula did not properly reflect deprivation, rurality and other issues that add to costs in particular areas, we abandoned it. We have introduced a new formula that is much more generous to areas such as Exmoor, although it will take several years before Exmoor is on target for the total spending that we expect it to receive. However, the area has already benefited significantly from the new formula, and it will continue to benefit as it approaches the target in the coming years.

I hope that, following that brief canter through the issues that the hon. Gentleman raised, I have addressed his concerns. If I have not, I am happy to meet him to discuss them further.
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