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15 Dec 2009 : Column 189WH—continued

The hon. Lady spoke about the impact of 12 years of Labour rule in Buckinghamshire. However, to introduce a note of discord, we must remember that when the
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Conservatives left office in 1997, we were spending a third less than the European average on health, and the consequences were there for all to see. The problems about access to health care continued for some time, and when I arrived in Parliament four years later, my first debate in this Chamber was on orthopaedic waiting times in Norfolk. At that time-I am sure that it was similar in Buckinghamshire-people sometimes waited for three years to get to hospital for a hip or knee joint operation. The situation was not good in those days, and there was a strong case for increasing investment in the health service. If that investment had not happened, I have no doubt that the position in Buckinghamshire would be even worse than it is today. None the less, the hon. Lady pointed to some important issues about how funding is allocated around the country.

What the hon. Lady said about her experience and what her hon. Friends described reminded me of the situation in Norfolk-a rural county with quite an elderly population. The pressures and strains on the health service in such an environment are very real. The ambulance service not meeting its target for getting to emergency calls on time was one issue that the hon. Lady raised. Poor access to dental care was another example that she gave. The ever increasing number of emergency admissions to acute hospitals is causing enormous strain. Her hon. Friends also made the point that there was the sense of the whole system under intense strain, and that is a picture that I see in my county of Norfolk.

Mrs. Gillan: I could have added that we also have problems with low rates of Chlamydia screening. We have problems supporting people quitting smoking. We have problems with proactive management of long-term conditions. I did not give the whole list, because I wanted to set the scene for the debate, but I do not want the hon. Gentleman to diminish the problems by trying to draw an arcane parallel with what happened 12 years ago. I am talking about today. The Government who came in 12 years ago also removed the tax breaks for private health care from my constituents, many of whom then felt that they could not afford it and fell back on the NHS.

Norman Lamb: I do not in any way wish to diminish the problems. I am simply saying that I see many of the same problems in my county of Norfolk. I intended to go on to discuss mental health, which the hon. Lady and some of her hon. Friends also discussed. Mental health is at a particular disadvantage in the health service because it does not benefit from any centrally imposed target. Such targets have driven improved access in other areas of health care, but one consequence of targets is that areas that are not targeted lose out. In many cases, people in Buckinghamshire and elsewhere wait for months on end for access to cognitive behaviour therapy and other objectively approved therapies that can help people to recover, get them back to work and so on. Access is appalling.

The hon. Lady, in her intervention, and the hon. and learned Member for Beaconsfield (Mr. Grieve) lamented the loss of subsidy for private health care, which is something that causes me real concern. Do the Conservatives propose a reintroduction of that subsidy?
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If the hon. Lady and the hon. and learned Gentleman lamented its loss, the clear implication is that they want it back.

Mr. Grieve: What the hon. Gentleman has just said is a complete load of nonsense. I made the position clear. The reality in the area that I represent is that if everyone in the area solely made use of the national health service, the system would collapse. Because there are wealthy people, many of them do not do that. After 1997, when certain tax breaks for the elderly to get private health care were removed, more of them became dependent on the NHS. I used that example to illustrate how a bed use crisis developed over a winter in one of my local hospitals; on the evidence of the administrators and doctors, the crisis was entirely the result of that change. I simply used it to illustrate the consequences, in an area where services are already stretched, of introducing another element into the equation.

Norman Lamb: I am grateful for that clarification. The hon. Member for Chesham and Amersham said that the funding formula delivers 17 per cent. less for her area than the national average. There is concern in many parts of the country that the funding formula does not sufficiently recognise the cost of delivering health care in rural areas, particularly in areas with an elderly population. Even if an elderly population happens to be relatively well off, they still have health needs. It still costs money to provide for operations in acute hospitals and so on. However, the funding formula does not appear to recognise that sufficiently.

All the problems that the hon. Lady described, fairly and accurately so far as health services in Buckinghamshire are concerned, are likely to become significantly worse unless we are smart about how we use the available resources in the health service. Whichever party wins the general election next year, the prospects for the health service look bleak, because even if we ring-fence, protect, or safeguard funding for the NHS, the reality is that throughout the developed world, we are seeing rises in health costs. That has happened over many decades, and that trend is likely to continue with an ageing population and with lifestyle conditions such as obesity, and others caused by alcohol abuse and so on.

