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Why are we here? Are we here to complain about less money for healthier, wealthier areas? No, I am not. I accept the principle that health service funds have to be targeted and that that may mean that areas such as Gloucestershire receive less funds per capita under some circumstances than areas of greater overall deprivation. However, one of the problems with the cuts and the savings proposals that are being imposed on Gloucestershire is that even in towns that may be prosperous as a whole, such as Cheltenham, there are areas of deprivation. It is the most vulnerable and poorest people in those towns who are being hit hardest, because they are the people without transport. They are the people who find it difficult to access services in other towns.
Are we here to blame local NHS managers? That is what the Under-Secretary of State for Culture, Media and Sport, the hon. Member for Tottenham (Mr. Lammy), said on Newsnight last week. He was asked whether local NHS managers were to blame and he said, Yes. But surely that cannot be true. As neighbouring Members have said, in Cheltenham and Tewkesbury in particular, we have a partnership trust with three stars that was about to be in the first wave of foundation trusts; Gloucestershire Hospitals NHS Trust, which is a low-cost provider of health care by national standards and is very efficient; and, above all, Cheltenham and Tewkesbury primary care trust, which has never been in deficit and this year posted a £1.2 million surplus. Our NHS managers have done everything right. They have done everything that the Government asked of them. The primary care trust was described in The Daily Telegraph, which I do not often read, but which I am sympathetic to todayas arguably the perfect PCT that has done everything that the Government asked.
Are we discussing how patient care is improving everywhere, as the Secretary of State told the House last week? Well, no, that cannot be true either, although I will prevent the Minister from having to recite the usual things about additional investment in the NHS by saying that I am pleased that there has been additional investment in the NHS. I recognise that, and my party welcomed and supported additional investment in the NHS. We acknowledge the real improvements in health services that have taken place, including the reduction in waiting lists. However, that is not the issue today. The way in which the Government have gone about delivering that spending has led to breathtaking inconsistencies and results that I am sure that they did not intend, but which are proving devastating for our local NHS. We have overspending on things such as the GP contract, the consultant contract and the new out-of-hours service, and even on worthy initiatives such as NHS Direct, which I understand has gone massively over budget.
We have the nonsense of consultants being flown in to Cheltenham general hospital from Germany and France to meet Government waiting list targets at enormous expense at a time when we are facing cuts in front-line services. Initiative after initiative and target after target are being imposed on local managers to the point where it is impossible for people to keep track. Let us think about the simultaneous initiatives that are going on at the moment: payment by results, patient choice, agenda for change, practice-based commissioning, the change
to the trusts funding tariff, the change to funding NHS dentistry, the reorganisation of the strategic health authorities, and the reorganisation of the primary care trusts, which means that the very managers who are supposed to be coping with all this change and coping with the cuts in front-line services are in the process of having to be made redundant and applying for new jobs themselves. It is little surprise that the overall sense is of panic and confusion and that, as the hon. Member for Stroud pointed out, there is a real misunderstanding of exactly which numbers are which and whether savings have to be made month by month, or whether we are talking about clearing all the financial deficits in one year, which is the line that has been fed down to local managers, as they understand it.
Then we have the political decisionin effect, the political decision that the deficits, however they have arisen and whoevers fault they are, have to be cleared in one year and have to be funded not from other areas of Government spending, but from the successful areas of the NHS such as ours. There is no law that says that the NHS has to live within its means in any particular budget year. Once the deficits have arisen, it is a political decision as to how unsuccessful areas are bailed out. If one wants to be brutal and insist that they live within their means and make up the whole deficit in one year themselves, that is one argument, but that is not what the Government are saying. The Government are saying, Well, actually, we will bail them out. They dont have to live within their means this year. Where one bails them out from is the political decision. The Government are saying, We wont bail them out from ID cards or from troop commitments in Iraq or any number of other areas of Government. We will bail them out from the most successful areas of the NHS such as Cheltenham and Tewkesbury.
What result does that have for the perfect PCT that has done everything right? On 28 March, 27 Gloucestershire health community savings proposals were announced. I am afraid that no clinical justification was given with them. Of those proposals, 22 are about front-line care. For Cheltenham and Tewkesbury, this means that we have faced a triple whammy. First, our primary care trust economised and tried to live within its meansdespite less funding for being a healthier, wealthier area. It made economies and did not launch initiatives that it could not afford. So we lost out there. Secondly, there is top-slicing, which the hon. Member for Stroud has talked about. Finally, we are losing services that we simply share with primary care trusts such as Cotswold and Vale, because they are our neighbours and, overall, we have to make savings on the basis of what has now been invented as the Gloucestershire health community. The promise that I was given about a year ago that the savings and the financial recovery plans would apply only in their own geographical areas has gone by the wayside.
