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NHS Structure (Northern Greater Manchester)

11 am

Graham Stringer (Manchester, Blackley) (Lab): Sadly, today is an appropriate time to talk about the delivery of health services in north Manchester, given the information on the front page of The Times this morning about the unfortunate patients who were misdiagnosed by the radiology service in Trafford and north Manchester. I shall mention that briefly later.

North Manchester has some of the worst health statistics in the country, the most startling of which is that a male child born today in north Manchester has a life expectancy of 72.3 years, whereas a similar child born in east Dorset has a life expectancy of 80.8 years. For every 10 years that that boy from north Manchester lives, a boy born in east Dorset can expect to live an extra year.

Those statistics are from an extremely detailed and, in a sense, depressing publication called "Where Wealth means Health" by the Centre for Public Health at John Moores university. The report points out that there has been no real change over the past 10 years in the relative rates of good and bad health as they relate to class. Even though people at the bottom end have become healthier, they are still just as far behind people at the top end.

My constituency is among the top 10 in terms of the number of people claiming incapacity benefit and the level of heart disease, and the number of people suffering from cancer is also among the highest in the country. Consequently, the mortality and morbidity rates are very high. By quoting health statistics from different documents, I could probably fill the whole hour and a half with that depressing story, but I put those statistics to hon. Members simply to show how important it is to deliver health services as effectively and efficiently as possible in a poor area where people suffer from poor health.

Most of my area is covered by the Pennine Acute Hospitals NHS Trust, which consists of one headquarters and four hospitals—North Manchester general and the Bury, Oldham and Rochdale hospitals. It is the second largest trust in the country, employing more than 300 consultants and covering five primary care trust and five local authority areas. It is an unusual trust, and it was conceived and set up within the past four years in answer to a particular problem.

Services were being reconfigured in the wake of improved resources and of the child care problems in Bristol and the report that followed. It was recognised that a concentration of specialists needed to work in one place to ensure that health care standards were right and that services would have to be reconfigured. When the Pennine trust was being set up, however, there was a worry that many of those specialist services would end up in the centre of Manchester. It was thought—incorrectly, as I shall argue later—that the configuration of the hospitals at Oldham, Bury, Rochdale and north Manchester would allow those services to be organised rationally. That, then, is the background in terms of the quality of health and the delivery units for health care.

Like many hon. Members, I have had several meetings with patients, trade unions, doctors and administrators, and I was told that everything was not
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well in the Pennine trust. However, things really came to a head last summer, when an extraordinary alliance was formed. The consultants passed a vote of no confidence in the whole management team. Although that was initiated by the discussions on the new consultant contracts, the consultants' resolution went much wider. The trade unions passed a similar resolution, which was initiated by a disagreement about car parking charges. Again, however, that was the spark, and the discontent and complaints went much wider.

The strategic health authority responded by asking Professor Alberti and Dr. Joan Durose to look into what was wrong in the Pennine Acute Hospitals NHS Trust. They interviewed about 1,500 people and talked    to trade unions, the consultants and the administrators. After two months, on 17 October, they produced a report, which was given to the public on 1   November. It was a rather sad, critical analysis of poor administration, bad communications and low morale, and 25 recommendations were made at the end.

The human resources director and the medical director left, and that could have been it. The administrators—the management—said that they accepted all 25 recommendations, but several of my hon. Friends and I were again approached by medical staff and trade unions at the hospital, and we wanted to find out more. The report wanted the answers to three key questions, and so would any sensible person who looked at it. First, could the trust carry on with the personnel who remained after the human resources director and the medical director had left? Had there been sufficient changes? Had the right decisions been taken or was more needed? It became clear that the trade unions and many medical staff thought there should be greater changes.

Secondly, the Pennine trust is, as I said, the second largest NHS trust in the country. Were greater structural changes needed? Was it too big to be managed? Clearly, it had not been managed, but was one reason for that the fact that it was simply too big? As I said, it covers five local authorities, five PCTs and four hospitals.

Thirdly, there is the common-sense question—the first I was asked by journalists and the first thing that people living in north Manchester and patients want to know: are health services being delivered as effectively as they could be and are patients safe? When consultants say that they have no confidence in the management, we should all worry.

I read several times Professor Alberti and Joan Durose's good, well-balanced report, which does not go further on those points. I also took the trouble, as did other hon. Members, to go and talk to Professor Alberti, the trade unions and administrators all over the system to see whether enough was done with those recommendations, and whether there has been progress in the three months since the report was written. The one person to whom I have not spoken in the past week, since I found out that I had been fortunate enough to come up in the draw and secure this debate, but to whom I would like to speak, is the chief executive of the Pennine trust. Since he was appointed, I have had regular meetings with him and have found him to be a reasonable man to deal with, but my phone calls have not been returned in the past four days, so I do not have
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the value of his views on what I am going to say. However, I talked to virtually everybody else in the system in that time.

I return to the first point about personnel. Do we have the right balance now? Two senior members of the executive have left. Was that right? That is as far as the report goes. On page 6, Alberti and Durose say:

What conclusion would you, Mr. Olner, or any other reasonable person draw from those two sentences? I draw the conclusion that even though it is not written in black and white, Professor Alberti thought that the chairman should take the same decision as the medical director. I can think of no other way of interpreting that part of the report.

When I talked to the trade unions and the medical staff—I do not want to misrepresent matters and say that this is the formal view of the trade unions, the joint medical committee or any other professional body—I formed the view that they do not believe that it is possible for the trust to improve with the current chairman and chief executive in post. The trade unions and a consultant said to me, in effect, that it is all right for the director of human resources to go, but he was the chief executive's representative on earth. He was head-hunted and appointed by the chief executive, and his actions were under the direct control of the chief executive. It is unlikely that the communications and management style will change.

On the third point, a series of reviews is going on in the health service in north Manchester, as is the case elsewhere in the health service. Children's services are being reviewed, as are maternity and young people's services; major changes in configuration are being considered at the four hospitals; the primary care trust structure is being changed; and cancer services have been reviewed.