Another factor is the cost of new drugs coming on stream. A fortnight ago, I talked to a group of consultants in Norfolk who told me that two new drugs approved by the National Institute for Health and Clinical Excellence had a cost impact on Norfolk PCT of about £2.5 million. That is from a fixed budget, not a budget that is increased by that amount to fund it, so something else has to give. The impact of an ageing population, new drugs coming on stream and lifestyle conditions means that we have rising health costs at a time when health budgets are likely to be fixed or rising very slowly. That creates the potential for a perfect storm, and the risk is that the most vulnerable lose out in those circumstances. Some of the public health services to which the hon. Lady referred are often most at risk.

When the health service was last under financial pressure, in 2005-06, the Select Committee on Health concluded that services such as mental health and public health programmes were cut, rather than services that
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might be able to take the strain a little better. There was no attempt to improve productivity at that time, or no success at improving productivity. Services such as mental health took the hit.

There is a risk that when the financial pressure increases, crisis management takes over and there is a process of slash and burn. Instead of doing that, we must consider how we can redesign services to improve the efficient use of resources in the health service. One problem is that financial levers in the health service incentivise activity. We pay acute hospitals more and more for doing more activity. We do not pay to optimise health care and quality. We do not pay to incentivise primary care to keep people out of hospitals. The system of payment by results was criticised by Mark Britnell, the former director of commissioning in the Department of Health. Just before he left in the summer, he said at a conference in London that there was an urgent need to abolish or radically reform payment by results. That is the Government's own system, and it was the director of commissioning who made that case.

The Government have introduced a concept called practice-based commissioning, which is designed to encourage primary care to do more and to take work that is currently undertaken in acute hospitals and do it closer to home, in the community. The hon. Member for Aylesbury (Mr. Lidington) made a very good point. When GPs go to the PCT with proposals for services that they could provide under practice-based commissioning, all too often they are turned down. I understand the concern expressed by the hon. Member for Chesham and Amersham that sometimes we try to redesign services too fast, but when there are opportunities to develop community-based services around GP practices, those proposals are rejected by PCTs, which simply refuse to engage in the whole concept of practice-based commissioning. The person responsible for practice-based commissioning for the Department of Health has himself said that the concept appears to be failing and is almost dead in the water. That system to encourage GPs to do more, closer to home, appears to be failing. What should the way forward be, given the acute financial squeeze on public services such as health, which means that little new money is coming in and that costs are rising? There are a number of elements-

Mr. Peter Atkinson (in the Chair): Order. I am sorry to interrupt the hon. Gentleman, but I would be grateful if he would keep an eye on the clock. He has been speaking for more than 10 minutes, and we need to hear the Minister.

Norman Lamb: I am grateful for that reminder, Mr. Atkinson.

Let me summarise. We need to decentralise power and accountability so that Buckinghamshire PCT is accountable to its local community. We need to integrate health and social care, focusing particularly on those with chronic conditions so that we keep them out of hospital and prevent crises from occurring. We need to break down the divide between primary and secondary care. Finally, we need to get NHS financial incentives working so that we can focus on the prevention of ill health and on health and well-being. We can then end the crazy process of simply incentivising more and more activity that does not optimise health in the community in Buckinghamshire or anywhere else.

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10.40 am

Anne Milton (Guildford) (Con): I, too, congratulate my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan) on securing the debate. I welcome the fact that she also spoke on behalf of the constituents of the right hon. Member for Buckingham (John Bercow), who presides over this place.

My hon. Friend described PCT and local health care services that are in absolute crisis. She rightly highlighted the fact that the current reconfigurations are taking place much too quickly to enable standards of care and quality to be maintained. She highlighted the 40 per cent. cut at clinics in Amersham and the complete cut in counselling services.

As my hon. Friend said, the right hon. Member for Buckingham is concerned about mental health services-£35 million has been stripped out just so that they can break even. Our greatest concern is that it is precisely mental health services that are being cut back to deal with our financial deficit. As the Minister is well aware, mental illness costs this country £77 billion. Sadly, after 12 years of this Government, they remain a Cinderella service and they are very vulnerable.