Mr. Laurence Robertson: The hon. Gentleman makes some powerful points. Does he agree that there is a further problem, albeit a short-term one? Given that the PCTs are going to be changed this year, there could be redundancy payments and extra pension payments. I accept that that will be a one-off cost, but it will make balancing the books even more difficult. Is it not only reasonable that the trusts should be a given a little bit of time to balance the books?
Martin Horwood: I entirely agree with that. In fact, the atmosphere in which things are being done is so febrile that, at a recent meeting where all the countys MPs met the chief executives of the trusts, I asked about the impact of having to take more timequite properlyover consultation. The impact was another £1 million of savings that they were told to find. The manager who replied to the question said that they did not think that even the existing savings proposals would make up the amount that they were being asked to save by the strategic health authority and, above it, the Department of Health. The atmosphere of financial crisis is all-pervasive. The numbers vary. I managed to find a total of £29 million, but the hon. Gentleman has mentioned figures in excess of £30 million.
I am afraid that the result is not, as the Secretary of State believes, patient care improving everywhere. Instead, there are real impacts on front-line care. St. Pauls maternity wing is a first class maternity ward that is just 10 years old. We celebrate its 10th birthday party this Wednesday. It is in Sandford park at 12 oclock if the Minister cares to come along. She might find a rather hostile reception. I was born in its predecessor hospital. We have had that service in Cheltenham since the 1940slong before this Government were elected. My children were both born in the ward. It delivers 2,600 babies a year and serves a town with a population of 110,000 people. It draws in mothers who wish to give birth there from as far afield as Banbury, Malvern and Evesham, and even from beyond Gloucester in the Forest of Dean. One might arguably say that if one maternity ward were to close it might be Gloucesters rather than Cheltenhams, since Cheltenhams seems to be rather more popular. However, I would not want to encourage recent accusations of snobbery in that respect. The most important thing is that Cheltenham women want to give birth in Cheltenham.
A patient safety argument has been made in favour of the proposalrather after the event since it came up as a savings proposals. It is argued that bigger and better maternity wards are always safer. That might be true, but in the end that is an argument for the entire country going to St. Marys in Paddington for their delivery. There is always a balance of risk to be struck. In a meeting today, midwives put to me the risk posed by combining dual centres into one centre. That makes the maternity ward more vulnerable to infections such as clostridium difficile and the much more widely known MRSA. The whole trend of obstetrics and midwifery recently has been away from big hospitalised units towards smaller, friendly units, and away from treating maternity as a sickness and towards regarding it as a healthy, normal process.
Mr. Drew: The hon. Gentleman is making the case for Stroud, which is a wonderful midwife-led unit. I am sure that he will agree that there is a lot of evidence that, where obstetrics and gynaecology are in an acute setting, there is a tendency for more intervention, whereas obviously in a place such as Stroud and in midwife-led units elsewhere, there is a belief in natural childbirth, which is what a lot of women choose. If we close down Stroud and Cheltenham, we are taking away that choice.
I certainly agree that smaller, friendly units will have a tendency towards fewer
interventions. The midwives I met to discuss this issue with, who were concernedindeed, appalledby the proposed closure of St. Pauls, were worried that a bigger, more industrial-scale unit at Gloucester would lead to more interventions, not fewer interventions, thereby achieving exactly the reverse of what Government policy is supposed to be. The notion of patient choice is ludicrous, because Gloucestershire has been left with a single maternity ward. Where is the choice? There is a choice of one, as we will close two maternity wards that would have provided some competitionin new competitive speak.
The increased drive time to the new maternity centre in Gloucestershire poses a risk to Cheltenham. The drive from one of the poorest parts of my constituency, Clyde crescent, to Cheltenham general hospital takes five minutes in the middle of the afternoon. If maternity services move to Gloucestershire royal hospital under the proposal, drive time will increase to 23 minutes, which is a fourfold increase and represents nothing other than an increased risk.
Mr. Clifton-Brown: If the hon. Gentleman is concerned about the risk of travelling from Cheltenham to Gloucester, will he consider the position of my constituents in the north Cotswolds? It will take them at least 20 minutes to reach Cheltenham, even by ambulance, and they will have another 20 minute ride from Cheltenham to Gloucester, so they will indeed be at risk.