Any hon. Member knows that conclusions on the reorganisation of health services are not reached by any process that could be described as an exact science. Usually, everyone is well motivated and people want the best for the service, but the process involves an element of horse trading and the attitude that, "If Salford gets this, Tameside will have to get that." I am concerned that if a public report implies that the chairman and the chief executive of a large trust are not doing their jobs as well as they should, the people in the Pennine acute trust area whom I and other people represent will lose out in those discussions. I know that the Minister for Local Government, my hon. Friend the Member for Oldham, East and Saddleworth (Mr. Woolas), is concerned about the debate on whether a linear accelerator should be placed in Hope hospital in Salford or in Oldham. In such a debate, will the same confidence be placed in a management that has been so heavily and publicly criticised?

David Heyes (Ashton-under-Lyne) (Lab): The case was made strongly in terms of priorities that north-east Manchester is at the head of the queue regarding the need for improved cancer services. Does my hon. Friend agree that if there is a lack of confidence in the
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management and leadership of the trust, questions will be raised about whether it should still be accorded that priority?

Graham Stringer : That is precisely the point that I am making. If difficult decisions are to be made and if there is weak leadership, as the Alberti report says, there is likely to be a different result—not necessarily a happy one for my hon. Friend who, like me, represents many people who need high-quality health care.

I will not go through all the reorganisations that are taking place, but the same is true for the reorganisation of children's services. There has been a ministerial commitment from this Government and the previous Conservative Government that secondary paediatrics will be moved from Booth Hall hospital, which is closing, to North Manchester general hospital. I want to be sure that the top management understand that and are in a position, when difficult decisions have to be made, to ensure that that commitment is honoured.

I did not enjoy making those comments. As I said, I have had no personal difficulties with the chairman or the chief executive of the trust, but I think that the report and the issues speak for themselves. As one administrator said to me, "If somebody wrote a report like that about me, I would want to move quietly on to another part of the health service and leave it." I do not wish either of those people ill, but it is clear that they have failed in this case and need to move on.

The second issue is structure. Again, the Alberti report does not say as a recommendation that structure is a problem, but if one reads the report it does suggest that. It says that the remoteness of the four hospital sites from each other has been a problem in their   communication and management, and that the geographical problems have been mirrored by emotional problems. To put it another way, people have been emotionally committed to, say, North Manchester general or the Royal Oldham hospital, but there has been neither the site management at that hospital nor the integrated management throughout the Pennine acute trust to make them believe that those hospitals are part of the same organisation. That has led to demoralisation.

When I have gone to those hospitals, as either a visitor or a Member of Parliament, or when members of staff have come to my advice bureau, I have found that people all believe that their hospital will close in favour of the other three. That is clearly nonsense, but it is a measure of the poor communications and management structure across the five sites. There is a fundamental problem, and it would have been difficult to make the five sites work, even with the best administrators in the world.

It is worth quickly going through the rest of the Government's policies for the delivery of health services in Manchester. PCTs are being organised on the basis of local authority boundaries, which means that there is a proposal to put the three PCTs in Manchester into one; the mental health services have been reorganised into one trust across the city of Manchester; and the local authorities have been given a monitoring role in the health service. It would be sensible to follow that line of
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argument and move North Manchester general hospital to the city of Manchester, either into Central Manchester and Manchester Children's University Hospitals NHS Trust, with Manchester royal infirmary and the children's hospital, or into a trust of its own. I realise that there would be problems in doing that immediately—although there is some urgency about the matter—as well as administrative difficulties, but I do not believe that the Pennine acute trust will ever work given its current structure.

Mr. Stephen O'Brien (Eddisbury) (Con): I have listened to the hon. Gentleman's argument with great interest and care, and he makes his case extraordinarily well. He mentioned the reconfiguration of PCTs—along county boundaries, for instance—which in almost all cases will make them much larger, yet earlier he made a powerful point about the Pennine acute trust being simply too big—indeed, it is one of the largest trusts. Does he draw the conclusion that, in fact, the bigger and more centralised such organisations become, the less responsive they are to local patient need, and that perhaps there ought to be a review of their restructuring into bigger configurations rather than smaller ones?

Graham Stringer : The hon. Gentleman makes a good point. Size is an issue, but so is complexity. The Pennine trust, on five sites, is the second largest in the country; it is too big and too complex. My guess is that if it was scored for size and complexity, it would score higher than any other in the country.

The hon. Gentleman knows, because I think that in another life he was an accountant—

Mr. O'Brien : Business man.

Graham Stringer : The hon. Gentleman knows that there is always a balance to be struck between economies of scale and complexity. The case that I was making for North Manchester general hospital was for it either to be a stand-alone trust, in which case all the size problems would be solved, or to go into Central Manchester trust. That would be a large trust indeed, but it would be lined up with the PCT and the local authority, in terms of accountability and the normal patterns of travel in the area.

When the Pennine acute trust was set up, patients did not have the choice that the Government have given them in the past few weeks to go to one of four hospitals. I would say to the Under-Secretary of State for Health, my hon. Friend the Member for Don Valley (Caroline Flint), that, given a choice, people in north Manchester are much more likely to go into central or north Manchester than to travel to Oldham, Rochdale or Bury.

I make no point about any of those hospitals, but those are the travel patterns of people in north Manchester. That will make the reconfiguration of services around those four hospitals very difficult. If one set of services was introduced in Rochdale, for instance, and people had the choice of going to Manchester royal infirmary in the centre, where the services were replicated, I have no doubt that 99 out of 100 people in north Manchester would travel in to the centre, not outward. Those are the reasons why the structure is not right.
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On safety and the delivery of services, again, Professor Alberti said that patients were not put at risk. However, the report says:

but continued that

That is worrying.

I do not intend to delay hon. Members by discussing all the people who come to my advice bureau to tell me about the problems they face when they go to hospitals. All hon. Members have such cases because, as anyone    who watches "ER" or "Casualty" would know, clinicians are not all saints and hospitals are not all perfect. The real question for the Pennine trust is whether its structure and that of the management mean that services are not delivered as well as they might be.

