I am grateful to have an opportunity to debate the problems of hospital transport in Gloucestershire. I am also grateful to the Minister for being here to reply.
The provision of hospital transport for patients in my constituency is inadequate. I have received a flood of complaints from constituents who rely heavily on the provision of transport to and from hospital for appointments for in-patient and out-patient treatment. I shall focus on key aspects of the system that are letting patients down. I want to question the national and local criteria for assessing the patients who receive national health service-provided transport and I am concerned about the funding settlement for Gloucestershire health authority, which has had to divert money from the provision of transport to meet other Government health targets. I shall cite several constituency cases to illustrate the problem and explain that current criteria are incorrect because decisions are taken on a patient's medical condition, not on his or her capacity to travel.
I have corresponded many times with the Department of Health about the problem. It says that if a patient has a medical need for transport, it should be provided free of charge as part of NHS treatment. No one would disagree with that. It also states that medical need depends on the medical condition of a patient, the availability of public and private transport and the distance travelled. However, the principle that should apply is that each patient should be able to reach hospital in a reasonable time and in reasonable comfort without detriment to their medical condition. My examples make it clear that that is not the case. I will name only one person because others who have corresponded with me are elderly and worried about their names being divulged.
Mrs. Jackson is 83 years old. I have been in touch with her regularly in recent months. She had to go into hospital for an eye operation and also suffers from angina, but, because she is not in a wheelchair, she does not come within the C2 category for provision of free transport. A 67-year-old patient was sent to Cheltenham general hospital when she cut her leg badly. The hospital refused to provide transport home despite the fact that she suffers from a varicose ulcer on her other leg and is in great pain when she walks. The size of my constituency means that taxi fares are expensive. I met an 89-year-old lady who was forced to pay a £45 taxi fare to and from hospital. One constituent is crippled with arthritis and could not afford to pay the fares. Her daughter had to take her to and from hospital and, on her last visit, had to wait from 8 am to 5 pm to bring her home.
Those cases graphically illustrate the way in which our elderly patients are being treated by the NHS. According to the Department of Health:
"if a patient has a medical need for transport, then transport should be provided free of charge as part of NHS treatment". How does that square with my constituency cases? The Minister needs to take urgent action to address that shameful problem. The health authority cites funding as the main problem and it is the Minister's responsibility to address that.
Gloucestershire health authority has introduced a new set of criteria for assessing whether people need transport. It provides transport for walking patients under the C1 category in four circumstances: first, if a patient is registered blind or partially sighted; secondly, if he or she has a combination of poor sight and total hearing loss; thirdly, if the individual is undertaking oncology treatment; or, fourthly, if he or she is receiving peritoneal dialysis treatment.
Under the separate C2 category, transport will be provided only for patients who are unable to walk and require the assistance of two people from their home to get them to the vehicle and back. Transport will also be provided for patients who are confined to their wheelchair and must be transported in it. The final category includes patients on stretchers who must be transported completely or mainly lying down.
In other words, Gloucestershire health authority is able to provide transport only for those who are deaf, blind or a combination of both, on a stretcher or receiving oncology treatment or treatment for coronary heart disease. We know that many sick people have serious conditions but do not fulfil those criteria. They, too, should be eligible for transport.
As a result of those restrictive criteria and the need to redirect funding, patients are not being treated with respect. The criteria unacceptably exclude many patients who desperately need hospital transport. Gloucestershire cannot provide that service because it is obliged to meet national targets that unfortunately do not recognise rural sparsity and the transport infrastructure of the area. There is little value in diverting money to meet national targets if that undermines other essential services that the NHS was set up to deliver. Hospital transport is an essential service for patients in my sparsely populated rural constituency. The Minister must recognise that they rely on it. There is often no suitable public transport for rural villages.
The Government have increasingly prescribed the way in which health funds can be spent by local health authorities. The problem is that the more that policies are prescribed, the less discretion the health authority has to meet the needs of patients in its area. Thus, spending on initiatives, however worthy, such as the waiting list initiative, ignores the clinical needs of health authorities and prevents them from having the freedom to spend money on local priorities, including hospital transport in Gloucestershire.
