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1 May 2007 : Column 390WH—continued
“There are overall fewer GPs per head of weighted population in the east and north of London (where health need is greatest), compared to the south and west”.
I would not dispute the fact that that may be true, although the situation in areas such as Ealing probably does not look as good as elsewhere in west and south London. We are desperate for a strategy that will build all of London, not one that will siphon resources out of the west and south, where need is great, even though there might be a greater need in the north and east.
We look at this issue in the context of Mayor Livingstone’s focus, which seems constant, on pouring resources into north and east London—it is partly driven by Olympic fever, but it is also a fundamental view—while the population insists on coming to the west and south and building their homes there, no matter what the authorities would like to do to direct them elsewhere. The need of, and the resources that have to be put into, health services in west London should not be discounted by an institutional wish for a population shift. I suspect that such a shift will not occur—there is certainly no evidence of it occurring.
The Government’s response to west London’s health issues has been one of chaos. Others have talked in great detail about the Paddington health campus scheme, and I echo the comments made, although I shall not reiterate them. One would have thought that after putting hospitals such as the Royal Brompton and the Harefield into a period of such uncertainty, stress and concern, the response after the Paddington scheme fell through would have been carefully to provide genuine certainty to overcome the damage that had been done by what most people now regard as an idiotic scheme. That has not happened. We see the same thing repeated in the case of the Mount Vernon hospital cancer specialty unit. Proposals to take everything to Hatfield were abandoned and nobody knows where the programmes will be taken. That does not help the health service at all.
That kind of chaos is being increased and intensified yet again by a policy that I wish the Minister would address, because I cannot get to the bottom of it. As I understand it, there is a requirement for about 15 per cent. of health services in the London area to be provided by the private sector, with the result that the strategic health authorities have been building up independent sector treatment centres—in other words, private centres—at a time when there is overcapacity in
the system and when we need such additional facilities like we need a hole in the head. We need improved, regenerated and modern facilities. The notion that we need increased facilities for increased competition in London misunderstands the whole London health environment. That is aggravated by the fact that none of us has been able to see the underlying contracts that go with these independent sector treatment centres. We are suspicious that they contain language that essentially gives guarantees of minimum numbers of patients, which translate into financial security for those private centres, while the NHS facilities face constant uncertainty and risk.
I shall give a tiny example, although it is not particularly a south-west London example. I have talked to representatives of the breast screening services at my local hospital—those services being provided by a private group within the context of an NHS hospital—and they were naively delighted to explain to me how the patient guarantee from the NHS takes away all their financial risk. That allows them to use all their spare time to seek private patients for breast screening. They said, “It is a wonderful system because we have no financial risk at all. That is carried by the NHS, so all we have to do is build our profit opportunities on the back of it. The system works extremely well. We are a wonderful and very profitable company.” I do not think that they anticipated that my reaction might be that whoever negotiated that contract for the NHS services was not adequate or up to the job. I understood that transferring the risk from the private sector to the public sector was not supposed to be the goal.
I understand that those independent sector treatment centres will not provide training for junior doctors. This week and last week, we saw the devastating impact of all the uncertainty surrounding junior doctors, yet the programme in London seems to aggravating the situation, rather than diminishing it. That brings me to the financial crisis in the NHS, whether in west London or in all of London.
The NHS deficit in London in 2005-06 was £174 million, which is proudly said to have reduced to £55 million in 2006-07. The sum is huge, and it has largely been reduced by top-slicing from the financially successful trusts, to support the ones with deficits. Much of the price has been paid by cutting NHS jobs—for example, the 900 jobs in London, plenty of which are on the front line, and we are all aware of them. People tell me that such cuts do not impact on service, but I suspect that some hon. Members present would be able to give many examples of where service has been severely damaged.
One issue that is often not flagged up is that primary care trusts, whether in west London or elsewhere, have been reluctant to move outside National Institute for Health and Clinical Excellence boundaries for the prescription of cutting-edge medication. One example of that involves the drug Temodal, which is used to treat brain cancer. As we know, NICE can be exceedingly slow in providing approvals, so we end up with a situation where we know that approval of a drug will be given, but the paperwork and the rest of the pieces take a further 12 months to roll through and be
put in place. In the past, PCTs have been willing to prescribe in such circumstances, but now they are not, given the financial pressure that they face. I suspect that lives have been lost—lives have certainly been shortened—as a consequence.