A lady from the constituency of my hon. Friend the Member for Heywood and Middleton (Jim Dobbin) came to my advice bureau to say that she desperately wanted the Pennine trust to be broken up, because she had received terrible services in one hospital. She had watched a patient not being fed, who later died, and the conditions were unhygienic. That may be so, but I    cannot show a direct relationship between the structure of the trust and the management in that case. There may be, just as there may be a relationship—I do not know—between the tragic cases of those women who, according to The Times today, were diagnosed by a radiologist as being clear of breast cancer when they were not clear. However, where there are problems such as those that the trade unions and consultants exposed in the Alberti report, one has to worry about those processes more intensely than normal.

There is a further stage of concern. A constituent came to my advice bureau and said that, as she was recovering from a gynaecological operation, the surgeon had said to her, "I have had to hack about a bit because the laser that would normally have done the work accurately has been transferred to Oldham." That is a cause for concern. I am still waiting for the chief executive from the Pennine trust to reply to me on that point, but this begins to look like a structural problem.

More directly, talking to consultants, they have told me—there is nothing wrong, and I do not want the Conservatives to get excited—that, quite normally, there are two waiting lists, one active and one clinical. The active waiting list is the one we usually talk about; the clinical is the one for people coming in for return check-ups, such as coloscopies or other invasive treatments. They are two separate lists, but a consultant told me he believed that administrators were interfering between those two lists without consulting clinicians. That is not acceptable and is evidence that people are being treated according to administrators' interference rather than the decisions of clinicians.

Another point was made strongly to me: within the system of waiting lists and timing, there is no administrative system—even though clinicians have asked for it—to determine whether there is only one surgeon in the whole of Greater Manchester capable of carrying out a particular procedure. So, people are left
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on waiting lists. They are sent to the PCT and then on to the private, independent treatment centre in Trafford, where it is found that the expertise required does not exist there, so they have to come back. That is poor administration.

I come to my final point on the quality of services delivered and, potentially, the safety of patients. There is a nationwide shortage of pathologists, but I was informed that a pathologist was not appointed, although he was medically suitable, because the administrators refused to sign the contract. If there are positives instead of negatives in the pathology laboratory, or negatives instead of positives, people's lives are at risk.

In bringing my remarks to a conclusion, I hope that I have been able to show that the Alberti report amounts to more than its simple conclusions. Underlying the report, there was a view within the health establishment and the strategic health authority in Greater Manchester that more change would be damaging to the service. I understand that view—it is not unreasonable—but we must consider the evidence to weigh up whether more change would give better delivery of services, as opposed to change that can be shown to be in line with the rest of Government policy.

I also believe that there was a view—it would not surprise me if any administrator had this view—that trade unions and consultants, even in an unprecedented, revolutionary partnership, should not be able to sack administrators. I hope that I have shown that while the conclusions of the Alberti report do not suggest moving people on, the detail quite clearly suggests doing just that.

No one in north Manchester is under any illusion: health services have to change and improve. In my constituency, a number of hospitals have closed during the past 20 years. Monsall isolation hospital, Ancoats hospital just outside the constituency and the Northern hospital have all closed, and Booth Hall hospital for children is to close in 2009—a decision taken in the dying days of the last Conservative Government.

People recognise that there is a need to change, but the Government also need to ensure that there is support for those changes. Rearranging children's services, maternity services and cancer services causes people with relatives who have needed that care to worry. If there is no public support for the changes, they will be more difficult to achieve. From a political point of view, as well as from a patient-care point of view, I want people to recognise this Government's commitment to putting resources into the health service and making those resources work. I do not want the public to feel so alienated from the services that they think that those extra resources are wasted or being used in the wrong place.

If the structure of the Pennine Acute Hospitals NHS Trust continues as it is, I worry that it will be an inhibitor to the reorganisation and reconfiguration of those services. I worry that if the management continues as it is, neither consultants nor other staff will give it their support. Having listed some problems that I have been told about, I must say that it is a tribute to all staff that the service has continued at such a high level, but I believe—it is impossible to read the reports without thinking this—that the level could have been higher if the administration and the structures had been different.
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I hope that my hon. Friend the Minister will respond positively and consider these issues, which relate to the future and the best configuration of health services for one of the poorest populations in the UK and, indeed, in western Europe.

Several hon. Members rose—

Mr. Bill Olner (in the Chair): Order. There are three Members standing, all in a line. I hope that I can call them all, but the time restriction is that I want to start the Opposition Front-Bench spokesmen's winding-up speeches just before 12 o'clock. If hon. Members can limit their speeches to that time scale, they will all be able to speak.

11.37 am

Jim Dobbin (Heywood and Middleton) (Lab/Co-op): I congratulate my hon. Friend the Member for Manchester, Blackley (Graham Stringer) on securing what Members of Parliament who are affected by the Pennine Acute Hospitals NHS Trust and the reorganisations that have taken place will feel is an important debate on a sensitive subject. I want to declare an interest: I worked at the Royal Oldham hospital, which is part of the trust, for more than 22 years and I was also a member of a former Rochdale health authority for a number of years, so I know many of the people who are involved in the reorganisation.

I would probably start from a slightly different stance from my hon. Friend. We have discussed the problems that have arisen because of the reorganisation and we each understand where the other is coming from. When a massive reorganisation takes place—I am talking about the creation of the very large trust, with mergers within primary care trusts, and all the other reorganisations that are taking place in the health service—and the same people manage the whole process, it causes huge problems. Some thought must be given to that issue.

When the Pennine Acute Hospitals NHS Trust was set up, I agreed with the move for the reasons that my hon. Friend has given. In other words, there was a fear of marginalisation if it became part of a much larger Manchester trust. My constituency does not have a hospital, but it is surrounded by four of the hospitals that make up the trust: the Royal Oldham hospital, North Manchester hospital, Fairfield general hospital in Bury and Rochdale infirmary. My constituents go to whichever hospital they are geographically close to.