My hon. Friend the Member for Aylesbury (Mr. Lidington) spoke of the reduction in health visitors, school nurses and district nurses and of particular concern at the Wycombe and Stoke Mandeville hospitals. He also spoke of his extensive use of NHS care, which is perhaps why he looks so well this morning.

My hon. Friend the Member for Wycombe (Mr. Goodman) talked of his constituents' massive concerns about the significant changes at Wycombe hospital. He spoke at length about reconfigurations and the fact that the Government have continued the ghastly cycle of constant change.

I sat on the Health Committee when it undertook an inquiry into reconfigurations, and there has been one reconfiguration every 18 months since the NHS started. At the time, the Committee highlighted the significant loss of focus that occurs following reconfigurations, as well as their absolutely paralysing effect, and that has never been truer than it is today. At the end of the day, reconfigurations deliver few cost savings; in fact, they are a cost in themselves.

The funding formula is the crux of the debate, and my hon. Friend the Member for Aylesbury rightly pointed out that the supply of money is not infinite. However, demand probably is. When I first trained as a nurse, people would come into A and E wheeling their hernia in a wheelbarrow in front of them, but expectations today are such that they probably would not accept a 1-inch hernia. Expectations have rightly gone up, but the demand is a constant pressure on the NHS, which does not have an infinite supply of money.

There is rightly concern about the dance that takes place between the NHS and social services, as my hon. Friend the Member for Aylesbury pointed out. At times such as this, everybody scurries around trying to dump the costs of care on somebody else. In my constituency, there is concern that the move to reconfigure services and look after people in their own homes will see the NHS dump costs on social services, which face similar budgetary constraints. The patient ends up being looked
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after in their own home and receiving worse care and services-less physiotherapy and less occupational therapy. Indeed, they are often unnoticed by services.

On the funding formula, I must tell the hon. Member for North Norfolk (Norman Lamb) that the issue is not just what we spend, but how we spend it. Buckinghamshire receives 17 per cent. less funding than the average, but as my hon. Friend the Member for Chesham and Amersham rightly said, her constituents' needs are not 17 per cent. lower than the average. The cost of providing ambulance services and many other services in areas such as Buckinghamshire is also greater than the average. The Government White Paper "Our health, our care, our say" was quite explicit about the fact that changes in services should not be made in response to short-term budgetary constraints, but that is exactly what we are seeing.

Healthy and wealthy areas often have older populations with a much greater need for health care services. As has rightly been said, it is simply not the case that wealthy areas have less need. Although such areas are relatively affluent, they are the big users of health care services. Wealthy areas also have significant, albeit small, areas of deprivation, and people should not live in such areas, which do not attract the significant funding that other areas do.

When I sat on the Health Committee, we also did a report on budgetary deficits, and I point the Minister to the work of Professor Sheila Asantha, who looked at the impact of the Government's funding formula on wealthy areas. She pointed out that those living in wealthy areas get the worst health care services, because the funding formula is skewed towards areas of deprivation, which need money for public health improvement but do not necessarily have demand for health care services.

The Government have never fully understood that issue. In this season of good will, I do not want to make too many party political points, but I hope that the Minister can respond and demonstrate that he has some understanding of the difference between money for public health improvements, which needs to go to deprived areas, and money for health care services.

We need to separate the money for health care service delivery from the money for public health improvements, and that is the Conservative party's policy. As I am sure the Minister is aware, improving public health takes more than money in the health service. In many ways, it is not appropriate to deliver such measures via the health service-we also need social and economic change if we are to make a difference. That is exactly why we have seen health care inequalities rise despite the Government's best efforts. The Government have been ill informed.

Targets have been mentioned, but not as much as they should have been. Again, as I said, the issue is not just the money we spend but how we spend it. I recently went to a conference attended by a lot of senior doctors and surgeons, although I will not identify it because of the comments that were made. However, there was quite a lot of talk about targets, and that is the same wherever I go. Those at the conference went on and on about targets distorting clinical priorities. Indeed, people in the audience started talking about the fact that they now have training days to work out how to play the system-it is called gaming.

