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Primary Care and Ambulance Trusts

2.30 pm

Charlotte Atkins (Staffordshire, Moorlands) (Lab): I am grateful to have the opportunity to open this debate, particularly under your expert chairmanship, Mr. Chope.

The reconfiguration of primary care trusts and ambulance trusts has concerned Members throughout the country. The timing over the summer, the lack of consultation with MPs, clinicians and PCTs and the rushed timetable have worried us all, but the Secretary of State for Health has already apologised for much of that, so I will not dwell on it. However, the impression left is still that strategic health authorities have come up with a plan based on Sir Nigel Crisp's letter of 28 July commissioning a patient-led NHS, and that that plan—a one-size-fits-all formula—will be forced through despite local views.

In Staffordshire and Shropshire, we had a short pre-consultation period, from 26 August to 16 September. The responses were mostly critical of the recommendations, but the recommendations went forward to the Secretary of State unchanged.

There have been far too many NHS reorganisations. The NHS craves and needs stability, not permanent revolution. I recognise that there is a need for some changes first, to strengthen commissioning in order to hold acute hospitals to account, and secondly, to bring PCTs together if that makes sense—for instance, in Stoke-on-Trent.

The reconfiguration does not seem to recognise what PCTs have already achieved. In my constituency, the PCT has done wonders for that semi-rural, former mining area of Staffordshire. For the first time, services are designed for my constituents, not for the people who live in Stoke-on-Trent.

I shall give a few examples. The local out-of-hours GP clinics now run every weekend, which avoids about 250 patients a month travelling 10 to 20 miles to Stoke-on-Trent. The PCT employs community matrons to work proactively with GPs, which avoids 6,000 emergency hospital admissions every year, and saves about £6   million. There is also a joint health improvement plan, involving the voluntary sector, housing associations, local government, GPs and local employers in promoting local public health. That is just what PCTs are supposed to be doing.

The strategic health authority proposal is to stick Staffordshire, Moorlands into a giant, county-wide PCT, to be coterminous with social services. However, that ignores the fact that north Staffordshire is already a natural health economy, with key north Staffordshire partnerships including the northern area social services department and the north Staffordshire police division. A county-wide PCT would weaken the commissioning of NHS services—not strengthen them, as the Government want—because Stoke-on-Trent, Newcastle-under-Lyme and the Moorlands already speak with one voice in regard to negotiations with the acute hospital. They already share functions and staff. A Staffordshire PCT would be far more remote than the old North Staffordshire health authority that we got rid of.

The only evidence so far that anyone is listening is that the Secretary of State has rowed back from the ban on PCTs employing community staff. However, all the
 
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uncertainty is still causing anxiety and a slump in staff morale. We need to know what the impact will be on PCTs that run community hospitals such as Leek. Will PCTs be able to continue to provide those services directly?

David Taylor (North-West Leicestershire) (Lab/Co-op): Does my hon. Friend agree that this issue goes further than the uncertainty that PCTs are subject to because of the Government's drive for yet one more reorganisation? Is it not also the case that in some PCTs some managers welcome yet another opportunity to lose their deficits and to progress in career terms? It is not always the case that senior staff are being forced reluctantly down the aggregation road? In some cases that is happening with their consent and approval.

Charlotte Atkins : In some circumstances, yes. I am pleased to say that within my own PCT I am working closely with both the chairman and the chief executive. They both recognise that it makes no sense to move the community hospitals to alternative providers when no such providers are available at the moment. It makes no sense to look for contractors when the goal is to provide better patient pathways, not greater fragmentation of services.

The Government tell us that public services should modernise and learn from best practice. But no other ambulance service has learned the lessons from Staffordshire. It has been the best service for 10 years. The Minister knows all about it. Not only has it been the best, it has been the cheapest emergency ambulance service. Let us consider some of the facts: 86 per cent. of all emergency calls are met within eight minutes compared with a national average of 62 per cent. The NHS target is 75 per cent. but many ambulance services are not meeting it. Yet still the lessons from Staffordshire are not being learned.

More lives are saved by ambulance services in Staffordshire than elsewhere. They achieve 200 successful resuscitations from cardiac arrests every year. Staffordshire is the cheapest service. Why? Because it is the most efficient. It can treat 40 per cent. of emergency and urgent responses at home saving £100 per hospital visit. That amounts to £9 million per year, which is worth saving and also avoids unnecessary and stressful ambulance transports to hospital. How has that been achieved? Not by fiddling the figures as some would have it and not by tinkering at the margins. It has been achieved by using an entirely different operational system. It is called system status management.

When it was introduced it caused tremendous anxiety and hostility. I know. I was working for the trade union at the time. It is a radical and innovative system which demands total and absolute commitment from staff. Emergency demand was analysed in great detail. As a result, an operating plan has been created that places available ambulances where life-threatening demand is expected. It puts more crews on duty when demand is highest. The rapid emergency call-answering system means that ambulances are dispatched immediately. There is no wasted time deciding what priority the call should have.

That is not all. Staffordshire is a highly rural constituency. Many of my constituents live in small villages in isolated communities. Staffordshire ambulance
 
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has therefore developed its own community first responders. In Staffordshire, Moorlands I have 170 of these people. They are fully trained to ambulance technician standard. These trained volunteers arrive within four minutes of a 999 call, backed up by community paramedics with additional treatment and advanced skills. Back at base—ambulance control—there is always a doctor to diagnose the patient. The crew is backed up via a telemedicine system, ensuring that life-saving treatment, such as the use of clot-busting drugs, can be started in the ambulance before the patient even gets to the hospital. That is about being patient focused.

The emergency response costs of a future west midlands merged ambulance service based on Staffordshire's operation would be £64 million. Based on the west midlands operation, it would be £83 million and would deliver a poorer service. Time and again I have heard Ministers say that the objective is to bring the rest of the west midlands up to Staffordshire's standards. Let us not kid ourselves. Staffordshire's performance has been achieved over 10 years of development. It has been achieved only through the determination and vision of one man, Roger Thayne, the chief executive of Staffordshire ambulance.

The NHS is hugely resistant to change. Ambulance services have for years known why Staffordshire is better, but they have been unwilling to follow in Staffordshire's footsteps. It will not happen with this merger; in fact, the reality of reorganisation is that the ambulance system in the west midlands will be disturbed for some time. No one has yet considered the size of the operational unit. Costs increase massively with an operational unit of more than 2 million people.

The original proposal, by Peter Bradley, was for 28 ambulance services. That would have created a Staffordshire and Shropshire ambulance service for about 1.5 million people, which would make absolute sense, as the two counties are similar and it would be within efficient operational dimensions. However, one service covering the whole of the west midlands is unworkable, especially if there is to be only one call centre. That would be madness.

One of my constituents, from Shirburn road, Leek, sums it up:

"My wife suffered a heart attack three years ago in the early hours of the morning. Within three minutes of making a 999 call the paramedic arrived, followed three minutes later by the ambulance. We feel her excellent recovery was largely due to the quick response and expertise of the service we are very lucky to have in place. We feel strongly that the merger with other areas will only result in a much less efficient service where lives would be put at risk. We cannot stress too strongly how much we are against such a merger."

I have had loads of other letters like that.

Tim Loughton (East Worthing and Shoreham) (Con): I am following everything that hon. Lady has said and I agree with everything so far. However, does she agree that the same circumstances that apply to the ambulance service, and the losses in local knowledge that will result from that, apply to the fire service as well? Presumably, therefore, she will object to the regionalisation of the fire services into a smaller number of regions, which the Government are bulldozing through as well?
 
