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This has become an issue because of the reforms that the Government have set in place to improve the
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national health service. Also, with the introduction of payment by results, and of GP-based practice commissioning, it is important that the NHS should be in good financial order.

Martin Horwood: Will the Minister give way?

Caroline Flint: I want to make a bit of progress, otherwise I will not even get to the questions that hon. Members have asked this evening.

Mr. Clifton-Brown: We have until 10 o’clock.

Caroline Flint: That is true, but I have just looked at you, Madam Deputy Speaker, and I think that you might want to get away before then.

It is important for the national health service to be in financial balance because it is fair to ask how the money going into the NHS is being used. All parts of the NHS in England have faced issues regarding targets, pay for staff, the agenda for change programme, and so on. They have managed all that and remained in balance. There is not just one reason for the problems. However, it is fair to ask those that are not in balance why they are not. Also, we need a system that will get them back into balance.

Mr. Clifton-Brown: We have suffered particularly in Gloucestershire because the Avon, Gloucestershire and Wiltshire strategic health authority had the biggest deficit in the country, at some £100 million. We are suffering because of the mismanagement in Bath and Bristol, and because for many years we have not had the capital allocations that other areas have had. Now the Minister is top-slicing us and giving some of our money away to Wiltshire, so we really are being hammered in Gloucestershire. I hope that she will take that into account.

Caroline Flint: I appreciate the difficulties experienced when areas that are in balance have to help out others. I, too, am in that situation locally to a certain degree. It is important that all Members whose areas are in similar situation should make this point locally, and ask clearly what they can expect back. This is not a process that will keep happening year in, year out. It is going to be put right, to provide a much more sustainable future. That is absolutely fair. From what I understand, trusts in deficit will have to provide to the strategic health authorities a clear plan for dealing with their deficit. This should also be open to the trusts that are in balance, so that those that are helping out in different ways will be clearer about what is being done to improve the situation.

Martin Horwood: The Minister repeatedly talks about the problems of tackling the trusts that are in deficit and their need to live within their means. However, the trust covering Cheltenham and Tewkesbury has lived within its means, but it cannot be repaid at some mythical point in the future, because it is merging with one of the trusts that is in deficit now. Local services are being hurt not only because of the top-slicing but because services that are shared with that neighbouring trust are being cut. So we are being penalised twice over.

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Caroline Flint: I cannot be clearer than I already have been. I do understand the hon. Gentleman’s point. However, we also have to work within a wider health economy than just one trust. People in Doncaster, for example, go to Sheffield for cancer treatment and to other parts of South Yorkshire for different services. Other people come to Doncaster from elsewhere for services. That is how the health community in which we live operates. We want access to the very best health care in some of the most challenging and demanding areas of health. That is something that we all sign up to. That is why we have to get this right, and why we have a responsibility to support each other within our local health economies. That is not letting anyone off the hook. That is what happened in the past and it was part of the problem.

It is all about changes for the future. The amount of money going into the areas of hon. Members who have spoken in this evening’s debate is substantial. There is no question that more money has been invested in the NHS. In all the constituencies of hon. Members in their places tonight, people have benefited from greater access to treatment faster than ever before. The minimum standards applied to our targets will continue to apply in the future, but to get to a place where we can think more creatively about provision of the services that we more or less all want, we have to deal with these financial problems and there is no easy route to achieve that.

I want to highlight a few points about how health is changing. In the Gloucestershire area, more people are admitted to hospital than the national average and more people are spending longer there. I acknowledge the point of the hon. Member for Cotswold (Mr. Clifton-Brown) when he said, “Hang on a second—we should not be kicking people out of hospital who need to be there.” Of course not. I have to say that I have heard some worrying stories of older people being kept in beds on hospital wards in unsuitable circumstances when they really would be better looked after elsewhere. I accept that it can be an issue around partnership with social services and it is sometimes the result of a baffling lack of co-ordination with respect to the particular problems.

Let me provide one example relating to another part of the country. Someone was receiving acute care in an acute hospital for his condition and was then transferred to a bed in a smaller community hospital. Why could he not come out of that community hospital? Partly because he had been diagnosed with diabetes and an at-home service for insulin care and management could not be provided. In that context, discussions about support for that individual included the point that choices had to be made about whether to provide the relatively straightforward services that were needed in that gentleman’s home in the community or whether he should spend four months in hospital until something was sorted out. There are legitimate debates about that choice.

