Dr. Richard Taylor (Wyre Forest) (Ind): It is my privilege to have secured the debate. I am delighted that the Under-Secretary of State for Health and two other Members who represent Worcestershire constituencies, are in the Chamber, because I have become used to these debates being pretty nearly one to one, without many other Members present.
This subject is extremely topical for my constituents, and it will be very relevant to the Opposition day debate later today. I shall try to show that this is not only a local issue, but an example of problems that are increasingly widespread throughout the country. I shall, however, try to show that there are answers, too. My points come under four headings: the need for a review; the selection of options; the consultation process; and answers and solutions, which I really believe there to be.
First, why is a review necessary? In the words of the trust, it is necessary to achieve financial balance and to secure sustainable, high-quality clinical services. We know that for the first year ever, the national health service as a whole has not achieved financial balance. Various sources disagree about the amount, but the NHS as a whole is in the red, which has led the Department of Health to instruct primary care trusts and acute trusts to fulfil their statutory duty to balance their books.
The Worcestershire acute hospitals NHS trust tells us that it can break even in the year 200506 only with a cost-improvement programme of £15 million and with the support of the strategic health authority of £6.7 million. There is therefore a gap of £20 million to £30 million in the trust's finances. That does not include the PCTs, which also have deficits.
The problem is intense because of the unknown effects of payment by results and practice-based commissioning, because of the consultant contract, which is working out to be far more expensive than anyone predicted, and because of out-of-hours care, which is also more expensive than people predicted.
The trust brought in an external, independent management consultant to work out options for the review. The first thing that it discovered was that the trust is a high-cost provider compared with its peers, that the use of beds and theatres is inefficient, and that there are different deficits on different sites and among different specialties.
The first actions on the list are absolutely obvious: improve productivity, reduce bed occupancy, reduce length of stay, increase theatre productivity, and review the skill mix. No one argues with that. The aim and the figures that the consultant quotes depend on reaching the upper quartile for the length of stay in the peer group for all specialties.
I do not expect an absolute answer today; instead, I shall submit a parliamentary question. Will the Minister say whether the aim is feasible? Is any trust in the country in the upper quartile for length of stay in its peer group for all specialties? That is what the trust is aiming for.
The trust must reduce bed occupancy to 90 per cent. That should be possible if the trust ensures that there are no unnecessary admissions and that the entire process is
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speeded up. It is essential to reduce bed occupancy because the people who worked out the contract with the private finance initiative hospital in Worcester allowed there to be a surcharge for occupancy above 90 per cent. It is well known that 85 per cent. is the ideal for bed occupancy in an acute general hospital. The trust worked on a figure of 90 per cent., which was unrealistic given that people now agree that there has been a reduction in the number of acute beds. The trust is therefore paying some £2 million a year more simply because it exceeded 90 per cent. occupancy. Unfortunately, those who were involved in the negotiations have long since left, so we cannot hold them to account.
The second option in the list is about reconfiguring and rationalising sites, particularly focusing on sites and specialties with big deficits or staffing difficulties, but they include some of the bread-and-butter things that are most important to people: obstetrics, paediatrics, accident and emergency, and cancer services. Obviously, reduction or loss of such services will be violently opposed by everybody. I shall return to that issue.
Another option is to increase tradingagain, absolutely obvious. Bring back the work that is going out of the county. However, that will be harder with choose and book, and with competition from the private sector, particularly if it is allowed to compete on advantageous terms. Another option is to improve income recoveryagain, obvious. Get back every bit of money. That should be done.
An ominous option is to cease trading in unprofitable activity. Thank goodness, that is not being followed up immediately. Based on the trust's own figures, unprofitable activity involves obstetrics, A and E, and cancer. Even in a health market, one cannot reduce such services. The only other option that I shall mention is refinancing the PFI contract. If, as I presume, that means lengthening the mortgage, I would be very sorry if that were to happen.