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Charlotte Atkins : No, I do not accept that, because the success of Staffordshire ambulance is not all about local knowledge, but the operating system as well. It can track its ambulances wherever they are, which is an entirely different situation from that in the fire service.

In conclusion, I ask the Minister a number of questions. Can he assure me that the consultation on the PCT configuration and the ambulance mergers is not a foregone conclusion, as we are led to believe by the SHA, and that there is not a one-size-fits-all plan to which all PCTs must comply, which will not take on board local circumstances? Can he assure me too that PCTs will be able not only to employ community health staff but to run community hospitals, as they do so well in Leek at present? Will it be their choice, not that of the SHA? On ambulances, will he assure me that Lord Warner, the Minister of State, will learn the lessons from Staffordshire ambulance, and that Staffordshire ambulance will maintain full operational independence with its own call centre, so that it can continue to perform as the best and cheapest ambulance service in the country?

2.43 pm

Mr. Paul Truswell (Pudsey) (Lab): I congratulate my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) on securing this important debate and on her eloquent speech. I know from many discussions since the summer recess that the situation in Leeds is replicated throughout the country. At the end of July, a tablet of stone was dropped down from the Department of Health. On it were etched two commandments: first, there should be fewer PCTs; and secondly, PCTs should divest themselves of service provision. MPs were invited in by West Yorkshire strategic health authority and were told—not consulted—about what was expected of the SHAs and the PCTs. When we spoke to PCTs, they clearly felt that they had been guilty of failure without any investigation, evidence or trial.

MPs in Leeds have generally found the PCT configuration as it stands to be very effective. The PCTs have adopted a very effective approach—they assess need and commission local services accordingly. They have also been robust in their relationship with Leeds acute trust, and have, I stress, developed services to meet local needs. Indeed, community services in Leeds were successfully transferred to PCTs from the then community mental health trust in order to achieve just such an improvement.

West Leeds, one of the PCTs in my area, is developing a rapid response team, the aim of which is to avoid unnecessary admissions of older people to hospital. That is a big problem in Leeds. Statistics show that we hospitalise too many people and keep them there for too long. In addition, a respiratory team is being developed so that people can be treated in the community rather than in hospital, and we have a team of advanced specialist practitioners who work with patients who have already had multiple admissions to hospital, and who regularly require the assistance of their GP.

If we have a problem with the NHS in Leeds, it is with the acute trust, and with the measures that it has been forced to take despite massive extra investment to deal with its deficit. The shortcomings of the trust have been largely responsible for the loss of some of the PCTs' star ratings.
 
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I am aware that many hon. Members want to participate in this debate, as they do in any discussion on the issue, so I shall conclude, like my hon. Friend the Member for Staffordshire, Moorlands, by asking the Minister a few questions. First, and most importantly, what was broken in Leeds? What needed to be fixed? We would be grateful if he could tell us.

Secondly, there must be proper recognition that the process that was so eloquently described by my hon. Friend was fatally flawed. It is to the credit of Ministers that there has already been some acknowledgement of that, but they have not gone far enough. Thirdly, it must be made crystal clear—I make no apology for reiterating the comments of my hon. Friend—that PCTs will continue to be service providers where they so wish. Statements so far have moved in the right direction, but not far enough to assuage the concerns of my constituents, the PCTs in my area and organisations such as the Royal College of Nursing which, I understand, might even seek judicial review.

My final point is that reconfiguration proposals that have already been submitted should be viewed in the context of a flawed process. They are not carefully considered plans for the improvement of commissioning and services. They are an acquiescent response to the commandments set down in Sir Nigel Crisp's letter of 28 July. As such, they must be revisited.

2.48 pm

Mr. Paul Burstow (Sutton and Cheam) (LD): I, too, will try to limit my contribution, as there is a lot of interest in the subject. Like everybody, I am interested in the way in which my local health service is developing and in the threat to continuity of care and to working relationships between the PCT, local authorities and other agencies. Sutton and Merton primary care trust has good working relationships with my local authority, the London borough of Sutton. It is making progress on a host of the issues that the Government would be interested in, including integration of services, and it is a key player in the development of the local community plan and strategy. However, because of the Government's requirement for it to look at reconfiguration, all of that must necessarily be put to one side or given a lower priority than it would otherwise get. At all levels of the PCT, people are thinking about their own future and that of the organisation; that is the nature of reorganisation.

One of my concerns is that PCTs came fully into existence across the country only in April 2002. We have had some three years in which to assess whether they are fit for purpose and can do the job of providing and commissioning services, as well as holding GPs and other parts of the health economy to account. How can the Government have formed the clear view, as we heard, that they are failing organisations that need to be cast into uncertainty and made to reorganise?

What criteria are the Government using to evaluate the effectiveness of PCTs—they have been around for only three years—and how long will the new structures be allowed to stand before they, too, are subject to
 
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further review? We seem to go through cycles—big is beautiful, then small is beautiful, then big is beautiful again. Many of the proposals, which include London, would make SHAs coterminous with regional offices. Only a few years ago, Ministers stood at the Dispatch Box and said that the NHS no longer needed a regional tier. We are now back with a regional tier. When will these constant changes stop? As important, when will they stop giving the appearance that they are change for change's sake?

I have some questions on divesting the services. Sir Nigel Crisp's letter of 28 July to primary care trusts and strategic health authorities seemed incredibly clear:

"the direction of travel is clear: PCTs will become patient-led and commissioning-led organisations with their role in provision reduced to a minimum. We would expect all changes to be completed by the end of 2008."

The RCN is seeking a judicial review on that subject. However, Sir Nigel's statement seemed to be slightly qualified in a letter of 26 August from John Bacon on "Commissioning a patient-led NHS". It said that we do not have to reorganise the way in which services are provided by October 2006, and that it does not have to happen until 2008.

That has left PCTs uncertain about whether, in the longer term, the Government intend that PCTs should focus on commissioning and provide a minimum of services or, as we heard in Health questions last week, that services may be retained. No one can plan sensibly or rationally in such a situation. The Government must be clear about what is to happen. I certainly need clarity in my patch, because it is in the midst of a major reconfiguration of services under the health care close to home initiative. That involves the establishment of local care hospitals—they will provide many services hitherto provided by the acute trust—and a new critical care hospital.

The problem with such projects is that they can go on for decades—and that one certainly will. Who will form the decision-making body for it? Will that body still be around to account for any errors in judgment? Will the decision makers still be around? There may be no continuity, but continuity is essential in order to ensure that those projects are completed on time and on budget, and that they deliver the sort of health care close to home that my constituents want.

I end with a question about the proposals for my patch. There may be some sense in having one SHA for London, but I am concerned that everyone might move up a size and that PCTs would step into the shoes of the old SHAs. The PCTS may thus become remote organisations, and in a few years' time people may say that they are too far away from the public to understand local health needs and that we need new, smaller PCTs. I hope for an assurance that, if the PCT has well established local relationships, a strong case can be made for it being genuinely coterminous with the local authority, which would lead to the integration of local services. If not, we will be going backwards.

I want clarity on the direction of travel. Have the Government put the brakes on? Are they going backwards, or are they going round in circles? We also need clarity on whether coterminosity can deliver joined-up services on the ground.
 
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2.56 pm

Paul Farrelly (Newcastle-under-Lyme) (Lab): I congratulate my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) on securing the debate. Hers is a neighbouring constituency. I welcome the Minister to Westminster Hall. I assure him that I am the first to recognise the huge difference that the Labour Government have made to investment in our NHS.