About 70 per cent. of people now have surgery as day-care patients, which is a huge change from the past. Nationally, the number of NHS beds has fallen by more than 30 per cent. over the past 20 years, while the number of NHS out-patients has risen by almost 60 per cent. That has changed over the decades, not just in the last few years. Of course, there are new technologies,
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better drugs, advanced surgical techniques and improved management practices— [Interruption.] The hon. Member for Cheltenham (Martin Horwood) keeps making comments from a sedentary position, but every time he raises questions about new drugs and other choices, it goes to the heart of the issue of trying to provide a health service that can meet people’s needs, but needs to be managed locally.

Martin Horwood rose—

Caroline Flint: No, I am not giving way again. I have already given way several times to the hon. Gentleman and responded even to his sedentary comments.

The hon. Member for Tewkesbury raised some specific questions about Winchcombe hospital. I understand that, as part of the consultation, it is planned to enhance services at the Tewkesbury hospital, invest in community services and provide more rehabilitation and support in the home. The consultation will be for 12 weeks and he will be able to explore how that will happen—a pertinent question for the consultation.

I understand that some of the Winchcombe hospital’s problems relate to the building and that maintenance costs are £500,000 a year. The point was raised whether the hospital could be refurbished and used for other services, but it is felt that the fabric of the building is too old, so it would not be cost-effective to do so.

I understand that out-patient and therapy services will be relocated and that, working in partnership, another eight beds will be provided elsewhere for rehab and palliative care. Clearly, those issues will be discussed as part of the consultation exercise. Certainly, in a number of areas, including Gloucestershire, as with other parts of the country, there are options that seek to enhance and improve some of the other community hospitals or services. I understand that one of the options for Dursley is to build a new health and social care facility in partnership with an independent sector provider.

The hon. Member for Cotswold made a point about possible partnerships at Fairford hospital. It is difficult for me to comment to on that, but, clearly, he could have a conversation with PCTs and SHAs about any possible partnership development. Although the number of beds has been reduced at one facility—I think it was Tetbury hospital, which is an independent not-for-profit hospital; I look to the hon. Gentleman for reassurance and see that he is nodding—I understand that there is a discussion about how that service provider could provide more support and care in people’s homes, rather than in hospital, and that it is keen to explore those opportunities.

I will come to the financial balance, but I want to say something about maternity hospital services—an issue that has been raised by several hon. Members this evening. I have glanced at the report in The Citizen local paper. Clearly, there was a well-attended rally on the issue at the weekend. As hon. Members will be aware, the proposal is that, over the next three years, all in-patient births at Stroud maternity hospital will move to Gloucester. I understand that there are just under 6,000 births in the Gloucester area, which services Cheltenham, Gloucester and Stroud, of which about
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300 take place at Stroud hospital. Again, I am sure that that issue will be discussed as part of the consultation exercise, but that is quite a small number, and the birth rate is dropping, too.

Clearly, considering what services need to be provided is an issue. This might not meet everyone’s concerns, but I noticed in the article in The Citizen that one lady was talking about the fantastic service that she received in having a midwife-led home birth. That service will continue, including, I understand, both antenatal and postnatal support. The difference is—I am not going to cover it up, because it is in the consultation—that in-hospital births at Stroud will be moved to Gloucester. However, I want to put on the record that antenatal and postnatal services and the opportunity for those women who want to have a midwife-led home birth will still be available to women in Stroud and the surrounding area.

Again, this is a difficult issue. I have looked at the figures: women are having children older, which presents some issues. Women who have IVF treatment are more likely to have multiple births. Other issues need to be considered when providing consultant-led maternity services, particularly working times and the hours worked by consultants, as well as other health professionals. Again, those are factors in the provision of services. There are clearly financial considerations, as in everything, but there are some real issues about providing the best service possible, particularly to those most in need of that specialist service. Several Members have made points about the arrangements for getting to hospital in time, and there is no easy answer. Planning in relation to antenatal services is part of that process, and women and their partners and families need to be aware of what services are available and what arrangements they might need to make in such circumstances. Although I was in hospital for four days when I had my first child, times have changed, and for a straightforward birth, most people are in and out of hospital that day. Everyone wants to be there in the first few hours—I am not trying to mitigate that—but, for most people, days do not have to be extended for visits to their daughter or sister and her new child.

On mental health, my hon. Friend the Member for Stroud (Mr. Drew) referred to the percentage contribution being asked from mental health services, which I will draw to the attention of the Minister of State, my hon. Friend the Member for Doncaster, Central (Ms Winterton), who has been monitoring how mental health services are being affected, the proportions involved and what the safeguards should be.

