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18 Mar 2009 : Column 266WH—continued
“People in poorer areas, with lower life expectancy, have always had the least access to primary care. Cambridgeshire has more than twice as many doctors as Manchester, and men in Cambridgeshire will live six years longer.”
That is not acceptable in a modern society, and it is not acceptable in the UK.
I welcome the many initiatives that have been put in place by the Secretary of State and his predecessors to tackle health inequalities: the healthy towns initiative, spearhead PCTs, the extra GP surgeries that are going into my constituency and many other under-doctored constituencies right across the country, and the open access GP surgeries that will be provided as well.
However, welcome as those things are, I do not think that they will actually solve the problem. There needs to be more recognition that initiatives should be backed up by more and more core funding in areas with health inequalities. That has been recognised: one of the first things that the present Secretary of State did when he took office was to ask the Advisory Committee on Resource Allocation to look at the formula for dividing up health funding.
Mike Penning (Hemel Hempstead) (Con):
The hon. Gentleman is making an excellent and passionate speech in defence of his Government. On the funding formula,
the reason that the Government introduced the review was actually the Health Committee report on funding and deficits, which recommended that there be a review. That was why it took place. The present Secretary of State inherited the decision.
Mr. Turner: It is probably true that the Secretary of State inherited the decision. Nevertheless, what I was about to say was that having inherited the need to look at the formula, the Secretary of State told ACRA that it needed to ensure that the formula more accurately represented the health inequalities that exist in areas and that the funding and weighting of various elements within the formula more accurately reflected them.
Ms Karen Buck (Regent’s Park and Kensington, North) (Lab): I congratulate my hon. Friend on the quality of his speech. Does he recognise that inequality in health outcomes and health funding is not just an issue between regions, or, indeed, within regions, but actually within very small areas? My borough of Westminster—a single local authority—has health inequalities within it that are as extreme as those between regions. For example, if one were to leave this building and walk to my house through some of the more deprived wards in my constituency, they would encounter a nine-year variation in life expectancy. Therefore, the formula needs to recognise that there are acute inequalities even in otherwise apparently affluent areas.
Mr. Turner: I accept that. My hon. Friend makes an important point, and I could say the same about my constituency, which, broadly speaking, is very deprived. We have super-output areas in the most deprived 3 per cent. of areas, but equally, we have super-output areas that are above average for quality of life. They are within easy walking distance of one another, so I recognise the issue. However, it would not be fair to tell the Secretary of State for Health that he must ensure that funding reaches such areas; locally, people should be able to make allocations dependent upon need. That is why it is important for the primary care trust to get the right amount of money and to put it into the areas that need it, both in my hon. Friend’s constituency and in mine, so that it goes to Pemberton—sorry, I do not know the equivalent area in her constituency—rather than to Standish and Shevington, which have fewer health needs. The PCT, given proper direction by the Secretary of State, must tackle health inequalities with its allocations.
Andrew George (St. Ives) (LD):
The hon. Gentleman makes a strong case and I, too, welcome the extra funding in the NHS over the years and the additional resources now. Before I was elected in 1997, and since then, I have campaigned for a fair funding formula—one reflecting not only need but poverty in the area that I represent, taking in Cornwall and the Isles of Scilly. The trust there, following the recent ACRA review of the funding formula, has certainly resolved to increase the funding to Cornwall and the Isles of Scilly, which is very welcome. However, because of the way in which the funding is delivered over time, and the pace of change at which the target is ultimately reached, the problem is that the Isles of Scilly has been left at a
distance of 6.2 per cent. from its target—equivalent to £56 million—as it is a very large trust area. Will the hon. Gentleman comment on how such deprived areas as his and mine, which require additional funding, can move more rapidly towards the target that they clearly deserve?
Mr. Turner: The hon. Gentleman pinches a later part of my speech, and although I appreciate that he cannot stay in the Chamber for long, if he will excuse me, I would rather not answer him now. I will do so later and he can read it in Hansard.
ACRA was asked to put greater emphasis on areas with health needs and to ensure that the resources went to tackling them. We should make it clear that ACRA is an independent body; it is not appointed by, or answerable to, the Government. The university of Bristol is its lead academic institution and the body is medically advised. Its report and allocations are robust and, being an independent body, it cannot tell the Secretary of State what to do. I accept that, but it is important that the body advises the Secretary of State on how to make allocations, as it has. I welcomed the report when it came out, because, as the hon. Member for St. Ives (Andrew George) said, areas of severe deprivation got quite an additional increase in the resource allocations to recognise their health inequalities and deprivation.
