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Martin Horwood: I am extremely grateful to my hon. Friend for being so generous with his time. I agree with both him and our hon. Friend the Member for Falmouth and Camborne (Julia Goldsworthy). Does he agree that the problems with the contract date back even further,
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to the early 1990s and the last Conservative Government? It was they who first mucked about with it in a way that would slowly and quietly send dental practices bankrupt if they maintained NHS services as they had been before. Now the Government have managed the amazing trick of renegotiating the contract and making the position even worse, leaving us with what is becoming almost a privatised dental service.

Andrew George: I certainly think that that is true, but I must also say that there are geographical differences across the country as a whole. The Government measure, and the means by which they pay for these services, is the average units of dental activity. On that measure, NHS provision per head of population in Cornwall is about half the national average. Professor Steele has been looking at this issue, and I am told that provision is significantly better in some parts of the country than in Cornwall. In west Cornwall, the situation is that about one third of the population can get some access to NHS dentistry, and emergency access is even more difficult.

Professor Steele tells me that the unique geography of Cornwall makes it particularly hard to get services in the right place, and when they are not in the right place, travel is, of course, difficult and expensive. Even if the combination of rurality and poverty does not make Cornwall unique, it certainly makes it a very good example of the problems that there can be in delivering services. We in Cornwall hope that, as a result of the review, the review board will come up with proposals that acknowledge the geographically specific problems in some parts of the country, and that it will perhaps even encourage the Government to review again the basis of the funding formula—the allocation and notional level of funding that is available to places such as Cornwall to ensure that they do in fact have adequate provision of dental services.

Midwifery and maternity services in west Cornwall are another subject on which I would welcome the Minister’s encouragement. I shall shortly be seeing a group of community midwives in my constituency. They tell me that their complement of midwives in the towns of Helston, St. Ives, Penzance and Hayle in west Cornwall is significantly below the Government’s recommended level. That puts pressure on services and on what they can provide in terms of the whole-time equivalent assessment of the population they serve and their work load and its throughput.

I secured a debate on the Government’s policy as set out in “Maternity Matters” on 2 May 2007, when I welcomed its principles, but I also asked whether the Government had put the resources in place to ensure that their fine words could be met with action on the ground, so that mothers would have choices in the years ahead. That is clearly not the case in west Cornwall—and I am told that west Cornwall has better midwifery provision than many other communities.

Funding issues underlie all the concerns that I have raised. Services cannot be provided if the funding is not in place, and certainly if there has been a decade or more of considerable underfunding. In contrast with other parts of the country, as a result of its allocation, Cornwall has struggled year on year under the weight of national expectations and as a consequence of patients being aware of national levels of service. I congratulate
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the Government on their funding in general. Indeed, the Liberal Democrats have always welcomed the funding that the Government have been prepared to put into the NHS across the country, but the allocation has simply left places such as Cornwall behind, year on year, and therefore further behind overall, thus denuding and undermining services and making it increasingly difficult for the professionals who are providing those services to maintain them.

My other theme, which I very much hope the Minister will take on board in his reply, is that we need to provide a structure that not only allows the local community a say through the occasional consultation paper exercise, but genuinely allows locally elected representatives to determine the priorities and champion the interests of their local communities. Many of the decisions taken by the primary care trust are not only technical and medical, but political; they are about the allocation of resources in an area and the implementation of Government policy. We need to decide whether such bodies are simply agents of central Government and the local community is simply something that is occasionally consulted, or whether such bodies are there to reflect the interests and priorities of that local community and to ensure that it is fully engaged in the decision-making process.

5.56 pm

Julia Goldsworthy (Falmouth and Camborne) (LD): I am glad that I managed to catch your eye, Madam Deputy Speaker. I did not intend to contribute to this debate because I did not expect to have the time to do so, but I welcome the opportunity to add a few comments to those made by my hon. Friend the Member for St. Ives (Andrew George).

Although there have been significant challenges for the national health service in Cornwall, the county is greatly blessed in one respect: the quality of staff. The flip side of many of the geographical challenges that we face is that the staff are incredibly hard-working and committed, our staff turnover is a lot lower than that of other places and because the county is such a wonderful place to live we are also lucky to have incredibly and talented specialists who choose to live there. There are great opportunities in Cornwall, but the problem is that successive Governments appear to have been unable to recognise what the challenges are in providing a national health service in very different parts of the country. Our concern is that there has not been significant understanding or recognition of how rural needs manifest themselves and how they need to be addressed.

The Government’s approach has been very much to emphasise that the last thing they want is a postcode lottery, but our point is that the problem with a “postcode lottery” is the lottery bit, not the postcode bit. People want health services that address their needs, which may be specific to their communities. The challenges that we face in Cornwall stem from the fact that it is one of the most deprived parts of the country and from the fact that services can be difficult to access because of the geography. In addition, the county has to deal with huge fluctuations in population—Cornwall’s population doubles over the summer—which brings different pressures, and we have a greater and increasing number of elderly people compared with other parts of the country.