Cost-shunting between PCTs and local authorities has become acute—west London suffers from that as much as anywhere else—and it is resulting in diminution of community health services in west London. One reason for the shortage of training places for junior doctors this year is that PCTs have been clawing back from their original plans and posts have effectively disappeared.
Mental health services have taken much of the brunt of such cuts, and that is as true in west London as it is elsewhere. Hon. Members will be aware of the report by the Sainsbury Centre for Mental Health in July 2006 which said that nearly two thirds of mental health trusts have been asked to cut their budgets to cover NHS overspend in other areas.
Ironically, my area is officially south-west London, such are the weird boundaries for different aspects of the national health service, and Cassel hospital in my constituency falls into the west London family of mental health services, so I can see directly in my constituency how cuts in mental services have fallen on the most vulnerable. Superb services for adolescents have been merged with adult services with the loss of 10 beds.
I suspect that part of the reason why the Royal Brompton and Harefield NHS Trust is driving so hard to obtain foundation status is that it feels that, with overcapacity, only those who can get out early and obtain foundation status early will be able to survive, and that the inevitable rationalisation, particularly from introducing more competition, will not mean that those that remain are not necessarily not the best, but that others got out first. That seems to be a nutty way of trying to resolve the issue and to obtain the best health service structure in west London.
Although there is community involvement in seeking foundation status, that creates a false feeling, because there is no democratic control of the strategic health authority. People in west London have no mechanism for making their voices heard by the Department of Health. The chaos that has arisen because local voices are not in charge of decision making will not be resolved by giving foundation status to one hospital. Real focus on genuinely devolving accountability for health services to local people is needed, and that has not happened.
London is one of the great capitals of the world, if not the greatest. It should have a first-class health service in every part of its community and, given its history, it should have cutting-edge research. That is not the picture today, and that is a failure. The Minister must give us some coherent answers.
10.33 am
Mr. Andrew Lansley (South Cambridgeshire) (Con):
I congratulate my hon. Friend the Member for Ruislip-Northwood (Mr. Hurd) not only on securing this debate, but on his dogged pursuit of his constituents’ interests in relation to health services, as evidenced by this debate and his debate in February last year. He will not give up on the matter; he will ensure that the services on which they rely are
supported and maintained. That is all credit to him, and to my hon. Friend the Member for Uxbridge (Mr. Randall), who did likewise during his debate back in 2004.
My hon. Friend the Member for Ruislip-Northwood concentrated on the Royal Brompton and Harefield, and Mount Vernon hospitals, and I shall follow him. On the Royal Brompton and Harefield NHS Trust, I share my hon. Friends’ anger at what happened in relation to Paddington health campus, and the delays and £14 million of directly associated costs. Significant additional opportunity costs were associated with the failure of that scheme.
The hon. Member for Richmond Park (Susan Kramer) was absolutely right about what her constituents had a right to expect after the collapse of that scheme. The trust rightly called time on a project that was never, as the National Audit Office demonstrated, properly supported and organised. A simple question that must be asked in the national health service is “Who is in charge?” No one was ever in charge of the Paddington health campus scheme. The trust called time on it and had a right thereafter to expect to be able to manage its own affairs and to determine its own future. That is the point that my hon. Friend the Member for Ruislip-Northwood made. The trust has applied for foundation trust status precisely for that purpose. It wants greater opportunity and freedom to determine its own future. The London strategic health authority put the trust forward for foundation status, but Monitor has said no for the time being, principally because of the uncertainty attaching to the trust’s future income projections derived from research funding.
I confess that the NHS research and development programme and the reorientation to a number of biomedical centres makes me happy for constituency reasons, because Addenbrookes hospital in my constituency has benefited. There are winners and losers—[Interruption.] My hon. Friend the Member for Uxbridge reminds me from a sedentary position that the chief executive of Addenbrookes hospital is Gareth Goodier, former chief executive of the North West London strategic health authority and previously of the Brompton and Harefield NHS Trust. The national health service inhabits a small world. Ministers often remind us that the NHS employs 1.3 million, but it is funny how the same people keep turning up.