I understand where my hon. Friend is coming from with his concerns about the structure of the trust. My view is that there has basically been a management failure—a management problem—and had that been tackled correctly when the trust was set up, perhaps many of the problems might not have arisen. It is the second largest trust in the country, but its structure suits my constituency and my constituents fairly well in terms of access. However, there have been very serious management problems there. The biggest part of those problems was the lack of communication, and a failure to set up systems on the four sites that could relate to the centre.
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We made the point in the early days that that was essential because of the massive change that was taking place. There was no real leadership, and staff on the four sites had no clue about whom they were accountable and responsible to. There was a failure to make the presence at the centre of the four sites felt. I see that as the major problem.

A huge reconfiguration is taking place, which is being managed by one of the primary care trusts. It is being led by my PCT in Heywood and Middleton, which is due to merge with Rochdale. That reconfiguration is itself causing huge problems because of the lack of communication. Once the consultation process starts, there will be big improvements, and we have recently had discussions about that. However, the confusion created by the way in which the acute trust has been managed has caused concern at the public level and serious insecurity problems at the staff level on the four sites. That has led to the meetings that have been described and the votes of no confidence expressed. It is extremely serious.

With my experience in the health services, I have seen many reorganisations, which have led me to think that some groups of professionals are not innocent. There has been some territorial protection in the system, and we are beginning to see some of that emerge in certain hospitals because of the reconfiguration that is taking place. That has not helped, and the message that must go out is that no change is not an option. The consultation process must be improved, and as far as the management of the Pennine acute trust is concerned, I am not sure whether a change of leadership is the best move. However, it must be considered, and the emphasis that the Alberti report put on better communications and stronger links between the centre and the four sites is the way ahead, and that is what I would advocate.

11.43 am

David Heyes (Ashton-under-Lyne) (Lab): I start by congratulating my hon. Friend the Member for Manchester, Blackley (Graham Stringer) on securing this important and timely debate, which is of such significance to my constituents in Oldham as well as to people in north Manchester, Rochdale and Bury. He has given the context and a good overview of the health issues in his constituency. Sadly, those in my constituency are little better in many respects.

It would be wrong to start without putting on record an acknowledgement of the improvements that the Government have brought about across the board in    health services in the north-east and Greater Manchester, the area served by the Pennine acute trust. The extra investment put in year on year has had an impact on health prospects and outcomes for the 800,000 people served by the trust. However, the creation of the Pennine acute trust—the shotgun marriage of Bury, Rochdale, Oldham, and North Manchester about four years ago—was not a happy event. The hospitals across the sub-region did not, and still do not, sit comfortably together. The trust, which, as we have heard, is the second largest in the country, just seemed too big, unwieldy, and challenging to manage and lead effectively.

It is often felt that little progress has been made during the past four years to reshape the trust into a more manageable configuration. However, at long last,
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just over a week ago, we saw the launch of the public consultation exercise, to which my hon. Friend the Member for Heywood and Middleton (Jim Dobbin) referred, on proposals for the reconfiguration of services, including hospital-based services in the north-east and Greater Manchester. The document is entitled "Healthy Futures", but it is remarkably silent on the pretty unhealthy recent past. During the past couple of years, it became increasingly clear that things were not going well at the top of the Pennine acute trust. Relationships between managers, doctors and trade unions were far from healthy, as evidenced last summer by the virtually unanimous vote of no confidence in the trust's top management team, to which my hon. Friend the Member for Manchester, Blackley referred.

Against that worrying background, and like my hon. Friends, I welcomed the review carried out by Professor Alberti and Dr. Durose. The publication of their report in late October last year was keenly anticipated and, when it came out, the report was frank and hard-hitting. Alberti and Durose found deep-seated and long-established problems, many of which could be traced back to the time when the trust was established. Although they choose their words with care, the report is particularly critical of the top-level leadership at the trust. My hon. Friend the Member for Manchester, Blackley has already quoted the passage that states:

The report goes on to say that the chief executive's style of leadership

The report homes in on the role of the chair and non-executive directors, saying that they need to exercise

Tellingly, the report continues:

An important message to emerge from the Alberti-Durose report—I have to acknowledge that generally this matches my own perception—is that the quality of patient care at the trust's hospitals did not suffer too greatly during the difficult period when the trust's senior management came under such serious criticism from the staff. As my hon. Friend the Member for Manchester, Blackley said, that is not to say that there have been no problems but, to the extent that it is true, it speaks well of the dedication, competence and public service ethos among the middle managers, consultants and medical staff, and backroom and front-line workers at the hospitals—the phrase "lions led by donkeys" comes to mind.

The current position is that the medical director has gone, but the chair, non-executive directors and chief executive are still in post. I hope that they are working to   carry through the action plan called for by Alberti and Durose to implement the 25 far-reaching recommendations in their report. Soon, the chair, non-executive directors and chief executive will face the immensely challenging job of carrying through the trust reconfiguration process, which will be determined in the light of the consultation outcomes.
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I hope that lessons will have been learned, changes in    style effected, leadership issues addressed and communication links put in place, so that we can look forward optimistically. However, it could still be the case that the core problem has simply not been addressed. Even with a dramatic turnaround that sees the adoption of the best management practices and with inspirational leadership, the trust might be just too big, too cumbersome and too unbalanced ever to be capable of delivering the changes necessary to produce the quality of service that our constituents deserve.

Alberti and Durose conclude that

Their recommendations concentrate instead on strengthening site management and on devolution of operational decisions to divisions, with the chief executive and executive directors cast in the role of arbitrators. I hope that Alberti and Durose turn out to be right in declining to add to the complexities of the reconfiguration process. The public consultation, which is under way, is built on the same premise. The consultation document, the video presentations, the publicity bus that will tour the area—none of that envisages anything other than retaining the present hospital grouping. The option of cutting the size of the trust's geographical area to a more manageable scale is not on the agenda.

The immediate future promises much-needed expansion in community-based care and treatment, with 35 new health centres throughout our area taking on significant areas of work that would previously have required someone to make a hospital visit as an out-patient or in-patient. All that implies a difficult period ahead for our hospitals as they have to adapt to the new environment and carry through the huge organisational changes that are necessary. Based on their track record, it is difficult to be optimistic about the ability of the present leadership to make a success of that.