We know from the Black report and all sorts of studies that are constantly but rightly paraded before us that deprivation is a major cause of ill health, so putting the emphasis on deprivation will ensure that resources go to tackle ill health. We know too that access to primary care is vital if we are to tackle ill health. One difficulty is that if people do not have good primary care in an area, they will use secondary care—the hospital, or the accident and emergency department—rather than their doctor. If they do not have one, or if they know that the surgery will be full because there are insufficient doctors in the area, they will not bother going. Instead, they will wait until their condition worsens to such an extent that hospitalisation is the only solution. That puts more pressure on the health service in general, and on the primary care trust in particular, because it has to pay for hospitalisation, whereas if it had had the resources to provide more access to primary care, people might have been treated much earlier and more cheaply.
Ms Buck: Does my hon. Friend also recognise that those of us, myself included, who have a primary care trust that is significantly above target on its allocation, also tend to be over-represented—many are in London—among health authorities with proportionately fewer patients registered for primary care? We are very anxious about that, so I hope the Minister will respond to that point. Twenty-five years ago, the Aitchison report identified that in London in particular, but in other parts of the country too, there was a problem with patients being able to register with a family doctor—too many single-handed practices and so forth—which put extra pressure on hospital services. Importantly, when we look at the formula, we must ensure that we do not lose sight of that very important point and end up hitting hard the areas, particularly in the inner city, that have a long history of not receiving the primary care that they need.
Mr. Turner: I accept that inner cities, particularly London and many of our other major cities, have major problems. They have transient populations; people do not register for whatever reason and the Office for National Statistics has problems ensuring accuracy in the number of people it counts. I recognise all that and hope that ACRA, when it compiles its report and tries to ensure that PCTs get the right amount of money, takes it into account. Importantly, we must have a formula that is as accurate as possible and reflects the real needs of areas. If it does not, I advise my hon. Friend to apply for a Westminster Hall debate, so that she can make her points in more detail. I have no desire whatever to take money away from areas that have major problems; I want to ensure that areas such as mine, Cornwall and others, which have significant underfunding difficulties, are properly funded.
Returning to the point that the hon. Member for St. Ives made about allocations, I should say that the average allocation was 11.3 per cent. over two years, which is a welcome and significant increase in funding. There is no doubt whatever that throughout the country the health service has been transformed over the years and will continue to be transformed by the amount of money going into it. The other aspect of the allocation was that at the end of the two years no PCT would be at a distance of more than 6.2 per cent. from its target—the position of the PCT in Cornwall and many others. To ensure that those PCTs were brought up to 6.2 per cent., there had to be a floor of 10.6 per cent.; in other words, no authority would have its allocation reduced by more than 0.7 of a percentage point—the difference between the 11.3 per cent. average allocation and their 10.6 per cent. allocation.
I support the principle of floors. When huge changes must be made to PCT funding or, indeed, to any Government funding, it is right that they are managed properly. However, when the floor becomes so large, at 10.6 per cent., and the differences so huge, great problems are created. If the floor becomes too high and is coupled with PCTs that are massively over-target, it will take far too long under a pace-of-change formula for areas such as mine and those represented by other Members present today both to get the money to which they are entitled, and for authorities to get down to such figures.
One of the first speeches that the Secretary of State made when he took office was to the annual conference of local authority children’s and adults’ services directors in October 2008. He said that local authorities were
“uniquely positioned to play a major role in tackling the wider determinants of poor health, such as housing and transport, not to mention schools and children’s services... in partnership with the NHS”.
I agree. The PCTs and local authorities are working together, pooling resources and personnel. The public health director in Wigan, for example, is a joint appointment between the local authority and the PCT. That is replicated in many areas throughout the country. It is important that that happens.
The problem arises where the local authority is as underfunded as the health authority—the PCT. For example, for 2010-11, Wigan is almost £5.5 million—or 3.9 per cent.—below the amount that the Department for Communities and Local Government says that it is entitled to under the formula. Hull is just over £7 million below, which is 4.5 per cent; yet Richmond in
London is £18.5 million overfunded—a massive 193.8 per cent. When the Supporting People programme is added, Wigan is again underfunded to the tune of £5.5 million and Hull is underfunded by £2.3 million. The Supporting People programme is important and is trying to ensure that people are able to remain for as long as possible in their own homes, rather than having to go into more expensive and less desirable nursing homes, or other homes, and sometimes even into hospital. If we can get people out of those places and that is what they want, it is a cheaper and better solution all round. Supporting People is a good programme, but when it is underfunded, local authorities are underfunded and PCTs are underfunded too, there is a triple whammy of inability to supply the resources to satisfy the various health needs in the area.