I want to focus principally on the future role of primary care trusts, particularly what is happening on the ground following the Department of Health document "Commissioning a patient-led NHS". That does not mean that the ambulance service is not important to me. I simply do not want to repeat what was said by my hon. Friend. She spoke powerfully and persuasively on the matter as it affects our county, and I agree with her 100 per cent. about the Staffordshire ambulance service. Nor do I wish to dwell on the way in which the document was issued, save to say that the ineptitude over the summer was truly mind-boggling. My right hon. Friend the Secretary of State has since apologised for the way in which that was done.

The Secretary of State said:

"district nurses, health visitors and other staff who deliver services in the community will continue to be employed by the PCT unless and until it decides otherwise."—[Official Report, 25 October 2005; Vol. 438, c. 152.]

However, I am conscious that in a reply to me dated 24   October—just the day before, and long after the storm had broken in Parliament—Lord Warner continued to repeat pretty much verbatim the mantras of the NHS document.

We all know that a White Paper will be produced on those issues in December. Above all, we know that NHS managers, certainly those in Staffordshire, are preparing the way for many of the proposed changes, which are still to be submitted for formal consultation. I suspect that many colleagues have similar stories to tell.

One of the great values of debates such as this is to remind the Department that assurances given in the House need to be followed through in the White Paper and above all on the ground. My local PCT in Newcastle-under-Lyme was set up only three years ago after extensive public consultation and a major investment of NHS resources and staff commitment to the reorganisation. Since then, I have found my PCT to be approachable and very responsive to local needs—a refreshing change from the previous north Staffordshire health authority, the sub-regional health authority that served Stoke-on-Trent, Newcastle-under-Lyme and Staffordshire, Moorlands, which was bureaucratic and remote.

The new SHA proposal, which is before a vetting panel in the Department, is for a single Staffordshire-wide PCT that would be even more remote than the old sub-regional authority. Indeed, it would dwarf any of the other merged PCTs that are being proposed for the region. Moreover, the proposal was in no way justified by the pre-consultation conducted by the SHA in the brief time allowed it in the summer. Not a single Staffordshire MP supported it. Only two PCTs in the whole of Staffordshire supported it. Indeed, only nine of the 49 responses received by the SHA from the whole of Staffordshire and Shropshire supported so-called coterminosity with county social services.
 
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Regrettably, I must mention Staffordshire county council in particular. I understand that, on 9 August, the county did support a single PCT. I say that I understand, because for well over a month I have asked the county to confirm the processes by which the response was submitted in the council's name. Sadly, I have not yet received a satisfactory response, but it is clear that this was an officer's submission that did not go through the proper processes for such a major decision. In other words, it was not considered by the cabinet scrutiny committee and the full council.

David Taylor : Does my hon. Friend agree that the desire for coterminosity between the greater PCTs and shire counties is the final step before social services functions are removed from county councils, which, along with the elimination of their LEA role last week, would cast them aside as a husk on the path on which lie so many rejected values and principles that we have held dear over the decades?

Paul Farrelly : Such a reorganisation in this permanent revolution might well be in the offing. I believe that we would all support better joint working, but I would turn the question around and say that I wish that county social services were as responsive to me and my local people as my local PCT is.

Since the beginning of August, the county council has rowed back, for the precise reason that its members do not support its proposal any more than the local MPs do. I therefore ask the Minister to bring to the attention of the Department's panel, which is chaired by Michael O'Higgins and is vetting the questions and proposals due to go out to formal consultation in December, the fact that the proposal advanced by the Shropshire and Staffordshire SHA does not reflect the opinions of the vast majority of local partners.

I also ask the Minister to take note of another key issue.

Mr. Brian Jenkins (Tamworth) (Lab): I know that my hon. Friend has talked about the number of members in the PCTs, but I am not sure that what he said reflected the true extent of the situation. The PCTs outside Staffordshire are to have an average of 275,000 members, but the proposal is for 782,000 members in Staffordshire. That is a marked difference, which I want to emphasise. Does he agree?

Paul Farrelly : I certainly do. I have not gone through the figures because I do not want to take too much time, but it is right to say that a PCT of that size would dwarf any other. Again, that reflects the fact that that PCT does not adequately consider the realities and different health needs of different parts of Staffordshire.

Will the Minister take note of another key issue, which is breeding further cynicism locally? The belief is that the exercise will simply be a consultation with a pre-determined outcome. I say that because of the behaviour of senior NHS executives on the ground, not least the recently appointed chief executive designate of three west midlands SHAs, Mr. David Nicholson. We will be consulted on whether SHAs are, on a regional basis, the right way to go, but to my recollection we were not consulted on the appointment of a chief executive
 
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designate in the interim. I had the courtesy to inform Mr. Nicholson that I would refer to him by name in this debate. However, he has not yet had the courtesy to reply to my letter of 14 September on these issues. It is widely known that during the summer Mr. Nicholson—I hate to personalise this matter, but I feel that his role is so substantial that I must name him—was informing NHS executives at the PCTs that the change to single coterminous organisations was inevitable; it was going to happen elsewhere, so the question to ask was what was so different about Staffordshire.

Charlotte Atkins : I am sure that my hon. Friend will be delighted to know that the same Mr. Nicholson will appear before the Select Committee on Health shortly.

Paul Farrelly : I am delighted to know that and I look forward to Mr. Nicholson appearing before other Committees in the House with other NHS officials.

My response to Mr. Nicholson centred on why, given the fundamental differences between north, south and east Staffordshire, that was not the most intelligent question for him to ask. His guidance to career officials on the ground explains why many of them have reluctantly gone along with the way in which the wind was blowing. As we have seen, that wind was blowing right from the desk of the NHS chief executive Sir Nigel Crisp. I am referring to the way in which the document was issued during the recess.

That is the second issue on which I would like the Minister to reflect and respond following the debate: the signals that such behaviour sends across the country. The message is that the opinions of elected representatives and properly appointed representative boards can be ignored by officials on a whim. That is a dangerous development. It is not unique to the Department of Health, but it continues to be reinforced by that Department's behaviour in Staffordshire now.

I therefore ask the Minister to look into and respond to why, before consultation has even started, Mr. David Lingwood, the ex-chief executive of North Stoke PCT, has been moved to a post at the SHA to prepare the ground for a merger of all the PCTs in Staffordshire. In his place, Mr. Mike Ridley from South Worcestershire PCT has been appointed interim chief executive of the proposed single PCT covering the whole of Stoke-on-Trent.

People in Stoke-on-Trent do not oppose that logical development, but they question the way in which the appointments were made and, in particular, why a single name was put by the SHA to the boards of North Stoke and South Stoke PCTs, in effect for them to rubber-stamp. There is, of course, immense disquiet in the NHS locally—warm formal press statements from the boards notwithstanding—about the way in which such things are being done. Will the Minister reflect and respond on how that behaviour accords with the procedures for senior NHS appointments and the role of the NHS Appointments Commission?

Mr. Ridley's appointment is understood to be interim because he intends to retire following the proposed merger in Stoke. Therefore, just as we are about to commence work on a brand new £250 million hospital,
 
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yet another chief executive will have to be appointed. That instability in senior appointments goes hand in hand with the uncertainty caused by the NHS paper's dogmatic insistence on a division between PCTs as commissioners and as providers of health care.