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The problem with process-driven targets is that care that does not have a target simply does not happen. The Government have never fully understood the difference between a process-driven target and an outcome. To take as an example follow-up for long-term conditions, many people with diabetes and conditions such as epilepsy need follow-up in secondary care; however, they currently do not get it because of Government targets relating to first appointments. The process is driven entirely by centrally-driven Government priorities, not clinical needs.

My hon. Friend the Member for Aylesbury mentioned paperwork, of which targets attract a huge amount. We have many people now employed in the health service solely to deal with that. There are outstanding questions, but I realise that time is short so I shall draw my comments to a close.

Perhaps the Minister can explain what is happening to the £30 million of reserves that the strategic health authority currently holds. What plans do the Government have to look again at the funding formula? Can the Minister state, hand on heart, that the reconfigurations in the past 12 years have produced better delivery of health care services? Does he understand how damaging that change has been, and how much it has cost?

10.51 am

The Minister of State, Department of Health (Phil Hope): In the nine minutes left for me to reply I want first to congratulate the hon. Member for Chesham and Amersham (Mrs. Gillan) on securing the debate. I also congratulate the hon. Members for Aylesbury (Mr. Lidington) and for Wycombe (Mr. Goodman) and the hon. and learned Member for Beaconsfield (Mr. Grieve), who joined her in making a strong plea on behalf of their Buckinghamshire constituencies and that of Mr. Speaker. Their plea, essentially, when we get to the bones of it, is "More money for Buckinghamshire NHS, please." That may be a bit of a shorthand version, but I think that is essentially it. They raised some specific issues that time will not allow me to cover, and I am sure that the NHS organisations in Buckinghamshire that will be following the debate will take forward some of the detailed points.

Mrs. Gillan: Will the Minister give way?

Phil Hope: I have only just begun.

Mrs. Gillan: I and my hon. Friends would all be delighted to receive a very detailed letter from the Minister about the issues that he has not the time to cover.

Phil Hope: The hon. Lady is of course in regular conversation with her NHS organisations and I am sure they would be delighted to write to her about the details that she and her hon. Friends have raised, which are of course a matter for local NHS organisations.

We have had a decade of expansion and of a massive catch-up in health funding, which has yielded big improvements throughout the country, Buckinghamshire included. Opposition Members will know that in Buckinghamshire 99 per cent. of patients attending accident and emergency are now seen within four hours;
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91 per cent. of patients now receive treatment requiring hospital admission within 18 weeks, with that figure rising to 97 per cent. for day cases; and more than 93 per cent. of suspected cancer patients are seen by a specialist within a fortnight of referral. As far as delivering outcomes in the past decade, those figures are a testament not only to the additional funding from the Government, but to the hard work of local NHS staff, whom I thank for their efforts. We are determined to bank that progress and to continue to improve standards in a very different financial climate.

I think that every hon. Member who has spoken has raised the issue of the national funding formula and suggested that it penalises Buckinghamshire unfairly. The new funding formula that we are using was developed by the Advisory Committee on Resource Allocation, an independent panel of experts. It has been designed to meet the twin objectives of equal access for equal need, and reducing health inequalities-themes that hon. Members repeated throughout the debate. The funding formula recognises that the principal cause of variation in health care needs is the age structure of the population, so it factors in the number of older people and the expected number of births.

It is widely acknowledged that poverty significantly increases people's chances of getting sick and needing health care, so the formula also increases funding if a primary care trust region has a high level of deprivation. In Buckinghamshire, the proportion of people over 60 is 22 per cent., the same as the England average. I agree that there are pockets of deprivation, which is something that local providers must take into account when providing services and allocating resources. Overall, however, although I would not describe Buckinghamshire as rich, as the hon. and learned Member for Beaconsfield did, it is, as other hon. Members said, one of the more affluent parts of the country. That means, according to the funding formula, that it receives a lower proportion of funding than somewhere with, say, 30 per cent. of its population aged over 60. The point is that it is the independent expert panel, the Advisory Committee on Resource Allocation, that believes that the formula is the best way of allocating funding. Whatever the arguments about the formula-and I believe I have made a powerful case for it-Buckinghamshire's funding will continue to grow. The NHS in Buckinghamshire will still get more than £652 million this financial year and £686 million in 2010-11-more than a 10.5 per cent. increase over the two years.

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