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All those issues throw up different challenges for the health service. My hon. Friend focused on the funding challenges, but they are just one aspect of the wider problem. Successive Governments have given insufficient recognition to the cost of providing health services in rural areas, and although the review has, perhaps for the first time, exposed how big the gap is, we still do not clearly understand how quickly it should be closed. Given that some authorities are far from their target, it is very difficult to understand why overfunded authorities are not meeting the cost of the lowest funded. One can understand why no trust would want its funding to be cut, but I do not understand why the ceilings need to pay for the floors—I hope that makes sense; I might have meant it the other way round.

I have already mentioned the geographic challenges. Cornwall is a long, thin peninsula, surrounded by water on three sides, with one main arterial road that gets very blocked in the summer. That poses specific challenges to the provision of services, and people in Cornwall have to look to other alternatives to meet some of those challenges. Cornwall air ambulance, which is funded entirely by charitable donations, is essential in the summer to ensure that people can be transported to accident and emergency. Last summer, we had the ridiculous situation of motor ambulances queuing outside Treliske, the main accident and emergency centre, to ensure that the hospital met its four-hour waiting times, with the air ambulance having to transfer nursing home patients.

The most frustrating thing is that, while the staff are doing all they can to humanise services, the Government’s approach is that one size fits all, which is why dental services fail to reflect the county’s needs. Only one NHS dental surgery is treating new patients. There is an obsession with a choice agenda, but in Cornwall the most important thing for many patients is to know that their nearest service—which might actually be a long distance away—will be able to provide them with a certain standard of care.

Many services are being centralised outside Cornwall, and decisions are being taken without an accountable process. The Government just do not get how these things need to work in rural areas. Recently, we had a heated, so-called consultation on transferring surgery for upper gastrointestinal tract cancers to Derriford. The strategic health authority said that, to ensure high standards, the service needed to be provided by a team of people who had the experience to ensure the best outcomes, but it seems that every service is being transferred—salami sliced—further away. The Government should consider operating a specialist network that allows skills to be spread throughout the area. Cornwall could be responsible for delivering one of those specialist services, and people in the county would have access to at least one centre.

Andrew George: I agree with those professionals who argue that we want to ensure the best possible outcome for patients, and if that requires a concentration of services, so be it. But, as my hon. Friend says, we should perhaps look at networks and at ensuring that the concentration comes westward as well as going east.

One of the problems for our constituents is that accessing specialist services requires lengthy journeys—to London for neurosurgery, for example. The health care travel costs scheme is not sufficient for people on low
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incomes, but not on benefit. Many of our constituents are clearly disadvantaged by the lack of funding to compensate them for the impact that the concentration of services in just a few places has on them and their families.

Julia Goldsworthy: My hon. Friend is right. No account is taken of the costs or the time taken to travel such distances. In parts of my constituency, visiting a sick relative being treated in Derriford can take three hours by car every day. Such factors should be taken into account, but currently are not.

That can also be seen in other policy areas, where once again the approach seems to be that central Government take a decision and the strategic health authority and primary care trust see it as their role to implement decisions locally rather than to feed information back up the line to make the case for what they consider to be most appropriate for the needs of their area. We see that happening in a variety of ways. The example that springs most obviously to mind is that of walk-in centres. It has been decreed that every primary care trust must have one, and the primary care trust has to justify where it puts the centre and why it is needed.

It turns out that the PCT has decided that the walk-in centre is needed in my constituency. The justification is that it is the most densely populated part of Cornwall and that some regard has been given to the fact that there are lots of migrant workers who will need the centre, as they are unlikely to be registered with a doctor. If such centres are to be of any use, they should be in areas where a lot of people are travelling to work. One could argue that other places in Cornwall, such as Truro, have huge numbers of people travelling into the area every day. If they want flexibility in being able to drop in and see a doctor, they might want the centre to be there.

GPs with surgeries in more rural areas say that the best way of ensuring that migrant workers have access to the health services they need is for an individual relationship to be built up between the surgery and the farmers who employ agricultural workers, rather than simply plonking a massive centre on an industrial centre somewhere. These people, who have no access to their own transport and who might be able to catch a bus every other Monday, if they are lucky, will have no means of getting to such a centre. It seems that the decision is made centrally and then it is up to the PCT to justify why it is needed locally.

Andrew George: I am grateful to my hon. Friend for giving way a second time. This is a rather classic example of the Government’s imposing a solution that might be satisfactory in an urban setting but that is still an urban solution to a long-standing rural problem. Cornwall, from the Tamar to the Isles of Scilly, is more than 100 miles long. We have to question whether alternative provider medical services will provide for the whole of Cornwall. The PCT has not been able to show that those services will not undermine the settled provision of existing services in a way that damages the local community or that the benefit of the investment will be spread for the benefit of the whole population served by the PCT.