Martin Horwood: I am inclined to agree with the hon. Gentleman, as he knows the statistics in his constituency. However, in some cases the percentage increase in drive time is worse in urban areas than in rural areas.
Turning to adult mental health services, which deal with some of the most vulnerable members of my constituency. The loss of non-geriatric mental health services at the Charlton Lane centre in my constituency will be reflected in the loss of adult mental heath places overall in Gloucestershire. The mother of a girl who suffers from paranoid schizophreniaI shall change her name to protect her identityrecently wrote to me:
Younger patients, like Emily, will either go to an already existing hospital in Gloucester, whose beds will be heavily over-subscribed, or be...treated in their own homes by rapid response teams. These people cannot give the 24 hour treatment that Charlton Lane Centre gives, patients will be left in their homes to fend for themselves for much of the time. When Emily is poorly, the voices take over the whole of her thoughts and she is unable to cook, clean, shop or take proper care of herself. Those are the physical problems, added to these are the mental problems, the fear, the thought that someone will kill her is always very strong in her mind at these times, that is why she runs, to escape. The voices always tell her she is going to be killed, which in itself is a totally distressing and debilitating state of mind. There are lots of mental health sufferers in the community, but there are times that they can only properly be cared for on a 24 hour basis with properly trained staff in hospitals designed for this purpose. With this closure, there will be a chronic shortage of beds. I feel the Government and the Local Government will be letting down the most vulnerable section of our community with what is so obviously nothing more than a cost cutting exercise. A broken arm can mend at home once the patient has received the correct medical care, a broken mind requires a lot more care and attention if the patient is to survive.
I could not have put it more eloquently. We need to consider whether the decision to provide more care in the community for mental health is the correct direction of travel. There is an argument for trying to encourage clients to be less reliant on institutional services, but surely that proposal, along with bed closures, should follow the successful implementation of community care. It is particularly brutal to close the service and hope that those vulnerable people will cope while it is withdrawn.
There have been cuts in community nursing, health visitors and community palliative care, too. Surely, the Government should encourage such services in the new direction of travel, but I met nurses today who said that the implementation of the cuts had resulted in qualified district nurses being replaced by nursing auxiliaries. The mix of nurses in Cheltenham and Tewkesbury is 85 per cent. qualified and 15 per cent. unqualified nursing auxiliaries, but under the proposals, that will change to 50 per cent. qualified and 50 per cent. unqualified. Nurses will arrive in someones home in the community and find that they have complex health needs. Those nurses may be unable to cope, whereas in hospital they could ask a more senior or qualified nurse for assistance. A palliative care nurse told me that she was certain that there would be a big impact on the care provided to patients. The first community palliative care nurse post has been frozen, although the population is ageing and improved therapies mean that people spend longer in the palliative care phase of treatment. As a result, more care is needed, not less.
Finally, there is a deep sense of injustice in Cheltenham at the loss of overnight childrens care at Battledown. The loss of that service is a stark illustration of the fact that, even though the clinical case was made for its retention, it was subject to a budget cut. A year ago, after a 27,000-signature petition and a £40,000 consultation, in which 98 per cent. of correspondence was in favour of the service, a recommendation was made to accept the clinical case for keeping overnight care at Battledown childrens ward, as 350 children a year would benefit. I pay tribute to Julie Coles, Carol Jones, David Downie and many others who campaigned tirelessly for the service. The recommendation resulted in the acceptance by all three primary care trusts in Gloucestershire that a nurse-led unit should proceed. The decision that overnight care should be saved was minutedI have provided the Secretary of State with a copybut it was overturned only weeks before the launch of the unit on the basis of cost. It was listed as a savings proposal, and thus the death knell was sounded for overnight care.
Mr. Drew: I know something about the issue, which I have debated as a governor of the acute trust. I agreed with the clinical judgment, but the campaigners made a great deal of effort to find an acceptable compromise. That was discussed properly by the acute trust, but none of the proposals, including proposals from the trust itself, were discussed by the governors. Does the hon. Gentleman think that that is the right way to proceed? There is a great deal of unease about the role of foundation governors, and this does not help.
I agree entirely, and I am sure that the hon. Gentleman agrees with 13 of his fellow
governors of the NHS trust, who wrote to the Secretary of State on 11 April:
Over recent times, Governors, Members and local people have worked tirelessly in order to maintain overnight Childrens Services at Cheltenham General Hospital. This and the wider services are now under threat, as are many others, including our Community Hospitals. All this makes the national requirement that significant NHS service changes need to be the subject of full public consultation to an absolute farce.