It is obvious, as my hon. Friends and the trust acknowledge, that there has been cross-subsidisation from money intended for research and development into service support. The plea of my hon. Friend the Member for Ruislip-Northwood is that, if there are to be substantial changes of the sort proposed under the R and D programme, the financial consequences must be subject to a reasonable transition. There must also be significant opportunities to enable those who are losers for the time being, but have high quality research projects, to win other research projects, even if they have not secured a position as a centre of excellence or biomedical centre for the time being.
At the same time, if I understand the way in which cardiac services are moving and particularly the sort of work carried out by the Royal Brompton and Harefield hospitals—it bears comparison with that at Papworth
hospital in my constituency as a cardiothoracic centre—they need rapid adjustment in the payment-by-results and tariff system. There are too many instances of hospitals such as the Royal Brompton and Harefield, which have a relatively complex case mix and are likely to be tertiary referral centres, dealing with patients for whom the tariff is not well designed. The Minister will understand that the Government’s response to the turbulence caused by the introduction of the tariff has led Ministers to hold back in the latest payment-by-results consultation document. We are moving to a timetable that is a year slower than was intended.
In reality, the proper response to that turbulence is to make faster progress and to move the next iteration of the tariff. If one does not arrive at a point where there are recognised exceptions to the tariff and recognised outliers and where the cost is not better disaggregated to individual treatments—often the complex treatments provided by tertiary centres—often hospitals of a more specialist character lose out as a consequence of the roll-out of the tariff across the NHS. I am sure that the Royal Brompton and Harefield NHS Trust needs that to happen.
I am sure that it should not be Monitor’s job to seek to engage in reconfiguration as part of its authorisation process. That should not happen. It is Monitor’s job to encourage as many hospitals as possible to secure the financial status that allows them to become more independent. Configuration is much more a matter of the relative choices of commissioners. I am sure that the Royal Brompton and Harefield NHS Trust would not complain if, in the long term, it had to begin a reconfiguration of its services because of a change in demand for its services. Anyone working in cardiac services at the moment knows that they have shifted from cardiac surgery to cardiology and intervention in a way that is redesigning services. The trust knows that it must do that, but it is doing so in response to demand and changes in technology, not as a result of a top-down process.
I must confess that I remain sceptical about the benefit of the strategic health authority—through Sir Ara Darzi—engaging in trying to determine the future configuration of services before GPs and local commissioners have had the opportunity to determine where they want services to be. I suspect that access and specialist centres will be lost, which would not happen if decisions were left to local commissioners.
The hon. Member for Ealing, Acton and Shepherd's Bush (Mr. Slaughter) made a helpful speech. I do not necessarily share his immediate optimism about Sir Ara Darzi, but I share his optimism about the coming together of Imperial college and St. Mary’s, Hammersmith and Charing Cross hospitals. In the health service of the future that we all want to see, in which patients increasingly make choices and GPs and local commissioners make choices, hospitals will begin to make their way in the NHS on the basis of reputation, results and outcomes for patients.
An academic centre with the foundation status that Imperial and the two trusts—St. Mary’s NHS Trust and Hammersmith Hospitals NHS Trust—propose could be precisely the kind of major centre that attracts demand from within the NHS, makes its way in the NHS and becomes a world-class centre. We need to
establish such world-class centres in this country. Cambridge is aiming for one, and west London can achieve one through such a merger.
Like the hon. Gentleman, I met Professor Steve Smith and Christopher Tugendhat, and I very much share the hon. Gentleman’s enthusiasm for their vision. However, I caution against their allowing it to become wrapped up in the strategic health authority reconfiguration proposals. Their vision stands on its own merits; it is not designed to achieve a certain reconfiguration effect throughout London. The two must be kept entirely separate.
My hon. Friends the Members for Ruislip-Northwood and for Uxbridge made a perfectly straightforward, rational and passionate case for Mount Vernon hospital to be allowed to get on with its job in a place and in circumstances that the local population, GPs and commissioners support.