The Gloucestershire health authority has revealed that it cut funding for the provision of transport to meet other national targets. In September, the chairman of the health authority wrote to me stating that NHS resources have been made available to meet national priorities, such as improving services for people who suffer from coronary heart disease and mental illness and reducing waiting list times. I accept that those are laudable targets, but the health authority has had to adjust the criteria that determine whether patients in Gloucestershire receive hospital transport free of charge. The changes have saved £170,000 and NHS patient journeys have dropped from 200,000 in 1998-99 to approximately 135,000 in 1999-2000. I am all for saving money and for people providing their own transport when they can, but the criteria are too restrictive.
Health authorities with a market forces factor of 117 or higher are eligible to receive additional funding, especially for the recruitment and retention of nurses and doctors. The problem of funding Gloucestershire health authority has been a matter of extreme concern to me over several years and its solution is essential for the provision of hospital transport. Gloucestershire receives a lower weighting than it should because it is not considered to be an urban authority. That is because Gloucester and Cheltenham are six miles apart, but they have a high proportion of the council's population, so the authority is not considered to be rural. From a funding point of view, we are neither urban nor rural, so we get a poor deal from discretionary funding because of the market forces factor.
I represent 10 market towns covering almost 1,000 square miles of Gloucestershire, which at the extreme could be 30 miles from the district general hospital in Cheltenham. I say to the Minister in what I hope is non-partisan way that it is essential that, whoever is elected at the general election, the inequality of Gloucestershire's funding is addressed.
We should broaden the assessment criteria so that when a patient needs transport they will get it. The criteria must be based on the principle of the patient's capacity to travel and not just on their textbook medical condition. Funding should recognise the great distances that patients have to travel in rural areas and the poorer transport infrastructure in those areas. I make no political point about that; it is a fact of life that people in villages have little or no public transport to and from the local hospital.
Often, if there is transport, it does not operate at a convenient time to get people to their appointment, and if the appointment is delayed, it may not be available to take them back home. That is why the emphasis must be on capacity to travel and not just on medical condition. Common sense needs to be applied so that patients are not let down and harrowing cases such as those that I have cited do not happen in future, as I am sure everyone listening to the debate agrees.
I re-emphasise the point that we must treat elderly patients with dignity. According to Age Concern, almost one in three people in my constituency are pensioners, which is among the highest proportions in the country. The elderly can be very confused when they go to and from hospital. It is a stressful time, and it should be a fundamental principle of a decent society that we offer them the basic courtesy and respect of providing comprehensive hospital transport services. I hope that the Minister will recognise that human problem, and I look forward to her positive response.
I congratulate Mr. Clifton-Brown on securing the time to debate a topic that is clearly of considerable, long-standing concern to him. I note that, last year alone, he wrote to me on the subject and asked questions of my right hon. Friend the Secretary of State for Health.
Before I deal with the patient transport service in Gloucestershire, I should like to explain a little about the Government's national policy. Although I do not wish to be partisan or to score party political points, I point out that the guidelines were introduced in 1991 and have not been changed since, but there is the question of how they are implemented locally.
The NHS has a responsibility, which it has recognised, to provide transport to get patients to and from hospital if it is considered that their medical condition makes it necessary. That decision is made by a doctor or other health professional who decides whether there is a medical need for transport to be provided free of charge, as part of the patient's NHS treatment. In arriving at the decision, doctors or other health professionals must take into account the availability of private or public transport and the distance to be travelled by the patient. The transport infrastructure therefore informs that decision.
The principle that should apply is that patients should be able to reach hospital in reasonable time, in reasonable comfort and without detriment to their medical condition. The availability and suitability of alternative forms of transport vary from area to area and it is important that local arrangements cater for local circumstances. As a Member of Parliament for an urban area, I am aware that distances that appear small on a map may be terribly difficult to travel. Over the past decade, a wide variety of social, health and similar specialist transport schemes have been set up for different purposes.
There is no intention to undermine such services, but I believe that now may be the time to examine that provision. I strongly encourage all those providing transport for patients in the NHS, social services, local authorities and the voluntary and private sectors to take this opportunity to review their services together to ensure that people can access the range of services they require, that we can make the best use of health and other facilities and that all transport resources can be used most efficiently and effectively.