I am therefore advised that the decision not to proceed with a proposal does not require consultation as it does not constitute a service change because the service does not exist.
There are many other savings proposals on the list that I would like to discuss, but time is limited. However, the closure of the Delancey hospital has raised fears about the hasty cutting of rehabilitative beds and care. The local branch of the National Council Women wrote to me:
We know that much of the responsibility for such care will fall on family members, usually women, and doubt that this will be satisfactory. Even care homes, where professional care is available, often have to send their residents to Delancey for specialized care. Relatives, no matter how well-meaning, will not be able to cope.
Accident and emergency services and patient support services are under threat. The prescription of drugs following new guidance from the National Institute for Health and Clinical Excellence is one of the savings proposals, so it will be deferred. I am sure that the Minister would like to claim credit for Herceptin when it is introduced in the rest of the country, but it may not be available in Gloucestershire. There will be cuts to patient transport and access to acute carethe list goes on and on.
We look forward to the consultation, but the result of the Battledown consultation does not give us great cause for hope. I beg Ministers to reconsider the situation in Gloucestershire, as the proposals will have an impact on one of the most successful parts of the NHS, which should be a model for other services. They must rethink the need to clear those deficits in a single year, if such a ruling has been imposed, and the damage to successful parts of the NHS, whoever is to blame for the original deficits.
Mr. Geoffrey Clifton-Brown (Cotswold) (Con): Thank you, Mr. Deputy Speaker, for allowing me to catch your eye in this debate. I congratulate my hon. Friend the Member for Tewkesbury (Mr. Robertson) on securing a constructive andgiven the circumstancesgood tempered debate. Rarely have I heard a debate in the House in which I have not disagreed with anything that other hon. Members have said. As my hon. Friend and the hon. Member for Stroud (Mr. Drew) made clear, this is a cross-party issue. There are no political differences between us. We are interested solely in our constituents in Gloucestershire receiving the best possible health care within the budgets available.
I thank the Minister for being present this evening. As the hon. Member for Stroud said, she has been
dragged to four such debates. She is in an unenviable position, but we would be grateful if we could get some answers and some clarity from her this evening. As has been pointed out by everyone who has spoken in the debate, the chief issue on which we need clarification is exactly what remit our primary care trusts are working to. Are they working to a remit of clawing back previous deficits, or are they working to a remit merely of bringing the situation back nearer to balance by the end of the financial year? That is critical.
I hope that the Minister, who is consulting her Parliamentary Private Secretary behind her, will be able to give us the answer tonight. If she cannot, I should be grateful if she placed an answer in the Library as soon as possible. More important, I hope she will be able to give an instruction to the strategic health authority if the remit is different from the one to which it is working. If the SHA is working to the more severe remit, it may well be making decisions and unnecessary cuts to institutions. We had a dire announcement on what I call black Wednesday a few weeks ago, in which 12 of our health institutions in Gloucestershire were shut or severely curtailed, and several hundred jobs and 250 beds were to be lost.
In my area, the Cotswolds, we had already had an announcement of closures in in-patient care in both Tetbury and Fairford. The in-patient care at Bourton is still subject to discussion, and we have had the curtailment of 10 beds in Moreton-in-Marsh community hospital, with the lure of the possibility of a new community hospital to replace those lost facilities in Bourton and Moretonbut only the lure, and with the scale of cuts that we are facing and the financial stringency, I wonder whether we will get any new facility builds. We may find beds being closed on the lure of a possible new facility, but we may well not get that facility. That type of comment pervades the whole debate. The hon. Members for Stroud and for Cheltenham (Martin Horwood) made that point clearly. In Cirencester I am faced with the cut of an entire ward of elderly mentally ill patients.
We were on the march together on Saturday, as the hon. Member for Stroud said. We were marching not only to protect maternity facilities in his constituency, which are attended by people from my constituency, but to protest at the cut of Weavers Croftfurther cuts in facilities for mentally ill patients. No new facilities are yet available in Gloucester, where all those elderly mentally ill patients are supposed to go. The existing facilities could be closed before the alternative is arranged. That would be a cruel irony for elderly mentally ill patients. The hon. Member for Stroud noted that a cut, if it is that, of 30 per cent. of the activity of the partnership or mental health trust is a huge cut, and it affects some of the most vulnerable people in society. My constituency used to haveI do not know whether the statistic is still up to datethe third highest number of over-80-year-olds of any constituency in the country. This level of cuts will affect my constituents very severely.
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