I shall not add much more on the subject, given what has already been said and the statements by the Secretary of State. I shall finish by pointing out that my local PCT runs a very successful community hospital at Bradwell in Newcastle-under-Lyme. It will be responsible for brand new health centres locally that have been financed by this Government's investment. It employs scores of district nurses. It is already tackling market failure by employing salaried GPs to fill gaps caused by retirement, when younger doctors have neither the wherewithal nor the inclination to buy into existing practices. Indeed, at one new health centre in Cross Heath, the PCT will also cut through the difficulties with NHS dentistry by employing an NHS dentist directly for the first time. Surely that is the way to go to fill such gaps.

The approach can be responsive to local need, and therefore efficient, because it is so local. It is not remote, as a single Staffordshire PCT might well be. I am sure that none of the hon. Members in the Chamber today is deaf to the argument that smaller PCTs might duplicate bureaucracy, or might not commission health services as effectively or cheaply as larger organisations. However, we have not yet seen any evidence from the Department that the policy is soundly enough based to justify yet another distracting and demoralising reorganisation of the NHS.

That is the final issue on which I urge the Minister to reflect and respond. If the evidence is not presented, people will perceive another change for change's sake—and, moreover, one that is based on dogma. They will see a top-down, one-size-fits-all business model that is not rooted in the reality of providing proper health care.

3.6 pm

Martin Horwood (Cheltenham) (LD): I congratulate the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) on securing the debate and declare a personal family interest in that my wife is director of public health in the Cheltenham and Tewkesbury primary care trust, and therefore faces redundancy under the proposals. I have not consulted her about the content of my speech, but I await with some trepidation her judgment on it when I get home.

The time scale for the proposed reconfiguration is very short. On occasion that can happen, but it is serious in the current case because so much else is going on. Ambulance trusts, the mental health partnership trust in Gloucestershire and the strategic health authority are being reorganised simultaneously. The reorganisation of the direct provision of services by the primary care trust has been discussed, and I add my support to the remarks of the hon. Member for Newcastle-under-Lyme (Paul Farrelly) about the need to retain the right for primary care trusts to provide the services in question directly, when they want to. We are not convinced that the statement was as unambiguous as he thought, but if he is right, I will be reassured.

The seriousness of the budget complexities is beginning to dawn on us. The Cheltenham and Tewkesbury primary care trust, with its three stars, has
 
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balanced its books, and has presumably made sacrifices on the way to achieve that. The other two primary care trusts in Gloucestershire face substantial deficits and have financial recovery plans. The strategic health authority has implied that those financial recovery plans will continue to apply, after the primary care trusts merge, in the geographical areas of the old PCTs. Is that true or will Cheltenham have to make the sacrifices twice and pick up the bill a second time?

Those are all major issues, which attract the attention of the senior management teams and boards of primary care trusts at a time when they are distracted by the need to attend to their own reconfiguration and reorganisation. In addition, there is a threat of pandemic flu, and primary care trusts will be in the front line for the implementation of action plans. Reorganisation in any organisation causes disruption and likely cost, and I endorse the comments of the hon. Member for North-West Leicestershire (David Taylor) about that. It is extraordinary that such disruption, cost and distress to staff should be undergone only three years after the organisations in question were set up.

I have a copy of the previous consultation document, which was published in 2001 and praised the existing set-up as more flexible and responsive, and on working more closely with partners, communities and the public.   It even used the new Labour buzzword "modernisation". It viewed the set-up as a more modern configuration of primary care trusts.

Mrs. Maria Miller (Basingstoke) (Con): The hon. Gentleman mentioned disruption. By focusing on restructuring, the Government are failing to grasp several other problems facing PCTs, particularly in the south-east of England. My constituency is covered by the North Hampshire primary care trust. Under the local health care funding formula we receive only 80 per cent. of the national share. That puts several of our health care activities in peril. Further reorganisation will only add to the confusion and take the focus away from resolving local issues.

Martin Horwood : The hon. Lady is right and underlines the serious problems caused by trying to do these things in such a short time. When bodies have to discuss their reconfiguration, other things are squeezed off the agenda, so it is a serious matter.

As the original consultation document said, the value of primary care trusts is that they have proved local and accountable, and all credit must go to the Government for setting them up. In my constituency, Battledown children's ward was threatened with being moved to Gloucester as an in-patient facility and would not have continued to exist as a 24-hour ward. In the end, the primary care trust intervened and was responsive enough locally to prevent that from happening. We are going to trial a nurse-led ward, and the 350 children a year who would have been transferred to Gloucester for in-patient treatment will now stay near their parents in Cheltenham. The primary care trust made a valuable contribution to the consultation process. However, would that have happened had the trust been based in Swindon? I am not sure that it would.

The primary care trust has built valuable partnerships, including with the Sure Start programme, for which the Government should also take due credit.
 
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There are also neighbourhood projects in less well-off areas of Cheltenham, such as Hester's Way and Whaddon. Those local partnerships are extremely valuable and are rooted in the fact that the primary care trust is based in the town and has good local connections of a kind that might not be preserved in a larger organisation.

The crisis in NHS dentistry has been mentioned. Again, our primary care trust has been responsive and attentive. It has tried to take steps to deal with the fall in registration in NHS dentistry, which is now below 40 per cent. in Cheltenham and Tewkesbury, although the greatest steps must be made in the Department of Health.

The primary care trust has also enjoyed good communication with MPs. I have very good relations with my director of public health—we are married, after all—and with the chief executive and others on the management team. There is, however, a serious point: if I had to liaise with a primary care trust that covered Wiltshire and Gloucestershire, there would not be the same chance of face-to-face communications with the chief executive and other members of the primary care trust board.

Why are we going back, in effect, to the old health authorities in terms of the geographical configuration? There seems to be a pattern, to which the hon. Member for East Worthing and Shoreham (Tim Loughton) referred. Primary care trusts are not the only things that are becoming less local: our ambulance trust, our strategic health authority, our children's services, our fire control centre and Gloucestershire constabulary are all becoming less local. The suspicion is that that is directed not by an analysis of each case, but by an overall need to reduce costs, to balance the Government's books post-election and to make savings. The Minister has to convince us that that is not the real reason and that we should look at such cases on their merits.

In the case of Gloucestershire primary care trusts, we were given six options, three of which were, in effect, for Gloucestershire. They were: Gloucestershire-only; the status quo, although it became clear that that was not a practical option in reality and that the strategic health authority would not accept it; and Gloucestershire plus Swindon, which was the worst possible combination. I see some advantages to a larger primary care trust. For instance, there would be some merit in having a greater bargaining position when commissioning services from the local acute trust. There is really only one powerful acute trust in Gloucestershire, and the three primary care trusts could have had a stronger position vis-à-vis that trust.

I disagree with some hon. Members because I found the strategic health authority consultation quite reasonable, given the parameters that the Department of Health had set. I also felt that the authority went to lengths to listen, and it is pleasing that the proposal that it sent to the Department is for a primary care trust that is as large as Gloucestershire, but no larger. Of the options that are available, I would certainly support that one. If, by any chance, the proposal was for a larger Swindon-based primary care trust, I would oppose it strongly.
 
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Mr. Jenkins : I am interested in the hon. Gentleman's comment that his authority is good at consultation. I understand that it will save £26 million. Was he given the details of the management and administration costs for each PCT so that he could estimate which were the best and make a contribution? If not, what exactly was the contribution to the efficiency savings?

Martin Horwood : No, I was not given those details. I was merely saying that I thought that the strategic health authority went to some lengths to explain the different options and the implications behind them. I felt that I was consulted by the SHA, but, as hon. Members have pointed out, that was within strict parameters effectively dictated by the Department of Health.