Paul Rowen (Rochdale) (LD): What does the hon. Gentleman think the solution ought to have been following the publication of Professor Alberti's report?

David Heyes : With respect to the hon. Gentleman, if he had been present earlier, he would have heard my views and those of my hon. Friends about the matter. The lesson for the hon. Gentleman is to try a bit harder to get to the debate.

One question remains unaddressed: given the scale and complexity of the trust, would any hospital management team—no matter how skilled and experienced—be capable of delivering the changes and improvements that our constituents rightly expect?

11.50 am

Mr. David Chaytor (Bury, North) (Lab): I congratulate my hon. Friend the Member for Manchester, Blackley (Graham Stringer) on securing the debate. I am sure that my hon. Friend the Minister appreciates the strength of feeling among all local Members about the issues related to the difficulties in the Pennine Acute Hospitals NHS Trust. Labour Members have discussed the matter at length. The four of us present met Professor Alberti to discuss the report, and we met staff representatives throughout the trust to discuss these issues.
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I speak as someone who was born in one of the four major hospitals in the trust. During the past 18 months, I have made 28 visits to those four hospitals in my roles as a Member, as a patient, and as a relative of a patient who needed treatment. I am familiar not only with the hospital in my constituency, Fairfield hospital, but with the other three major hospitals in the trust.

I have carefully considered the issues, especially during the past 18 months, and I do not entirely agree with my hon. Friend's conclusions. We have discussed them together, and I am happy for him to press the argument; however, I do not completely agree with him. He makes an important point about the text of the Alberti report, particularly its hidden meaning when it refers to the way in which the chair and the chief executive should respond to the report. Having said that, from my personal dealings with the chair and the chief executive, I have nothing but praise for the courtesy and efficiency with which they have responded to my requests for information, or, on many occasions, my complaints about certain aspects of the trust's operation during their term of office and mine.

I want to put aside the question about the current leadership and concentrate on the other issue that my hon. Friend raised: the structural issue about the size and location of hospitals in the trust. I do not believe as   a matter of principle that a trust of this size is unmanageable, nor that a trust spread across so many hospitals is unmanageable. I accept that the trust is very large. It is the second largest non-teaching hospital trust in the country, but one has to be the largest and another has to be the second largest, so that in itself cannot be an argument for inevitable change.

Many difficulties that have led to disputes between staff and management during the past few months have been due to the size of and inadequate attention to site management on each of the four main sites. That in itself is not an insoluble problem. However, where the trust may have a problem with size is due to the fact that its hospitals carry out too many basic NHS functions, with not enough being devolved to primary care. That problem is being dealt with by the "Healthy Futures" consultation.

We can confidently expect significant devolution to what I understand is to be 35 newly developed and refurbished primary care centres throughout north-east Manchester. I fully support that process of devolution to primary care. When the balance between what is carried out in primary care and what is carried out in secondary care is better achieved as a result of the process, many issues concerning the overall size of the trust may be resolved.

There is great controversy about some aspects of the proposals in the consultation on the reconfiguration within the acute trust and the consultation on the wider issue of children and maternity services throughout Greater Manchester. Now is not the time to get into the merits of that debate, so another Adjournment debate may be needed to explore fully the controversial aspects of those decisions. My hon. Friend was right to say that no one is arguing against change. We all accept that the   status quo with the large concentration of acute hospitals within a small geographical area cannot
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continue. The news from Manchester this morning about cancer care has highlighted the importance of the    concentration of specialist expertise in certain specialisms on particular sites. However, the precise location and on which sites services need to be will be debated in great detail during the next few weeks.

My hon. Friend has raised a crucial issue about health care in north-east Manchester, Miss Begg—Mr. Olner has disappeared. It has implications for health care in the centre of the city, too. I am not convinced that his argument that the Alberti report leads inevitably to a demand for structural change or a taking out of the North Manchester General hospital into the Central Manchester Healthcare NHS Trust is the case. I note that Professor Alberti and Dr. Durose state specifically in their report that they

They said "at this time", and that is an important qualification. Nor do I consider that the problems should lead inevitably to the immediate resignation of the chair or the chief executive, but whether that team can carry through the necessary changes and improvements remains an open question.

Although I do not agree fully with my hon. Friend's conclusions, he has raised an important issue. My hon. Friend the Minister would be well advised to give careful consideration to it and explore all the implications both of the capacity of the current management team and the future configuration of the trust.

11.58 am

Stephen Williams (Bristol, West) (LD): Good morning, Miss Begg. Welcome to the Chair. I congratulate the hon.   Member for Manchester, Blackley (Graham Stringer) on securing the debate. He started with a wide-ranging and detailed speech about services in his constituency and throughout Manchester. He described his constituency as an area of social deprivation and drew a contrast between that and Dorset, which was perhaps the most extreme case that he could come up with for differences in life expectancy. Although he drew on an extreme example, such differences in life expectancy can often be found within much narrower areas. I do not claim to know Greater Manchester that well, but I know that it has some extremely prosperous areas as well as extremely poor areas. That is certainly the case in my city of Bristol.

The hon. Gentleman said that his constituency was an area with a high intake of incapacity benefit. Indeed, I    read that in a table published yesterday in the newspapers. I empathise with such statistics because, although I represent a prosperous and well-educated city in the south of England, I grew up in the south Wales valleys and I know from childhood and early adult experience about poverty and despair and what effects that they can have on ill health and outcomes. The Minister, whom I often encounter at meetings, often points to the link between ill-health and poverty and the fact that one reinforces the other, and she will perhaps speak about that later. However, despite the Government's squirting billions of pounds into the national health service over the past eight and a half years, many pressing problems still need to be considered, most notably in the Manchester area, and that is the topic of this debate.
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Labour Members have referred several times to the Pennine Acute Hospitals NHS Trust, which covers north Manchester, Bury, Oldham and Rochdale. My hon. Friend the Member for Rochdale (Paul Rowen) was telling me this morning about the report produced by Professor George Alberti, and he had intended to speak about it in greater depth, but he was detained further along the corridor in a Committee scrutinising a statutory instrument, so we were unable to hear him make his remarks at length.