All Members who have contributed to the debate this evening referred to the financial balance. As they will be aware, strategic health authorities are responsible for the performance management of their NHS organisation and for ensuring that they achieve financial balance. The aim is for the NHS as a whole to have returned to financial balance by the end of 2006-07. As I mentioned this evening and in a previous debate with my hon. Friend the Member for Gloucester (Mr. Dhanda), who asked similar questions, within an overall NHS balance position, a minority of NHS organisations might be unable to achieve a balance position within the time frame. However, all organisations that overspend will be expected to show an improvement during 2006-07. By the end of the year, every organisation should have
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monthly income covering monthly expenditure or a date by which that will be achieved in 2007-08. Strategic health authorities take a reserve at the start of the year, mainly from PCTs, and will not redistribute resources to overspending organisations but will allow them to return to financial balance across the patch with any deficits offset by the reserve held by the SHA. Reserves will have to be paid back to organisations in future years when the organisations currently in deficit start producing surpluses.

The key benefit of the new system is that it provides financial certainty as reserves will be lodged from the start of the year. That means that SHAs will not need to spend time and energy later in the year trying to persuade organisations to underspend and produce a surplus. Despite the difficulties, that has tended to be the way that it has worked—people have planned for a year and then been asked to pull back later in relation to the year ahead. Trevor Jones, chief executive of Avon, Gloucestershire and Wiltshire SHA, said in his letter of 7 June that there is

That is saying that organisations must show that they are in balance in terms of their monthly income and expenditure, but that the pool provided allows the SHA to show that the whole local health economy is in balance against the deficits. That recognises that recovering some deficits might take more time in certain areas.

That issue will have to be explored locally, but it must also be recognised that the recovery of deficits cannot keep being put off until tomorrow. That is why consultation, not just about finance but about creating a health service that is better for the future, is so important. We need systems that will improve outcomes, but will also put the service on track to achieve a meaningful financial balance that is not just secured through the reserve produced by the strategic health authority.

Mr. Clifton-Brown: I think that the Minister is eliding two requirements. One is the return to financial balance by the end of the financial year: it seems that by the end of March next year, provided that primary care trusts are back in balance, the first of the Minister’s criteria will be met. However, the Minister confused the issue by quoting from a letter from Trevor Jones saying that past deficits must be recovered by the end of the financial year. That is a much stricter and more stringent criterion than our PCTs have been led to expect. Are they to expect the first, or the first and the second?

Caroline Flint: I think it is a combination of the two. Organisations must ensure that their income and expenditure are in balance on a monthly basis by the end of the year, but must also establish plans to show how they will recover their deficits. By pooling reserve money, SHAs are helping to ensure that the whole health economy is better protected against the deficits that some areas are facing. I shall be happy to write to
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the hon. Gentleman, but I can say no more than that. All organisations that are overspending will be expected to show an improvement during the current financial year, and by the end of the year every organisation should have monthly income covering monthly expenditure or give a date by which that will be achieved in 2007-08.

Mr. Laurence Robertson rose—

Mr. Drew rose—

Caroline Flint: I will give way to my hon. Friend the Member for Stroud first. Then I will give way to the hon. Member for Tewkesbury, as he initiated the debate.

Mr. Drew: The Minister will understand why we feel so much in need of clarification. I have seen the correspondence from and to the chief executive of the SHA. I would not like it, but I think that I would understand, if all parts of the SHA worked with the same rigour that is being requested of Gloucestershire, but I ask the Minister—if nothing else—to examine the figures from the different parts of the SHA. I cannot see that other parts of the authority are being asked to face the same pain as Gloucestershire. If they are, can the Minister make that clear in the letter that she is going to send us?

Caroline Flint: I shall be happy to follow that up.

Mr. Laurence Robertson: I think the hon. Member for Stroud (Mr. Drew) made the point that I intended to make, but I will say this. I am grateful to the Minister for her sympathetic approach and I think we all accept that the organisations should be in monthly balance by the end of this financial year. That is a sensible requirement, to which we have never objected. We should like to know, however, whether the requirement for everything to balance—including historic deficits—relates to this financial year. Could it be extended to, for example, three years? That would make all the difference. I realise that the subject is hugely complicated, but perhaps the Minister could focus on that when she returns to it.

Caroline Flint: As I have said, the problems in different trusts must first be identified, along with the amounts of money involved. The trusts will be expected to produce a financial plan to turn their position around, although we want to see a monthly financial balance. As I have said, I will write to hon. Members including my hon. Friend the Member for Stroud. My hon. Friend made a point that I intend to follow up.

Martin Horwood: I am grateful for the Minister’s patience in giving way to me again.

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