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Julia Goldsworthy: My hon. Friend is absolutely right. The nub of what I am saying is that people in Cornwall are not asking for services that are better funded than those anywhere else in the country. In a debate earlier this week on the impact of the recession on rural areas, my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron) emphasised that point. He said that the Liberal Democrats had made the case for extra investment in the NHS, and that people living and working in rural areas had contributed towards that extra investment like everyone else and that they want to see that they stand to benefit in the same way as everybody else. They should have health services that reflect their needs and that are able to meet them. The concern is that that is not happening and that, with the current lack of accountability in the way decisions are taken and resources are spent, they have no opportunity to have their voice heard.

There are two parts to the problem. We must recognise the need and must ensure that there is accountability in decision taking. Unfortunately, for too many people in Cornwall, not only are their needs not being met but their voices are not being heard.

6.8 pm

Dan Rogerson (North Cornwall) (LD): May I apologise to you, Madam Deputy Speaker, to my hon. Friend the Member for St. Ives (Andrew George) and to the House for not being in the Chamber at the beginning of his speech? I was involved in the debate on the Business Rate Supplements Bill and took the opportunity to leave the Chamber for a short while, anticipating that the next debate might continue for longer than it did. I am pleased that you found time to call me to speak, however, Madam Deputy Speaker, and I thank you for that.

I congratulate my hon. Friend on securing the debate, and it is fortuitous for Cornwall that he did so as we have the opportunity to debate matters in more detail than we might have anticipated. He addressed clearly the underlying funding issues in Cornwall and focused on some of the problems that have occurred, sadly, in the management of the Royal Cornwall hospital in Treliske. Of course, in turn that has caused problems for the acute trust, but it is important to note that the deal that has been worked out to allow the PCT to support the acute trust as it gets its finances back on track has longer term implications for resources across Cornwall.

Many of my constituents in the western part of north Cornwall use the Royal Cornwall hospital at Treliske and are very pleased with the service there, but people in the east of my constituency tend to go to Derriford hospital in Plymouth, the Royal Devon and Exeter hospital or the North Devon district hospital at Barnstaple. The question is whether the necessary support for the provision of acute services in Truro is drawing resources away from the more accessible services over the border in Devon.

If we were starting with a blank sheet of paper to plan for health investment in Cornwall, we would probably not begin by placing a major district general hospital in the middle of the county. We might put one in both the west and the east, but that is not how things are. Many patients in the east of Cornwall cross the border into Devon for their health services; not only does that pose
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transport problems, as I shall explain, but it causes peak-time car parking difficulties at Derriford. The fact that services are concentrated there—it is one of the largest hospitals in western Europe—may need to be examined in future.

My hon. Friend the Member for St. Ives mentioned the problems encountered by people living some distance away from major health care centres such as the Royal Cornwall hospital. A while ago, I came across a case involving an older lady in Camelford in my constituency. Having been prescribed a course of therapy in Truro, she turned to the hospital transport system to get herself there, but the cost became so prohibitive that she decided to abandon the therapy. Although her illness was not life threatening, it was enough to affect her quality of life. The therapy had been recommended by health professionals: they said that it would benefit her, and it was something to which she was entitled on the NHS. The only thing that prevented her from taking advantage of the therapy was the fact of where she lived.

A truly national health service must reach into every community in the country. Those of us who live in rural areas know that, unlike those who live in urban areas, we cannot have all services right on our doorstep. There are other compensations about living in a rural environment that people come to Cornwall—or stay there—to enjoy. However, there is a baseline of provision in all public services that people ought to be able to expect, and health is no exception to that. For that reason, I would welcome anything that the Minister is able to say about hospital transport.

Hospital transport services come under threat when fuel costs rise. Drivers get some money to provide those services, but in effect they end up subsidising them when mileage allowances do not properly reflect the costs that they incur. That problem eased when fuel prices fell recently, but it could return as they creep back up again.

In the past, Health Ministers have said that the problem relating to car parking provision needs to be addressed, as the NHS cannot be in the business of providing subsidised car parking. They have added that people need to accept that there is a cost to visiting hospitals, but that is all very well where there is a public transport alternative. In many areas, however, there is no such alternative to car use.

The problem is most acute for older people. So many young people have left Cornwall that the county has an ageing population, and that problem is predicted to get worse. Many older people would prefer not to be forced to use their car to travel the large distances involved in accessing health services, but that is what they have to do.

At the meetings that I have had with PCT representatives, they have said that they are keen to work with the acute trust and consider providing more community hospitals. That, of course, is something to be welcomed. There are many clinics, and there has been wider provision in some areas, but a lot more remains to be done on that. If the NHS were able to concentrate, in rural areas, on trying to widen the range of services available in our excellent community hospitals, that would make a great contribution to overcoming the problem of access; transport seems to be proving a barrier.

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