On consultation, I welcome the trust's promise that the process will be open and that decisions will not be made beforehand. At present, we are in a period of pre-consultation. I refer to the splendid document, "Keeping the NHS LocalA New Direction of Travel", which was published by the Department of Health in 2003. It states that consultation
It appears that the trust is taking those points on board in its pre-consultation, but there are huge problems for the managers in charge of the consultation. It must be seen to be fair to all people. I refer to a decision in Wyre Forest in 199798 that was, patently, not fair. It involved robbery of one area's services to attempt to solve problems elsewhere in the county's NHS, and was brought about at the end of the consultation by a pseudo-statistical option appraisal and a vote by 80 per cent. of the county against the other 20 per cent. The result was inevitable, and, as has been shown, did not lead to improved quality of care. That is why we cannot have any more drastic downgrading. It has not saved money but has cost local people a great deal of their own money and has led to many problems.
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"If the price of moving the complex emergency to an appropriate centre of expertise is that this patient is accompanied by another nine or 10 patients who are not complex acute cases then another set of problems is launched."
There certainly are problems when a patient is taken out of their own area. Sometimes it is easier to admit them than to let them go home in the middle of the night, particularly as a taxi from Worcester to Kidderminster can cost £40 in the evening. What elderly person has £40 in their pocket for an unexpected need?
I shall spend a few moments on answers and solutions, because I strongly believe that they exist, and again I shall refer to "Keeping the NHS Local". In the valuable summary of consultation responses that came out in July 2004 we find this sentence under the heading "What next?":
It is reconfigurations that always cause the problems. As I have said, they must be fair. They must also make economies where the major deficits are and must be viewed from a county-wide perspective to ensure that what is developed is best for the county as a whole and all the people.
No one is saying that we must keep everything at every site. We know that such complex procedures as cardiology and neurosurgery, transplantation, some cancer treatment and major vascular surgery are better carried out in major units. That is borne out again in "Keeping the NHS Local", which says:
That can be done by sharing and partnerships. Why have we not heard of trouble from Hexham and Bishop Auckland? It is because they have partnerships and degrees of downgrading that have worked, without causing a vast amount of strife. They have lost their A and E departments, but, in return, they have 24-hour urgent-care centres, where a doctor is always present. They can fulfil the requirement of "Keeping the NHS Local" to provide a minimum first port of call to assess, treat and, if necessary, transfer. They have kept medical admissions. What was so unacceptable at Kidderminster was the loss of the A and E and all acute admissions. That happened in the days when it was believed that hospitals had to have surgery if they were to keep medicine. Thank goodness that view has now been overruled, and acute medical admissions can be retained without keeping all of surgery
Miss Julie Kirkbride (Bromsgrove) (Con): The hon. Gentleman and I clearly share a great interest in this subject. Is he saying that the Alexandra hospital could
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become a centre such as the one at Hexham? Is he aware that at present about 48,000 cases go to the Alex every year and 52,000 to Worcester? Does he believe that it is remotely feasible that that could or should happen?
We lost so much in 2000 and we have borne the pain. We now have a modern treatment centre, which is not yet fully used, on which about £19 million was spent, not only for us but for the whole county, to separate elective from emergency treatment. That facility cannot be lost and must be used more. The annual audit letter for 200304 said:
"The trust sees an increased case load at Kidderminster as the solution to many of its resource configuration and financial problems, but progress will be hampered if arrangements for medical cover in the evening and at night are not quickly agreed upon and implemented".
We lost our A and E, and that certainly has not worked. We have only a nurse-led minor injuries unit and patients still unnecessarily travel to Worcester. To support the point made by the hon. Member for Bromsgrove (Miss Kirkbride), I know that many people in Redditch depend on that A and E department. Moreover, the journey from Redditch to Worcester is far more difficult than the journey from Kidderminster to Worcester. A nurse-led minor injuries unit at Kidderminster hospital is not adequate. We also may lose our chemotherapy suite, which £400,000 of the local people's money initially provided.
The review across the county must be realistic and fair. Pain, if necessary, must be shared. We hope against hope that history will not be repeated in Worcestershire, or in other parts of the country where fairer and more easily implemented solutions are available. I remind the Minister of the 2001 Nuffield trust publication, "Local medical emergency units: learning set interim report", which details partnerships between neighbouring hospitals that really can work.