I just want to touch on the figures in the recent PCT allocations. I shall mention Wigan again, for obvious reasons. At the end of the two years we move £56,000 closer to our target, with the distance from target being £25,381,000. Using simple arithmetic, we can see that it will take us 453 years to achieve the target. I suspect that I will not be around then, but I take some comfort from the fact that looking at the issue in percentage terms, we would move 0.2 per cent. closer in the two years in question and we will only be 4.5 per cent. below. That will take only 22.5 years to achieve. I doubt whether I will be in the House then, but there is a chance that I will still be around to see that happen.
Andrew George: Is not the situation in many parts of the country even worse than the hon. Gentleman describes? As I said earlier, it has taken more than a decade to get the ACRA funding formula reviewed—particularly its market forces factor—and for the funding formula to be altered, as was announced in December. Many parts of the country, such as the hon. Gentleman’s constituency and mine, have been significantly underfunded for more than a decade, so they have more than a decade of underfunding to make up for, as well as trying to achieve rapid movement towards the target.
Mr. Turner: Again, the hon. Gentleman is pinching my lines. His point is valid and important. The problem with underfunding, when it lasts for so long, is that it is not just £25 million this year, but £25 million last year and £20 million in the previous two years, and way beyond the previous 10 years, with perhaps even 20, 30, 40 or 50 years of underfunding in terms of facilities and doctors. That has an impact on health. That is an important point. We are talking not about a one-off situation—one year—but about a cumulative build-up, which means that we have to allocate even more resources to overcome it.
Hull is £698,000 closer to target, on £30 million, meaning that it will only take 45 years to reach the target, but in percentage terms, that is 0.2 per cent. in the time I am talking about, meaning 6 per cent. in total, so it will take Hull 30 years to get back to being allocated the resources that it is entitled to under the formula. Richmond and Twickenham PCT is £51 million away from target in 2009-10. Inexplicably, it will be £52.25 million away in 2010-11, so in fact it is moving further away from target over those two years rather than getting closer to it. At that rate of change it will never, ever reach the target. At a rate of change of 0.1
per cent., when it is 23.4 per cent. over, it will take 234 years. That is not an acceptable pace of change. There is sufficient leeway in such areas to be able significantly to improve the rate of change.
We need to take into account another element. HRG4—the health resource group funding—has just been announced. I welcome that because, again, it gives hospital trusts the right amount of money. My right hon. Friend the Member for Oxford, East (Mr. Smith), who is in the Chamber, and I have long campaigned together on the orthopaedic element of that to ensure that the extremely complex orthopaedic surgery that is carried out at the Nuffield and the Wrightington hospitals is properly recognised in the amount of funding. HRG4 does that, which is important, but its impact is enormous.
Wigan PCT has estimated that if it just makes the mandatory payments, £12 million extra each year will have go straight from the PCT to the hospital. If it does all the discretionary work as well—the discretionary part of the HRG4—it will cost £24 million. I want hon. Members to hold those figures for a while. Some £12 million will have to go and another £12 million may go. The increase in funding to Wigan PCT in one year is £27 million, so for primary care improvements, we will be left with £3 million at worst or £15 million at best. Obviously, all the drugs, pay increases and so on must come out of that sum. The effect will be that Wigan PCT will be in a reduced situation and will have to make changes to the way that it does things. If Wigan has to do that when it is £25 million below target, it is not beyond the wit of areas such as Richmond and Twickenham—I have chosen it as an example, but there are plenty of others—which is £50 million, £60 million, £70 million or £80 million above target, to make similar changes.
What can be done? We need to manage the changes. When the allocations were announced, inflation was somewhere between 3 and 4 per cent. I accept that the drugs bill has been announced and fixed, and wages agreements are in place for the next two years, but there will still be significant payments to be made in respect of the expenses that PCTs incur, even though those sums are significantly lower than anticipated, given the inflation rate when the allocations were announced. If we reduced the floor from 10.6 per cent. to whatever over a year, it would allow a significant amount of money to go to areas that are underfunded, bringing them closer to the target and increasing the pace of change.