We have picked on one London primary care trust, Hillingdon, but it is in serious trouble. It had an accumulated deficit of about £59 million at the end of the financial year just gone, and it clearly requires strong change. How should change be achieved? The Minister might like to tell us whether there is any prospect of the PCT taking advantage of the framework for external commissioner support, which the Department set up through its tendering process. The outsourcing of commissioning is one option. It may have some advantages, but even more importantly, responsibility must be transferred rapidly into the hands of GPs—the primary care commissioners.
Primary care trusts, of which Hillingdon is one, have demonstrated that there are serious dangers if they fail to do their job well. If we disaggregate budgets and ensure that the individual local commissioners—GPs—have greater control over them, we will bring together clinical decisions and budgetary responsibilities. The problem of Hillingdon PCT’s deficit must be tackled. It is not fair to try to transfer the deficit into the hands of commissioners under practice-based commissioning, although that is not the Department’s intention. One cannot expect commissioners to discharge their responsibilities on the basis of such a large deficit.
The Government must contemplate the transition that my hon. Friend the Member for Ruislip-Northwood discussed, involving changes throughout the system. There may be three financial years of transition ahead—not only this year, but the two beyond—for PCTs in the worst circumstances. Hillingdon may be in that position, and it would be helpful to know whether the Minister has received a request from Hillingdon for a plan that spans such a period.
I endorse what my hon. Friend said on behalf of the hospitals in his constituency. It is important that we address the issues in practical terms now. He has done so, and I very much endorse what he has said.
10.44 am
The Minister of State, Department of Health (Andy Burnham):
I, too, pay tribute to the hon. Member for Ruislip-Northwood (Mr. Hurd) for securing the debate and for the way in which he made his remarks. I have
no doubt about his personal interest and commitment to ensuring that his constituents receive the highest quality health care. I include the hon. Member for Uxbridge (Mr. Randall) in that tribute, as well.
I am pleased that my hon. Friend the Member for Ealing, Acton and Shepherd's Bush (Mr. Slaughter) joined us in today’s debate. It is the second time in recent history that we have debated the matter, but health care in west London arouses huge interest, perhaps because west London contains some of the most pre-eminent names, both of individuals and of institutions, in health care in the world. It is normal and natural that the subject always arouses huge interest. On a personal level, my family recently benefited hugely from the services of the Royal Marsden hospital, which is a fantastic institution. It is truly humbling to see the staff’s commitment to their jobs. All of us want to strengthen, develop and build upon such excellence in health care; there is no political difference on that point.
In many ways, our debate has touched on all those matters. Sometimes, the debate focuses on exactly how to make such changes, and although the hon. Member for Uxbridge used the word “vindictive”, as far as I can see, everybody is trying their best when they make judgments. NHS management are sometimes unfairly caricatured, and although we may not always agree about the right judgment, the vast majority of people are rowing in the same direction.
The hon. Member for Ruislip-Northwood began by saying that in west London, there had been a period of almost permanent change. In that sense, I suppose that the title of Sir Ara Darzi’s first publication, “The Case for Change: Healthcare for London”, depresses the hon. Gentleman. However, we will constantly return to such issues because there will always be a need to review and to change, particularly when we are discussing some of the leading health services in the world.
The hon. Member for Uxbridge was absolutely right to raise the profile and our awareness of the fantastic developments at Harefield hospital. Because the health economy is bringing some of the most advanced changes to us very quickly, there will need to be constant consideration of whether services are up to date and of sufficient quality.
Sir Ara Darzi’s document includes the phrase:
“Local urgent care is not good enough.”
That is a bold and clear statement, and I guess that all London Members of Parliament want to see changes off the back of it. Another paragraph in the document says that
“out of the thirty hospitals in London providing stroke services, only four treated over 90 per cent...in a dedicated unit, and, whilst patients should receive a CT scan within three hours, only in seven hospitals were 90 per cent of patients getting a scan within a less-than-ideal 24 hours.”
People like me are sometimes accused of always saying that everything is marvellous and fantastic, but one cannot read such figures from someone as eminent as Professor Sir Ara Darzi without agreeing that there is a case for change. There is a constant onus on us all to see whether we can do better in providing health care for our constituents.
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