The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing the debate. I also acknowledge the presence of the hon. Member for Bromsgrove (Miss Kirkbride) and of the Minister for Schools, my right hon. Friend the Member for Redditch (Jacqui Smith), who has written to my right hon. Friend the Secretary of State about her concerns for the hospitals in her area. Like the hon. Member for Wyre Forest, she has been in touch with Michael O'Riordan, as far as I am aware, about concerns over the proposals. The hon. Member for Bromsgrove may also have written to him, but that has not been brought to my attention.
These are complex issues. My primary responsibility as a Minister is public health, so I am always considering ways in which we can prevent people from ending up in hospital in the first place, as far as that is possible. I also examine the scope for providing the type of services that people in the 21st century want and that meet their needs, whether in hospitals or in local community
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services, which I would describe as "closer to home" rather than "primary care" services. Those outside the profession do not really know what that term means.
Before I deal with particular issues that the hon. Gentleman raised, I shall spend a few moments talking about some improvements that the Government have made through our programme of investment and reform, because the two go side by side.
I was pleased to attend a debate in Westminster Hall on 2 November during which my hon. Friend the Member for Waveney (Mr. Blizzard) talked about an orthopaedic surgeon at his local hospital who performs operations back to back. That surgeon performs more operations than two other consultants in his hospital. It is interesting to hear, for a change, about a different method of working that produces significant results.
We have significantly increased funding to the three Worcestershire primary care trusts of Wyre Forest, Redditch and Bromsgrove, and South Worcestershire. Hon. Members may be aware that, for the current financial year, these three PCTs have been allocated a total of £509.7 million, which is a cash increase of £43.1 million a 9.2 per cent. increase. In the next two years, these PCTs will receive a further increase of £113.4 milliona 20 per cent. increase.
These record levels of investment will help to improve the standard of health care for the people of Worcestershire, but that money must be used well. The money is provided for both the short and the medium term, but it also needs to be used to underpin necessary reform of the clinical service. That is very much linked to what the community wants and to the shape of the community and its different needs.
In March 2001, more than 1,200 patients at the Worcestershire acute hospitals NHS trust waited for between six and eight months for in-patient treatment. Almost 1,000 patients waited for more than nine months. However, by September 2005, only 154 were waiting for between six and eight months. Since March 2004, no patient has been waiting longer than nine months for treatment. So, congratulations to the planners and the staff for their role in that. Out-patient times have also been reduced. In March 2002, nearly 1,000 patients had to wait 13 weeks or more for an out-patient appointment. By September of this year, that figure had been reduced to 130. Again, good work is being done locally.
There are more staff working at the trust now compared with April 2000, when it was first established. There are more consultants, doctors, nurses, midwives, therapists and scientists, and 134 more health care assistants. I am pleased to say that, alongside that, money has been invested in better facilities for staff, because that is important in terms of recruitment and retention. That includes £87 million for the new Worcestershire Royal hospital and £14 million for the new treatment centre at Kidderminster. New MRI and CT scanners have been delivered to the Alexandra hospital, as well as a new cardiac catheter laboratory. That is progress.
I note the comments that have been made about the financial situation at the trust. Those are important matters. I do not think that the issue is necessarily
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something new that those locally have just become aware of. We know that with fundingI have outlined the substantial increase in fundingcomes financial responsibility. It is important that all NHS organisations aim to achieve financial balance. I am aware that there have been calls for the Department of Health to intervene in cases where the local NHS is struggling to achieve a financial balance. That has happened in a number of areas throughout the country. However, the problem is that intervening would penalise those organisations that do achieve a balance year on year. In such situations, the NHS organisations concerned must work with their strategic health authorities and primary care trusts to develop financial recovery plans that will help them to achieve a sound financial footing.
Comments have been madethe matter has also been raised by my right hon. Friend the Member for Redditch in letters to my right hon. Friend the Secretary of State and to the trustabout the private finance initiative and payments to the contractor arising from the building of the Worcestershire Royal hospital. Of course, PFIs have enabled us to progress to have the largest hospital-building programme in the history of the NHS. I do not think that anybody in the areas served by the hospital would say, "No, no. Have the money back. We wish that we hadn't gone down this route." However, some issues have developed with the initiative as it has grown over time. One hundred and twenty-seven new hospitals have been, or are in the process of being, delivered through this method.