I concede that the proposals might have possible benefits in strengthening the primary care trusts. However, I hope that they are worth the disruption, distress and cost of reorganisation so soon after the last one. Most importantly, if such reorganisations happen and we create a Gloucestershire primary care trust, those local connections that have been so valuable in maintaining local partnerships and connecting the primary care trusts to some of the least-well-off communities in Cheltenham should be preserved and some presence of the trust should be retained within the town. Otherwise, the record of the new trust will not be nearly as impressive as those of its predecessors.

Several hon. Members rose—

Mr. Christopher Chope (in the Chair): Order. We have to start the winding-up speeches at half-past Three and five hon. Members are seeking to catch my eye. It is a matter for them how they carve up the time.

3.16 pm

Mr. Gordon Prentice (Pendle) (Lab): I will be brief, because I want to hear what my colleagues have to say. I want to pick up on what the hon. Member for Sutton and Cheam (Mr. Burstow) said about clarity. We need clarity. I am fed up with wandering about in a hall of mirrors.

We listen to one Labour Minister and get the impression that something will happen and then that is immediately contradicted by the next. We were told, quoting the Secretary of State at Health questions, that it would be up to PCTs whether or not they divested themselves of their provider functions. Yesterday, the Chancellor of the Duchy of Lancaster, no less, told the Public Administration Committee that it is still Government policy to turn PCTs into commissioning bodies only, and the only thing that had changed was that the end date of December 2008, which is in the Crisp letter, had been lifted.

The pressure from the Government is to force and persuade PCTs to get rid of their provider functions: the occupational therapists, the physiotherapists, the health visitors, the midwives and the chiropodists. Those are serious issues. They were not in the manifesto. Every time I listen to a Minister, they quote the little red book; this is a Maoist Government.

The Chancellor of the Duchy of Lancaster made a speech in Portcullis House on 24 August and talked in terms of "continuous reinvention and renewal." That is
 
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what he wants to see. The point is that, in this little red book, there is nothing about transferring front-line medical and clinical staff from primary care trusts into the private sector, the not-for-profit sector and the voluntary sector. There is not a single word, and if there had been, we would not have got re-elected. Do not let any Minister—whether it be the Secretary of State, the Chancellor of the Duchy of Lancaster or the Minister here—refer us to the little red book and say that we are signed up to it. We are not signed up to it. It is unacceptable.

The proposals open the gate to a wholesale privatisation of our health service. I do not have time to go into that, but the Minister will be aware of the critique published by the Adam Smith Institute decoding the manifesto—we rely on it to do that—and drawing attention to the huge opportunities for the private sector. I have said before that the private sector is like a big 900 lb hairy gorilla. Once it has a foot in the door, it will be in there. [Interruption.] I say that for effect, but there is a wee bit of truth in it.

The proposals have not been thought through; they are back-of-the-envelope stuff. The PCTs have been told that the reconfiguration has to deliver 15 per cent. in cost savings, but there is no 15 per cent. in the ambulance trusts. In Lancashire, we are told that we should have one PCT across the whole county, but Lancashire is one of the biggest counties in the country, in which more than 1 million people live. That would involve replacing eight PCTs with two little PCTs: Blackburn—I wonder why that one survives—and Blackpool. There is no coherence there at all. I say to the Minister and the Secretary of State that I want clear answers to the clear questions that have been posed. The proposals are unacceptable in their current form.

3.20 pm

Mr. David Drew (Stroud) (Lab/Co-op): Follow that, as they say. I shall do so briefly. I am grateful to my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) for securing the debate.

This is the second debate today on the same general issue—some of us were here for the debate on community hospitals this morning. It is a seamless debate. We cannot separate the future of community hospitals from some of the things going on in primary care trusts and ambulance trusts. The message to the Government this morning was loud and clear: do not tamper with, and certainly do not destroy, community hospitals for the sake of a grand vision in which facilities are outsourced and someone will take up the work.

I am in favour of a degree of experimentation. The Minister may know that I put together, with others, the idea of a health mutual on the Standish hospital site—I mention that for my hon. Friend the Member for South Swindon (Anne Snelgrove)—and I hope the Government will seriously consider that. However, such ideas can work only in partnership with the NHS.

We are talking about disembowelling the PCTs, but we made a dramatic error in Gloucestershire from the outset in that the PCTs were too small. On virtually every issue, that resulted in there being a lead PCT of the three. It therefore makes sense to unify them. I would have gone with one for the west and for the east from the outset, but we now have a unified county. I will go with
 
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that provided that it is clear that commissioning and delivery are not separate entities. I hope that the Secretary of State, if she is rethinking the strategy, will carry on in the same vein.

I am worried about what will happen to the facilities. They might go to the acute sector, but people already face dramatic problems trying to manage the difficulties of acute hospitals and those people will be overpowered. I speak with direct experience. In my idiosyncratic way, I am a governor of a foundation trust and can tell hon. Members what it is like at the front end, trying to run facilities when the chief executive comes in in the morning and some wards are at 146 per cent. capacity. That is real pressure. I do not know quite how one deals with that, but the pressures exist.

If we are to consider types of outsourcing, we must consider carefully who we do that in partnership with. As for our relationship with the care sector, if we are increasingly revolutionising the way in which we deliver services, we know where the weak link is. Sadly, it is in the care sector, which is totally vulnerable. We need to make sure that there is a better relationship between health and care. If there is continual revolution, that will never happen.

I conclude with remarks on what I am most angry about: the reorganisation of the ambulance trusts. In Gloucestershire, we were given the answer at the outset and told that we would be consulted. The answer was that there would be a unified trust unifying Avon, Gloucestershire and Wiltshire. We had a wonderful report from PricewaterhouseCoopers with traffic light signals telling us that option 1, the status quo, is red, which means that it will not be chosen, and that option 3, the unified arrangement, is green, which means that it is the one that we will go for.

Clearly, the report is a self-fulfilling document, which comes up with the desired answer. I maintain that there is a different way of doing things through the tri-service arrangements that my near neighbour in Cheltenham mentioned. Such arrangements should be properly evaluated before we mess around with that vital service, which must be linked with health as well as wider ambulance provision. The failure to deal with problems on the ground means, effectively, that we have no passenger transport. We do well with emergencies and keep within most targets, but there is no transport to get our constituents to hospital and we rely entirely on the voluntary sector. We must do something about that. That is where the pressure points lie; let us forget the structural changes and get on with the real job.

3.25 pm

Mrs. Janet Dean (Burton) (Lab): I thank my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) for securing the debate. I shall be brief, but I echo her and other hon. Members' comments about the Staffordshire ambulance service, which is consistently the best in the country, offers value for money, and is innovative. If it is not broken, we should not try to fix it.

As for PCTs, we have waited 25 years to find the perfect solution to the organisation of health services. I tell my hon. Friend the Minister that there is no perfect solution. There are different geographical areas in this country and, because there is no perfect solution, we
 
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should stop looking for one. Through perpetual change, we create anxiety among staff and afford no opportunity for the health service to settle down.

I understand the need to ensure that the unprecedented expenditure on health is well used, and that we must reduce spending on bureaucracy, and instead concentrate it on patient care. However, I am concerned that the links of PCTs with local authorities and communities will be lost. I am also concerned that the ability to develop local services and meet local need will not be able to continue if PCTs are altered. I seek reassurance that the comparative underfunding of PCTs such as East Staffordshire will continue to be addressed, and that we shall not lose out in a larger PCT area, as we did under the old health authorities.