Paul Rowen : Does my hon. Friend not agree that Professor Alberti's report, which makes 25 detailed recommendations and is very damning of the Pennine trust's management, leads to the conclusion that the hon. Member for Manchester, Blackley (Graham Stringer) reached in my absence that the trust is perhaps too big to be managed efficiently? As an alternative, the Minister should perhaps look at some form of reconfiguration, given that north Manchester might fit in more sensibly with the other Manchester hospitals.

Stephen Williams : I thank my hon. Friend for his point, which was certainly made earlier. The hon. Member for Manchester, Blackley referred to the trust's size and complexity, and the hon. Member for Eddisbury (Mr. O'Brien), speaking from the Conservative Front Bench, alluded to fact that the size of NHS trusts sometimes contributes to such problems. So those points have been well made.

The NHS is in a time of great change and upheaval as a result of Government reforms. In a letter in The Guardian this morning, the Secretary of State for Health says that she intends

understand what is going on in the NHS. She outlines three main challenges. The first is

and the third is to "achieve financial balance". I am sure that we can all agree with the first and third of those objectives, but the second is perhaps contributing to some of the problems.

Just before the Christmas recess, I read a letter from Chris Ham in The Times. As the Minister may know, he worked in the Department of Health, and I believe that he was the director of its strategy unit until June last year. He said that the Government were at risk of unleashing a wave of "creative destruction" on the NHS through their mania for reform and change. That pattern is, of course, reflected throughout the country, not only in Greater Manchester. Representatives from throughout the country will share concerns about the restructuring of primary care trusts, the reorganisation of services, the impact of deficits and—this has perhaps not been mentioned—the impact of central targets on local clinical needs.

The Government often say that part of their solution to these problems is an enthusiasm for the market and the private sector, and that might be an appropriate response in some cases, but the impact of a private treatment centre in Greater Manchester—again, I do not think that this has been mentioned—has been to
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increase the deficit. The centre serves the 14 existing PCTs in Greater Manchester and has cost them £2   million over six months due to lack of use. The centre's contract allowed for up to 7,000 patients to be treated in a full year, but it has seen just over 1,400 in its first six months.

The NHS structure is going through constant change. The 14 PCTs in Greater Manchester will be reconfigured down to 10 so that they match local authority boundaries. I can tell hon. Members from a west country perspective that we wish that that were the case in our part of the world, where the PCTs have been made bigger so that they cross local authority boundaries, despite representations from all Members Parliament and all local unitary authorities in the former Avon area.

Liberal Democrats believe that local control and accountability of health care is the answer. I repeat the phrase used by the hon. Member for Manchester, Blackley: he referred to the size and complexity of local NHS trusts. When I first became a Member and went around meeting the various NHS organisations in the area, I could desperately have done with some sort of pictogram showing the structure of NHS services in the Greater Bristol area; it is amazingly complex. We need local, democratic control and accountability of our health care system. If there is to be major reform, that is the direction in which we need to go; that would be better than constantly reconstructing unaccountable trusts and management structures.

If democratically accountable local people take an interest in, and set priorities and local targets for, health care, the life chances of people in deprived parts of Greater Manchester, and in other cities and counties, will be transformed.

12.6 pm

Mr. Stephen O'Brien (Eddisbury) (Con): It is a pleasure to be under your chairmanship, Miss Begg, at least for the second innings of this debate. I congratulate the hon. Member for Manchester, Blackley (Graham Stringer) on securing this important and timely debate.

I shall consider the wider causes of some of the difficulties in the Pennine Acute Hospitals NHS Trust, and focus on the concomitant problems with which it has to contend. As the hon. Gentleman rightly said, this debate comes on a day when we read about a seriously unfortunate incident, in which patients in Trafford and north Manchester were mistreated and misdirected as to what might be a problem for them. As a fellow north-western Member of Parliament, I certainly share that concern; no doubt some of my constituents have been treated in those hospitals. The debate also comes a day after the Healthcare Commission's devastating report on the Mid Cheshire Hospitals NHS Trust in light of the   serious failings and mismanagement of that trust that followed on from the Barbara Salisbury murder conviction.

In many ways, in a debate of this type there is difficulty in judging what it is appropriate to air in this Parliament, and what a Minister is accountable for. There has to be a certain division between what is going on locally and what a Parliament and Government truly   have responsibility for. The hon. Member for Manchester, Blackley outlined that concern effectively
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and with some sensitivity, given some of the issues that he raised. It may be inappropriate for the Opposition spokesman to indulge too much in responding to some of those issues; that is properly a matter for the Minister, so I shall confine my remarks somewhat and shall deal with some of the underlying structures, rather than the people issues, as is appropriate.

I have certainly read the Alberti and Durose report; the obvious answer is swiftly to monitor the implementation of the 25 action points, and indeed any points that develop as a result of those being put in place. As we have seen, over the past few weeks pressure has been mounting on the Secretary of State, who is overseeing a state of tension, anxiety and even confusion in the NHS; that is because there is continual fiddling with structures, and a harrying of trusts over redesigning them yet again and over whether they should exist, rather than over what they actually do.

The Secretary of State and her Ministers are suffering sustained incoming fire from all quarters—from those on the Conservative Benches, from their own Back Benchers, and certainly from the media, health experts and Select Committees. No doubt there may be gratitude that the Secretary of State for Education and Skills has taken the focus off them in recent weeks. It is important that the accountability of Government is clear, and that structures have real, intended consequences—quite apart from unintended consequences—on local patient service delivery, because that affects the behaviour and the management of the trusts. Even now, with last week's revelations of    a cash-flow crisis in the NHS, the Secretary of State    and her Ministers have this blind spot for acknowledging the cuts in front-line services that they have made inevitable.

I welcome this debate, which provides an opportunity for us to give the Minister a little insight into some of the problems in the NHS brought about by the need to cut costs, not least, as has been so capably highlighted by the hon. Member for Manchester, Blackley and his three neighbouring colleagues, the hon. Members for Ashton-under-Lyne (David Heyes), for Heywood and Middleton (Jim Dobbin) and for Bury, North (Mr. Chaytor), in respect of the Pennine Acute Hospitals NHS Trust.