I understand what the hon. Member for Wyre Forest said with regard to the current financial pressures in the trust, which he and others feel are not being helped by having to make increased payments to the contractor concerned. However, my understanding is that some of the problems are created or exacerbated by the bed occupancy rates and the length of time that people are staying in hospital. The threshold is hit and suddenly the extra payments come into place. I hope that these issues will be considered closely during the pre-consultation period and also during the statutory consultation period due to begin in December. That particular aspect needs to be considered as a first requirementin relation to links to improvements in the service, both in terms of what is provided in the community and the high occupancy ratesbefore moving on to any other areas.
I know that there have been discussions with the Department of Health on the PFI and that questions have been raised about whether there is a possibility of changing it. All that I would say at this stage is that people should not be looking to thatI am not suggesting that the hon. Gentleman is doing soas a solution to the problem in the first instance. Part of the solution lies in the way in which beds are used in the hospital, how long they are used for and how they link to other services in the community that could meet needs better and either stem the flow or get people out more quickly into better social care settings. That is an important matter that has been raised.
Issues have been raised about the finances on which the current proposals are being based and the options that the consultants arrived at. I know that my right hon. Friend the Member for Redditch and other hon. Members are in close discussion about how the figures were arrived at. They are scrutinising them, which is
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entirely right; it is a proper way to engage in the process. I am sure that other hon. Members, like my right hon. Friend, are meeting their constituents to ensure that they understand what is going on so that they can ask questions of those who have to be held to account in relation to the proposals that they will put forward.
However, there are clearly some financial problems at the Worcestershire acute hospitals NHS trust that have to be overcome in partnership with PCTs and the West Midlands South strategic health authority, but also as part of the public engagement, which we hope will be understood and supported by the wider community and those served by the trust.
The hon. Gentleman has already mentioned that there was an accumulated financial deficit of £23.8 million that arose over a three-year period between 2001 and 2004. I should point out that the strategic health authority anticipates that the trusts will be in a break-even financial position in 200506, but there is an underlying deficit of about £20 million. That is why a major service and financial review is being undertaken by the trust. Its objectives are to examine how that £20 million will be recovered so that the trust can be restored to financial balance from 200607, and to have a better look at what services are working and how services currently provided might be better provided in future. I am certainly not an expert in that area; it is down to those closest to the local communities, including parliamentary representatives, to make such representations and, I hope, engage in the discussion of ideas.
The aim of the review was to identify the future size and shape of safe, affordable, high-quality secondary care services. The review is redefining where boundaries lie between primary and secondary care and how community hospital and services should integrate with the proposed future configuration of secondary care services. That is important, considering that the Department held a big consultation during the summer on what people want from health services in their community. This work concerns the provision of
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services that are fit for purpose and the needs of communities in the years ahead, but it also needs to be linked to sustainable financial balance.
I appreciate the concerns of hon. Members, who will no doubt be worried about particular specialties that I understand are now subject to further discussions and about the potential impact on their local hospitals arising from this work. The initial work was presented to the trust board on 6 October and those options are now being discussed as part of the pre-consultation stage. I shall get back to the hon. Gentleman on his question about trusts that are in the upper quartile in relation to length of stay, and I shall follow that up with a written reply.
The hon. Gentleman also made a point about those who are chronically ill and how they might be affected by the proposals. Any trust or strategic health authority engaged in this discussion has to take into account how it will deliver a health service for those most in need. Alongside that will be the Government's support and direction from the targets that we have set on those issues that are of most concern, such as cancer, chronic heart disease and so forth.
The pre-consultation work started in early October and will continue until December. The formal public consultation document is expected to be launched in December or January. I hope and trust that everyone concerned will feel that they have an ample and transparent opportunity to have a real say in that process and that hon. Members will be kept informed, rather than having to ask to be kept informed. I have talked to representatives from the local area and asked them to assure me that that will be the case. If any objections emerge, the local overview and scrutiny committee will consider those and the matter could be referred to Ministers for a final decision. I hope that there will be a full and detailed debate on those matters, which I know are of huge concern to right hon. and hon. Members.
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