I question whether there is true support among GPs for practice-based commissioning. Most important, I seek further reassurance, as have others, that PCTs will be able to continue to provide services directly. There is much talk about choice in primary care, but most people who need community nursing or physiotherapy do not want choice; they want a decent service in their own homes or their GPs' surgeries. Our district nurses and other health service professionals have seen numerous changes in recent years and they deserve certainty.

Finally, I turn to PCTs and the innovations that they can bring, and I shall quote two examples. The first is the renewal of Barton-under-Needwood cottage hospital, which was brought about because of the involvement of the PCT. Secondly, the development of a health centre in Winshill, in a relatively poor area of my constituency, would not have been possible had it not been for the PCT's ability to employ GPs directly, because none was interested in establishing a practice there. I seek reassurance that not only will the health centre be able to continue through whatever PCT we have, but that such services will be able to be developed in the future.

3.28 pm

Dr. Tony Wright (Cannock Chase) (Lab): If we abolish anything today, let it be the dreadful word "reconfiguration". It is an ugly weasel word, and the truth is that bad language conceals bad thinking. The fact that the NHS has an independent reconfiguration panel puts the fear of God into me. Whatever else we do, please, no more reconfiguration.

If I were asked to name the two public bodies that are working best in my patch, my answer would be the Staffordshire ambulance service, which is the best in the country, and Cannock Chase primary care trust, which has revolutionised health care for my constituents. I recently received a letter from the longest-serving GP in my constituency. He said that, were we to get rid of the Cannock Chase PCT, we would be putting all that we have achieved in recent years back into the great bureaucratic pot from which we once lost out.

I looked at the consultation of four years ago that set up the PCT. I shall not go through the whole thing because I do not have enough time, but the criteria that were brought to bear on the decision were exactly those that are relevant now, including locality focus. That consultation answers why we cannot merge three of the primary care groups in Staffordshire into a primary care trust. It states:

"This merger would involve a total population of 385,000. This would make it difficult to provide a locality focus for the specific areas."

 
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It goes on to say that the particular socio-economic characteristics of Cannock Chase would be lost were any larger scheme in place.

Four years on, the PCT has a population of 800,000. It is losing all its locality focus, as well as the attention that is paid to the socio-economic characteristics of the area. The PCT is the best thing to have happened to health care in my area, and I am not prepared to see it disappear.

I support the Government mantra on their approach to public service reform: "What matters is what works." That is a sensible, non-ideological approach. It is daft to replace it with one that says, "If it's working outstandingly well, abolish it"—sorry—"reconfigure it."

3.31 pm

Julia Goldsworthy (Falmouth and Camborne) (LD): I will keep my remarks brief because I am looking forward to the Minister's response to the thoughtful, passionate and often entertaining contributions.

I congratulate the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) on securing the debate. Many hon. Members think that the issue is important to their constituencies, not to mention the wider impact that reorganisation will have on the NHS.

The debate's thoughtfulness stands in stark contrast to the Government's approach. The speed with which reforms have been introduced and rushed out has allowed little opportunity for scrutiny. We heard several times about the letter from Nigel Crisp which hit hon. Members' desks. It was sent out on 28 July, after Parliament had gone into recess for the summer. The final sentence in the letter referred to the reorganisation of ambulance trusts. It did not merit more of a mention than that, and that is very concerning. The fact that the Royal College of Nursing is taking legal action because of the way in which the letter was issued speaks for itself. I am not sure whether it is because I am a new Member who does not understand the process, but it would have made more sense to consult on and issue a White Paper before any discussions were held on restructuring the ambulance trusts. Surely it makes more sense to decide on function before structure.

The speed with which reforms have been introduced has also been demoralising for primary care trusts and their staff. They were only set up three years ago, and this is the third restructuring in 10 years. Many think that their existing work programme will disappear and their priorities will be lost, along with the connections that the existing primary care trusts have established with local communities. Much of what we have heard has focused on the importance of those connections. It is not even a one-size-fits-all approach from the Government, but a case of any size fits as long as it is bigger than what we have now.

My primary care trust in Cornwall accepted that restructuring and some type of strategic vision were required. The three primary care trusts in Cornwall dealt, with varying degrees of success, with the financial deficits with which the previous restructuring had left them. Although some PCTs had good recovery plans in
 
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place and were returning to an even keel, others had fared much worse. As a result, their deficits have been getting much bigger.

Those that have been working hard think that there is no point in enduring all the pain if they will not see any gain. Why should they have any financial stringency if, in a couple of years, they are reorganised once again? Why work towards building good local connections and services if all that restructuring means that the progress is lost again? My hon. Friend the Member for Cheltenham (Martin Horwood) made that point well.

One of the Government's key comments about trying to build up good financial management is ironic when a key driver behind the reorganisation is economic savings rather than putting the patient first. The savings target from the restructuring of primary care trusts is 15 per cent. That automatically implies larger primary care trusts, irrespective of whether there is coterminosity with social services.

Coterminosity exists between primary care trusts and social services in London, yet the Government are planning to move to five super primary care trusts there. If coterminosity is a goal, why are the Government considering taking that away from London? Only speed, and the need for saving, is driving the move. Perhaps the plan is to fulfil the requirements of the Gershon review rather than to improve services.

There are many cases in which restructuring will result in turmoil, greater costs and poorer services. One example is Milton Keynes. The suggestion is to merge all three primary care trusts in Buckinghamshire, including Milton Keynes, into one, but because it is a unitary authority, Milton Keynes and Buckinghamshire want two PCTs—one to match the boundaries of Buckinghamshire county council and the other to match those of Milton Keynes. That sounds as if it makes sense, but they are being told that they have to move to one PCT. There has been a lot of joint working already. They have appointed a joint public health director with the PCT and pooled budgets in other areas of social care. Reorganisation will mean increased costs because they will have to undo that good work and start all over again. There will be not only a financial impact but a loss in terms of the progress they want to make.

Paul Farrelly : I know Buckinghamshire well because I had the pleasure of fighting Chesham and Amersham in the 1997 election. As with Milton Keynes and the rest of the county, Buckinghamshire is similar to Staffordshire and Stoke-on-Trent, yet in that city one PCT is proposed and accepted. There is no consistency of thinking across the NHS between different counties.

Julia Goldsworthy : I agree. It is difficult to understand the logic behind many of the restructurings. Rather than creating coterminosity and partnership working, those are being destroyed in many cases. As my hon. Friend the. Member for Sutton and Cheam (Mr. Burstow) said, continuity of care is being put at risk. Often, new structures for a move to PCT commissioning services are being created when there is no clear idea who will provide them or whether there is the capacity to make those changes. It makes one ask whether the changes are being driven by dogma rather than what is most suitable for local areas.
 
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Primary care trusts that continue to provide some care may strengthen their position as commissioners, as it could give them greater leverage to transfer out of hospitals rather than into them. The Department of Health may change its mind on that. Is it Nigel Crisp's guidance to move away from providing services by the end of 2008, or is it closer to what the Secretary of State said in Health questions last week—that community staff employed by primary care trusts will continue to be employed by primary care trusts unless and until the primary care trust decides otherwise, following full public consultation? Will the Government withdraw the guidelines? Will there be a move away from providing services? Will there be a clear statement of the direction of policy? I shall be grateful if the Minister makes that clear.