In spite of all the grand rhetoric of Ministers, who claim that no patient services will suffer in northern greater Manchester, the proposed scrapping of accident and emergency at the Rochdale infirmary is almost a foregone conclusion in the consultation. I note that the hon. Member for Rochdale (Paul Rowen) is in his place—or almost. Of course, all is done in the name of efficiency; but that is efficiency for Whitehall, not for local patients.

Saving some administrative costs by ever-increasing centralisation, as is happening with the conflation of PCTs, which is encouraged and targeted by the Government, does not even begin to count the real cost to the users or the staff in the NHS. One would argue that that is so, not least in areas of what were described as serious health deprivation, let alone socioeconomic deprivation, in respect of patients and residents in such areas.
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The Audit Commission study, "Quicker treatment closer to home" points out that patients are better treated

That is such an obvious truism that it makes one wonder why it took the Audit Commission to state it. The drive of the restructuring plan is to centralise, thus, inevitably, there will be cuts to services.

Paul Rowen : Does the hon. Gentleman not agree that the real reason why we are faced with this centralisation—he mentioned the closure of Rochdale's accident and emergency department—is because of staffing costs, which have gone through the roof, and structures, and that we are not getting the improvements in patient care that we ought to have expected, given the level of resources?

Mr. O'Brien : I am grateful to the hon. Gentleman for raising that interesting point. He and I debated the subject just over a week ago with some unity, versus the Government Back-Bench representative, on the most recent incarnation of the Granada political programme, "Party People". This was precisely the area that was covered, including the reference to the Pennine Acute Hospitals NHS Trust.

There is no doubt that the question in everybody's mind is, "Where has all the money gone?" No doubt, the Minister will be aware of this sustained attack on her and her colleagues in Government. When each Member of Parliament is looking for the demonstrable improvement in health services at patient level, the thing that comes through most regularly in our advice surgeries, bureaux, or clinics, or whatever we call them, is that there is no feeling that people have recognised the uplift that should have come through from the acknowledged increase in the funds available.

Mr. Chaytor : In response to the hon. Gentleman's question, "Where has all the money gone?", I can assure him that the overwhelming majority of my constituents recognise an immeasurable improvement in the local national health service since 1997. Whether it is in respect of the speed or quality of treatment, there is immeasurable improvement.

May I ask the hon. Gentleman a question? I said earlier that nobody I have heard locally is arguing for the status quo in this reconfiguration. The debate is about the location of sites and choice of specialisms. Is the hon. Gentleman arguing that there should be no reconfiguration in north-east Manchester?

Mr. O'Brien : I am certainly not arguing for that. I am happy to be asked that question and to answer it, albeit that the Government are accountable in this area. It would be highly presumptuous of me to make decisions about an area about which I do not have the closest knowledge. Certainly, at a national level the structural issue is both fair and important. The Government are driving the targets and designing the architecture within which trusts have to operate. It seems to me that the root cause of the problem that led to today's debate is that it was always misconceived—indeed, I remember the warnings that came from Labour Members—that the
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Pennine Acute Hospitals NHS trust should be configured as it is. I recognise that in all these cases there will not be a uniform view and that it will therefore become a balance of argument and judgment.

My constituency is very different from that of the hon. Member for Bury, North. We have a much sparser population, which is spread over rural, hard-to-reach areas, where there are enormous pockets of social and economic deprivation, despite a perception that it is all rather leafy and wealthy. There seems to be something of a postcode lottery as to whether constituents feel that they have received the funds that have gone into health services. I am not getting the same glowing refrain through my surgery door as the hon. Gentleman apparently is about the NHS and its patient service delivery.

The drive of the restructuring plan put forward today regarding what is going on in northern Greater Manchester, which looks like the centralising of services, would inevitably result in longer response times and make it harder for friends and relatives to visit in-patients, especially when the difficulty of travel through urban communities—it is bad enough in rural areas—is taken into account. Journeys may look geographically simple on a map, but travel times are often longer in urban areas because of congestion and the difficulties of patterns of travel, which the hon. Member for Manchester, Blackley and others mentioned. Clearly, the appropriate location is surely the most accessible one.

I return briefly to Rochdale, which could lose its accident and emergency department and become a locality hospital—

Jim Dobbin : It is not my information that the A and E will close in Rochdale. Eighty per cent. of the cases that would normally go to A and Es will still be treated there. I ask the Minister to clarify that point. There is some political opportunism in this debate.

Mr. O'Brien : This is a fair opportunity to raise such issues, although it may not suit Labour Back Benchers to hear that sometimes it is not all rosy in the garden. Whether it is the whole A and E department or just the emergency and immediate services that are to be affected, we must consider carefully what is intended. That is why it is quite proper to raise these issues of accountability with a Minister present. If it is to become a locality hospital—

Jim Dobbin : Will the hon. Gentleman give way?

Mr. O'Brien : I am running out of time. Having given everyone an opportunity to intervene, I need to move things on.

The Best for Health website optimistically describes a locality hospital as one that is

On closer inspection, we see that a locality hospital provides outside routine procedures as an urgent care centre—little more than basic first aid—and

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That would not be very reassuring with a serious A and E case. More worryingly, as we watch the Government's attempts to close or make cuts in at least 90 community hospitals out of the 323 in the country, how long would it be before the dispersed locality hospital, if that is what Rochdale is to become, is deemed no longer to be a worthwhile use of resources?

The other main argument put forward by Best for Health for restructuring is the prospective shortage of doctors due to the European working time directive, which comes into force fully in August 2009. Of course, it was the Secretary of State for Work and Pensions, who was then the Minister of State for Health, who in January 2004 after the SIMAP and Jaegar rulings said:

We continue to await the findings of the European Employment and Social Policy, Health and Consumer Affairs Council, and hope that it will confirm the decision of UK politicians that on-call time spent not working should not count towards total working time. That would certainly limit the damage and cuts in services. We will do what we can to help the Government win on that point of interpretation.

We want some accountability from the Minister regarding the effect that restructuring is having on the Pennine Acute Hospitals NHS Trust. If the Minister commented on the personnel issues, that would be helpful, because hon. Members are clearly looking for an answer.