We need a faster pace of change, and the Minister should commit to that today. Targets that cannot be achieved for tens or hundreds of years are not acceptable, because of the impact on people’s health, and because health professionals despair of ever being able to tackle inequalities properly. We should also have a debate on the allocations. It is amazing that we have debates on police allocations from central Government, on fire service allocations from central Government and on local authority allocations from central Government, but we do not have a debate on allocations to primary care trusts.
My local authority in Wigan receives £129 million of grant from central Government, and we have a half-day debate about that. We have consultation and debate and
then confirmation or alteration of the amount. The health allocation to Wigan PCT is £565 million, four and a half times as much, yet it goes through with no debate whatever, unless there is a Westminster Hall debate. That is a hangover from the Tory years when the Conservative Government did not want to talk about health inequalities and allocations. We thought ourselves lucky if we had a health allocation, let alone an increase. Ministers should relish the opportunity to champion all the good that has been done over the past 10 years, and to put the Opposition on the spot by saying, “We know what we want to do about health inequalities and we know how we are going to tackle them, but where are you? We know what you did with the Black report. Have you changed?” We should be able to look forward to an annual debate on health allocations when so much money is involved compared with police and fire authority allocations.
If we do not make inroads, we will go on the merry-go-round of people being unable to see their doctor, clogging up A and E, or leaving problems until it is too late to treat them with primary care so that they have to be treated by health care, with primary care having to fund that instead of funding family care properly. That is a downward spiral. So many effects of health inequalities need personal intervention, because health workers must talk to people and guide them. Obesity is not an individual problem; it is a family problem. One does not see fat people; one sees fat families. That is unfortunate, but if someone’s problem is only tackled individually, the mother or whoever does the cooking will continue to provide chips, pies and so on. It is unusual to hear someone from Wigan denigrating pies, but I accept that they are not a healthy pattern of eating. Smoking must also be tackled individually, so intervention is labour intensive and, therefore, expensive. If we do not have the resources to tackle it, we will not deal with health inequalities. Poorer health areas have below-target health and local authority funding and do not have the resources to tackle such problems.
I urge the Minister to commit to a debate so that we can raise the profile of health inequalities. I urge him to commit to a faster pace of change, and to considering the inflation element in the last year to see whether money can be pulled out and given to authorities that have less. The Minister could give a commitment today on those three practical areas, which would have a longer-term impact on health inequalities and ensure that this country is no longer scarred with areas where people have a mortality rate and morbidity rate of between 10 and 15 years higher than their more affluent neighbours.
3.4 pm
Mr. Andrew Smith (Oxford, East) (Lab): I congratulate my good friend, the hon. Member for Wigan (Mr. Turner), on his excellent, well-informed and powerful speech, as well as on securing this vital debate. I want to focus on two issues: the allocation of funds to GP practices that serve poorer communities, and GP practices with a high proportion of student patients.
First, ensuring that poorer areas receive their fair share of health funds is, as my hon. Friend said, at the heart of addressing health inequalities. It is not the only factor, and we know that housing, early years funding, schools funding and employment are also critical, but
they compound the challenge because resources are not always allocated in proportion to need in those areas either. In Oxfordshire, the primary schools serving the most affluent areas receive virtually the same funding per pupil as the most disadvantaged areas, and that must also be true elsewhere. However great the other impacts, it is certain that we will not increase equality in health outcomes, even as overall health improves, as has been the case, unless there is fair funding for primary care services in poorer areas. That is a question not just of primary care services as a gateway to secondary and specialist treatment, but of the vital role that primary care and ancillary services at health centres provide in health education and prevention.
There is an interaction between the funding mechanisms used at regional level and those used locally for practice-based commissioning. The money that ends up in a particular community is a product of both those stages. If a region is relatively affluent and with relatively good health, its regional allocation will be lower. We can all argue about the extent to which that may be the case, following the reviews of the formulae and so on, but within those more affluent regions, as my hon. Friend the Member for Regent's Park and Kensington, North (Ms Buck) said, it is all the more important that practices serving poorer areas and pockets of deepest deprivation are properly and fairly resourced. Yet demand pressures and historic factors suck resources in the opposite direction, or keep them in that opposite direction.
It is disturbing that the excellent work by the Health Service Journal last autumn, which was reported in the Library’s very good debate pack, shows that budgets have not matched their fair share as indicated by the toolkit methodology issued by the Department of Health and that the
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