Much has been said about the changes that have taken place, whether it is the new GP contracts, the strategic health authority reconfiguration, payment by results or foundation trusts, and there is much uncertainty about the impact of those changes. The Government are introducing more change and more uncertainty, not only for NHS staff, but for patients, too. Although there has been national public consultation events for things like the White Paper, there has been no proper consultation of staff or consultation at a local level for the reconfiguration, which might be in place by April next year. Will the Minister make the future direction of policy clear? If, after local public consultation, primary care trusts decide that they want to continue to provide services, what will be the Government's response?

3.39 pm

Tim Loughton (East Worthing and Shoreham) (Con): I start by congratulating the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) on securing the debate. It is notable that this is the third debate in two days in Westminster Hall which has centred on complaints about what is going on in the NHS. I fear that I have not so much been involved in a debate, as intruded into a meeting of the parliamentary Labour party, such has been the catalogue of gripes that Labour Members have come up with.

The hon. Lady herself said that there had been many objections to the proposals which had been ignored. There was no evidence that the Department of Health was listening. The hon. Member for Pudsey (Mr. Truswell) described the PCT proposals as tablets of stone that were dropped down from the Department of Health. He asked what was broken and said that the whole process was flawed. The hon. Member for Newcastle-under-Lyme (Paul Farrelly) described it as ineptitude of truly mind-boggling proportions, saying that it was change for change's sake, based on dogma.

The hon. Member for Stroud (Mr. Drew) talked about disembowelling PCTs. The hon. Member for Burton (Mrs. Dean) said that local links would be lost. The hon. Member for Cannock Chase (Dr. Wright) said that bad language conceals bad thinking and if something is working outstandingly well, it should be reconfigured. The priceless contribution from the hon. Member for Pendle (Mr. Prentice) was that he was fed up with the whole hall of mirrors and the Government's little red book of Maoist thinking. According to him, this is a continuous reinvention and renewal process and
 
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the wholesale privatisation of our health service—a 900 lb hairy gorilla plucking parts of the health service away. It is back-of-the-envelope stuff and there is no coherence at all.

3.41 pm

Sitting suspended for Divisions in the House.

4.23 pm

On resuming—

Tim Loughton : Having echoed all the excellent comments of Labour Members, there is little more for me to do in this debate. Their comments show that there is more than a faint whiff of suspicion that staff and patients are being bulldozed into the changes. It is understandable that many people are worried.

The proposals are the latest in a string of gaffes and shambles that have come out of the Department of Health in recent weeks, at a time when PCTs and other health trusts around the country are facing enormous financial deficits that have been greatly underestimated by the Government; for example, 80-odd community hospitals are under threat. As the hon. Member for Stroud said, this debate and the one in this Chamber this morning are one seamless debate. A recent British Medical Association survey found that three out of four trusts were facing financial shortfalls of between £0.2 million and £25 million each. There are, of course, the historic financial deficits that they took on; 19 out of 28 strategic health authorities predict deficits in their region approaching £1 billion overall. The RCN has predicted a loss of 3,000 jobs.

There is concern that the proposals for changes to structures are made from a position of weakness and financial necessity rather than one of strength, and that they are not driven by a desire to make improvements to patient service and staff support.

I shall quote from a member of staff from the East Staffordshire primary care trust in the county of the hon. Member for Staffordshire, Moorlands. Mrs. Susan Voyce, who joined the PCT two years ago, wrote to the Secretary of State, various other Members of Parliament and others as a fairly new employee of the NHS. She said:

"I couldn't help but notice the dedication and enthusiasm of the staff and their commitment to improving the healthcare of the local people in East Staffordshire—I really felt that, at last, I was doing a very worthwhile job.

During this relatively short time I have observed the instigation of many new initiatives, all set up to improve the health of the population in primary care, which I understood was on the Government's Public Health Agenda. If the proposed merger of the 6 PCTs in Staffordshire into 1 large organisation is approved, then all this hard work, dedication and improvements to our local health service will be lost."

I am sure that her comments are typical of many others who work in that PCT and others throughout the country which face an uncertain future.

The same is true of my own primary care trust in West Sussex. Adur, Arun and Worthing PCT has a population of 230,000 to look after, and five PCTs will be merged into one super PCT for almost 750,000 people in the whole county of West Sussex. That bears a remarkable similarity to the boundaries of the old
 
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West Sussex health authority with which we started in 1997. How much money, time and effort has been spent and expended to replace the structure that was in place eight years ago? What will happen to much of the expertise of those in other PCTs in West Sussex who will not form the management of the new super PCTs?

That reorganisation may be right, and we should welcome any reductions in bureaucracy, as they have not transpired so far. If it means saving about £636 million that can be recycled to front-line patient care, it has its merits, but why is it being done in such a hurry? Many people have said that local focus will be lost. We have heard that from many hon. Members present. The Government have performed a U-turn since the initial missive from the Department of Health in July.

The Health Service Journal and NHS Alliance carried out a survey of all PCT chairmen in England, revealing that three quarters said that local circumstances and patient needs were not receiving proper consideration in planning reconfiguration, while only 20 per cent. said that they were. Some 54 per cent. said that reconfiguration would have a neutral impact on the quality of patient care, while 31 per cent. believed that the impact would be negative. Some 58 per cent. said that patient care would suffer from the planned cut in management cost, and four out of five said that reconfiguration would weaken the clinical engagement of GPs and GP practices in their areas. The comments go on.

The RCN's comments reflect the criticism of the rushed and confused way in which reorganisation is coming about. It is taking legal action against the Government over their announcement of the document, "Commissioning a patient-led NHS". The RCN is seeking a judicial review of the Government's failure to carry out public consultation on the proposed changes to the role of PCTs in England.

The RCN says that giving PCTs a "minimum" provider role will dramatically redistribute the balance between public and private provision in favour of the latter and that there are enormous work force implications for front-line staff. That is right, particularly as we have been told that the proposals for the changes must be in place by October 2006.

What about the problems with PCTs with large deficits—which we know many of them have—proving unattractive merger partners for PCTs that have been able to balance their books? What is the rush that has brought about those changes, such that the documents for them were issued just a few days after Parliament went into summer recess? Where is the detail?

Cathy Newman and Nicholas Timmins in an article in the Financial Times two weeks ago said:

"250,000 staff have been left with no idea who their new employer will be—possibly the private or voluntary sector, possibly local government, possibly GP practices, or even themselves if they set up as local entrepreneurs."

Are the Government still to put a cap on how much will be done by the independent sector, or is it now a completely free and open market? There are enormous work force implications for front-line staff.

The idea might be a good one, but what is there to distinguish it from the extension of GP fundholders made under the last Conservative Government? That is
 
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another example of a wasted, expensive eight years. There will be a serious impact on the NHS because 300 PCTs in England control three quarters of the NHS budget and provide a wide range of non-hospital related services. I will not continue because I know that hon. Members want to hear the Minister's response on the ambulance trust, but many Members have reflected anger about another ill-thought-out regionalisation of services, which will reduce the number of ambulance trusts by a drastic 50 per cent. A reduction to such a small number was certainly not envisaged in the Bradley review.

The proposals are hasty and ill thought out with little genuine consultation. What is the hurry? What is the real motivation behind the changes? Is it making real progress in the health service, or dealing with deficits? At this time record amounts of expenditure are going into the health service, but what on earth will happen when that tails off in the next few years? Will yet more change help the NHS after years of permanent revolution, as various hon. Members have said? If it ain't bust, don't fix it. When will the Government acknowledge the genuine concerns of many members of staff whose jobs depend on the future structure of PCTs?