12.20 pm

The Parliamentary Under-Secretary of State for Health (Caroline Flint) : In the short time available, I shall try to cover the points that hon. Members have made in this Adjournment debate. I start, however, by congratulating my hon. Friend the Member for Manchester, Blackley (Graham Stringer) on securing it.

Some interesting points have been raised, but before I get into them, let me express my concern about the involvement of the two trusts in the anxiety caused to the women who were not properly diagnosed for breast cancer. The Greater Manchester strategic health authority has commissioned an independent review to discover how and why those errors occurred, and I am sure that we all want it to be rigorous, so that the problem does not, as far as possible, arise again.

Several points have been made about health inequalities and reconfiguration. At the heart of the discussion is the issue of what our health service is for. As Minister with responsibility for public health, I suggest that the health service has tended to focus on responding to illness, which is quite understandable, given that people who are ill want treatment and want it to be to the best possible standard. For the past 50 years, the emphasis has more or less been on providing services in hospitals, which is also understandable, given the development of the national health service from where it was 50 years ago, with the needs and priorities that existed then, to where it is today.

What is interesting about this discussion is that we have all experienced a change in how we think about the delivery of health services, whether as patients or members of the public with family members or friends in hospital, or as a result of taking advantage of health
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services in the community. In another Adjournment debate that I attended, it was suggested, for example, that 40 per cent. of orthopaedic referrals could be handled outside hospital, rather than inside.

Those issues are important because they have an impact on what we think hospitals are for and on how effectively they can deliver, which brings me to the point about health inequalities. It is undoubtedly the case that more people in England are living longer. More people from all social and economic groups are benefiting from the technology used to treat heart disease and cancer, and are getting the right medication and treatment. Although the overall picture is good, however, the reality is that there is still a gap on mortality issues between those who are less well off and those who are better off. We have to look beneath the radar to address what is happening.

As Minister with responsibility for public health, I suggest that one reason for that gap is that there needs to be a better focus on health inequalities within different areas. Regardless of whether a PCT is large or small, or whether the majority of people in a PCT area are relatively affluent and well educated, I would ask whether those who are less affluent and most in need are getting the health service they deserve to meet their needs. That issue must be addressed as part of the PCT reconfiguration.

PCTs, whatever their size, must look at the health outcomes for their communities to ensure that they attend to those most in need. Alongside that is the issue of whether how we provide health services meets the needs of those who most need them. Perhaps they need a different service that will impact in a way that traditional services clearly have not. That is a hugely important debate.

On the financial situation, it is interesting that we are getting better value for money in terms of delivery in some of our poorer neighbourhoods, where the health inequalities are very clear. When we look at the trusts in deficit, we gain some interesting perspectives on those that are most in deficit. Such trusts are in a minority, but some are in more well-off areas with considerably fewer issues of health outcomes linked to deprivation, although I am not saying that they have no health inequalities issues. There are some important questions to be asked about that.

My hon. Friend the Member for Manchester, Blackley hit on a number of issues, and was absolutely right to refer   to the Alberti and Durose report on the Pennine Acute Hospitals NHS Trust. We have had a reasonable discussion about the issues that have arisen. It is worrying that a clash between consultants and management led to a vote of no confidence by consultants, and it is worrying that the report had to be produced in the first place, but that's life—not everything works as well as we think it should.

There were 25 recommendations in the report, which were aimed at strengthening the organisation in a number of different ways. Linked to that is an important point raised about confidence in leadership. This
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morning, different views have been expressed about whether the chair and the chief executive should consider their position and about ensuring that the report's recommendations are made to work and kept under review.

A big issue was raised about the lack of communication, which seemed to be one of the issues at the heart of why the five sites were not working together effectively, how people felt about their part in the trust's organisation and the sense of ownership of all the sites. Those are important.

As I said, the report made 25 recommendations. It is important for all concerned that the action plan that I understand has been drawn up should be made to work, and that there should be transparency over how those recommendations are made to work and how the action plan is carried out for the future. Clearly, if the points raised by my hon. Friend the Member for Manchester, Blackley are not attended to, they will have to be addressed again to ensure that progress is being made, and to find out why if it is not.

My hon. Friend described how the structure of the trust has contributed to the situation. Different views on that issue have been expressed and the report stops short of suggesting that now is the time for restructuring and a break-up of the trust. As one of my hon. Friends said, the report is clear that there is not the best case for doing that now. However, in light of the comments made this morning and the report itself, those issues need to be kept under review. If the recommendations are to be seen to work, they need to take account of the concerns expressed by my hon. Friend the Member for Manchester, Blackley.

The size of organisations presents a difficult situation. I do not think that there is a perfect size in any situation; part of the problem is addressing how the structure and    management of the organisation work and, importantly, what the organisation delivers for people. That is key. Linked to that is a discussion taking place in the Greater Manchester area about how services could be better delivered.

I want to make it clear that the Rochdale hospital issue is not about there not being access to accident and emergency services; it is about a blue-light service not operating. As my hon. Friend the Member for Heywood and Middleton (Jim Dobbin) said, 80 per cent. of people who come to accident and emergency do not need a blue-light service. I have seen for myself the beneficial outcome of walk-in centres and other services that can better meet the needs of those people. They are important because hospitals can then get on with the jobs they specialise in on behalf of the local community.

My hon. Friend the Member for Manchester, Blackley made points about safety and choice. The issue of choice is important—speaking for my area, I am sure that many in Doncaster would choose to go to their local hospital—but if an elderly lady's family members lived 50 miles away, she might choose to have an operation closest to them so that they could look after and visit her. So choice is an interesting debate; it is part of the future and involves addressing what people need.
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A lot of issues have been raised this morning, and I hope that hon. Members agree that I have had limited time to respond to them, but I have spoken to the Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Hodge Hill (Mr. Byrne). As the Minister with regional responsibility, he is obviously concerned about the issues. This morning, he asked me to convey the fact that he is willing to look further into them to ensure that the recommendations are carried out to everybody's satisfaction.

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