Ultimately, has everything already been decided? Will the Minister come clean on that? Will he come away from the hall of mirrors that the hon. Member for Pendle said he was sick of, clear up the confusion and give a clear steer on the Government's intentions? They owe that to the many dedicated members of the NHS who work within PCTs, and for whom the changes will have a desperate and important impact.

4.32 pm

The Parliamentary Under-Secretary of State for Health (Mr. Liam Byrne) : Thank you, Mr. Chope, it is a privilege to serve under your chairmanship. First, I congratulate my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) on securing the debate on the future of primary care trusts and ambulance trusts. I congratulate her not simply on securing the debate but on the action that she has taken: she has raised the matter with the Prime Minister and on the Health Committee. Today she was admirably supported by my hon. Friends the Members for Newcastle-under-Lyme (Paul Farrelly) and for Cannock Chase (Dr. Wright). It is a good example of the way in which she has championed the issues that matter to her community.

The backdrop to today's debate is rapidly rising levels of investment in the national health service. It will have risen from £33 billion in the year the Government were elected to more than £90 billion in a couple of years' time, including £30 million extra for the local PCT of my hon. Friend the Member for Staffordshire, Moorlands. That increased investment, combined with the hard work of nearly one and a half million NHS staff, is transforming our hospitals, reducing waiting lists, improving accident and emergency departments and providing modern services, which means people are living longer. Rates of cardiovascular disease are down by nearly 31 per cent. and death rates from cancer are down by nearly 12 per cent. Those are admirable achievements for any Government.

However, the vast majority of patient contact with the NHS is through primary care. In fact, 90 per cent. takes place in primary care settings and the challenge in the
 
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next four to five years is how we improve primary and community services. We need dramatically to strengthen the services provided for people with long-term conditions and how we provide services in the community. In this country, 14 million people have a long-term condition and 2 per cent. of long-term condition patients account for as much as 30 per cent. of hospital admissions. Much of the care for those people can be provided far more effectively in the local community.

My hon. Friend the Member for Pudsey (Mr. Truswell) spoke of problems in hospitals in Leeds. I would add more challenges to the list he eloquently outlined this afternoon. Too many people are still waiting too long for treatment. Waiting times for diagnostic scans, such as MRI tests, are too long. Too many people, particularly those from disadvantaged areas, cannot find a GP fast enough or, when they have a family doctor, cannot get an appointment at a time that suits them. Too many patients are admitted to hospital because the care that they might have preferred to receive at home simply is not available in the right way at the right time.

Patients want more control over the care that they receive: they want to be able to make choices about how services are best delivered to them, they want the services to be more convenient, they want to have their voices heard and they want to be fully involved in the treatment plans. They want an NHS that works with patients, not an NHS that simply does things for patients. The question at the centre of today's debate is: how do we do that? How do we modernise the national health service? How do we create a patient-led NHS? I would argue that we have to invest more in community health and care services. An improvement—a step change—in the way in which we commission services is critical to the next period of change. That means that the NHS must get better still at securing the best possible services.

What that means for us at the beginning of this term of Parliament is that we must get the structures of primary care trusts right. We are about to put another £22 billion in growth money into the national health service. In our first two terms, we revolutionised hospital care—thanks not least to the 138 new or refurbished hospitals that have been delivered across the country. The risk we have to manage now is that a strong, vibrant and incentivised hospital sector has the potential to suck resources towards it, unless it is counterbalanced by an equally strong and vibrant commissioning function that represents patient interests effectively.

I welcomed the recognition of the need for reform expressed by my hon. Friends the Members for Staffordshire, Moorlands and for Stroud (Mr. Drew). My hon. Friend the Member for Pendle (Mr. Prentice) will be delighted to hear that I am no Maoist. I do not believe that permanent revolution is something to be encouraged. However, the hon. Member for Sutton and Cheam (Mr. Burstow) asked, "Why fix something if it is not broken?" I am afraid that that slightly misses the point. The question is not whether primary care trusts are broken, but how we make them stronger still.

My hon. Friend the Member for Newcastle-under-Lyme asked what evidence we had to back up our reforms. The sheer variability in health outcomes across
 
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the country is unacceptable and provides a clear sign that things have to change. Local primary care trusts must get much stronger. However, as part of the reorganisation, it is important that we ensure there is a proper consultation process. This was flagged up in March, so there has been some time since then. The initial proposals would be subject to full statutory consultation, where appropriate.

My hon. Friends the Members for Staffordshire, Moorlands, for Cannock Chase, for Newcastle-under-Lyme and for Pudsey raised some important concerns about proposals for PCT reconfiguration in Staffordshire and Leeds. I am extremely grateful to them for bringing those matters to the attention of this Chamber and I will personally ensure that the external panel is alerted to those concerns. My hon. Friends asked for reassurances that processes are not prejudged. It would be quite improper for statutory consultation processes to be prejudged in any way.

The hon. Member for Sutton and Cheam and my hon. Friends the Members for Newcastle-under-Lyme and for Cannock Chase alluded to the question of how we ensure accountability and local responsiveness in the reorganisation. Those matters will be dealt with in the White Paper that my right hon. Friend the Secretary of State will publish at the turn of the year.

The hon. Member for Cheltenham (Martin Horwood) raised important concerns about deficits and the treatment thereof in the proposed reorganisations. Work is under way on the financial strategy to accompany the White Paper and I will write to him with further details of that when it is ready.

Staffing is one of two central points. In the future, the way in which we deliver services should be varied according to the different needs that people have. The needs of people with chronic obstructive pulmonary disease are different from the needs of people who have had a stroke. In the case of prevention, the strategies involved in smoking cessation are different from the strategies needed to reduce levels of teenage pregnancy where they are too high. We need variability in different models.

However, there are three key facts and I hope that they provide some reassurance to my hon. Friends the Members for Pudsey, for Pendle and for Burton (Mrs. Dean). First, district nurses, health visitors and other staff delivering clinical services will continue to be employed by their PCT unless and until that PCT decides otherwise. Secondly, the terms and conditions of staff will be protected. Thirdly, any decision to alter the status quo would be driven locally following our White Paper deliberations. Form will follow function.

Mr. Burstow : The "unless or until" point has been repeated time and again as a mantra. How contingent is that "until" on what the White Paper tells PCTs what to do?

Mr. Byrne : I accept that point, but it would be wrong to prejudge the outcome of the White Paper. The heart of the matter is to ensure that, as the great philosopher Billy Connolly said, our "dogma mustn't run over our karma". That point was eloquently made by my hon. Friend the Member for Cannock Chase. I assure my hon. Friends the Members for Newcastle-under-Lyme
 
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and for Pendle that I am sure my right hon. Friend the Secretary of State for Health will have the last word on health policy on this matter.

Martin Horwood : Will the Minister give way?

Mr. Byrne : I will not because I have three more points to make before concluding.

My hon. Friend the Member for Staffordshire, Moorlands raised important concerns about Leek. I hope that my hon. Friend the Member for Pendle will forgive me for quoting from the little red book. It was clear on community hospitals and said that this Government's policy will be to ensure a new generation of community hospitals, which are extremely important, and that where staff are employed by the PCT the Government's policy—I have just outlined it—will apply.

My hon. Friend the Member for Staffordshire, Moorlands raised important concerns about ambulance trusts and reorganisation. I was first alerted to the brilliance of Staffordshire ambulance service by my hon. Friend the Member for Cannock Chase when I was writing a book about reform in public services a year or two ago. The plans that have been put forward in the west midlands confirm that there is a need for local call centres and local management autonomy and flexibility if we are to preserve the advantages and secure the further advantages of the plans for new investment.

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