Having set the national scene within which the Gloucestershire patient transport service operates, I turn now to the service itself. It is important to point out that the service in Gloucestershire fully meets the standards that apply to the NHS throughout England. This debate is not about the quality of the service provided by the trust, but rather about who should receive that service. I see the hon. Gentleman nodding, so we agree on that point.
The patient transport service is too often seen as merely providing a bus service to hospitals, but it is an extremely important service which complements the emergency services of the ambulance trusts, and that additional role is often overlooked. The staff who provide the service are all trained in first aid. They provide care and possible intervention to patients whose medical condition is such that they need transport by the NHS. They also provide help and support to patients at a time when they are understandably anxious about their treatment and are feeling vulnerable.
The Gloucestershire Ambulance Service NHS trust considers the patient transport services vital to the operational needs of the service, particularly when dealing with major incidents such as train or coach crashes. The patient transport service can be called on in those circumstances to transport large numbers of walking wounded to hospital, allowing paramedics to concentrate on the treatment and care of the more seriously injured.
In addition, in of their normal duties, staff in the patient transport service are often the first on the scene of an accident where they can provide basic first aid, help and assistance until the paramedic crews arrive. A number of patient transport ambulances within Gloucestershire are equipped with defibrillation gear, which enables staff to treat suspected victims of cardiac arrest within the critical time. Patient transport staff may provide a first response to other life-threatening calls and help to stabilise patients before they are transported to the nearest accident and emergency department.
I stress that the patient transport service is not an add-on to the ambulance service; it plays an integral part in that service and we take it very seriously, as I know Gloucestershire does. Working in the service provides good experience and grounding to staff who wish to train to undertake accident and emergency ambulance duties in the future. It gives them a good opportunity to improve their driving skills, to gain experience in the handling and lifting of patients, to develop communication skills with patients, relatives and carers and to widen their knowledge of the care and treatment of a wide range of medical conditions.
As the hon. Gentleman stated, a review of patient transport services was undertaken in Gloucestershire in 1999. Its main finding was that there was considerable over-use of the service by patients who did not meet the criteria that apply to the NHS for access to patient transport services. The hon. Gentleman quoted reductions in some of the figures. In developing the NHS plan last year, we found huge variations in the delivery of services. We have to establish a common base, so Gloucestershire, rightly, reviewed its transport services.
I do not disagree with the hon. Lady's point that hospital transport was being provided to people who did not need it. However, does she accept that cases such as those that I have cited today are unacceptable? Does she accept also that if there is discretion in the system, as there should be, it should be applied favourably to elderly people, first, because they are likely to be confused and anxious when they go to hospital, and secondly because there is a lack of rural transport in my big constituency?
I shall respond to those points.
The national guidelines call for the NHS to provide transport for those patients who have a medical need for such transport. In Gloucestershire, a considerable number of patients who had no medical need for transport to and from hospital received that transport none the less. Changes to the criteria have released £169,000 in the first full year of their operation; that money is now being used to provide health care for Gloucestershire.
I accept the hon. Gentleman's point about conflicting priorities: money is also being spent on reducing waiting lists and improving services. However, it is a matter of ensuring that all those things happen. To put it at its most extreme, it would be no good improving transport services if hospital services were not improved at the same time. A balance has to be struck, part of which is to ensure that the right people get the right service.
I am advised that the local health economy has kept the criteria under continuous review and has already updated the policy to ensure that vulnerable groups, including the mentally ill and frequent attendees at hospital, such as patients having renal dialysis and cancer treatment, continue to receive NHS transport. Other exemptions are made on a case-by-case basis. If the hon. Gentleman believes that any of his constituents who should receive patient transport have not done so, I recommend that he contacts the trust involved and asks for a review of the individual cases. From my knowledge of some of the cases that he has raised with Ministers, I know that he has done that in the past. The system allows discretion to be exercised, but if that does not happen in certain cases, it must be investigated.
I am grateful to the Minister for her suggestion. I have indeed drawn cases to the attention of trusts. The problem is that, by the time a case has arisen, it is too late. Is she prepared to write to the trusts today, stating that I have brought the issue to her attention and expressing the Department's hope that in cases involving that discretion, the elderly in particular will in future be treated sympathetically?
I have found that, even when debates on such issues are sparsely attended here, all the health professionals concerned keenly read Hansard afterwards. In addition, I shall ensure that they are sent a copy of today's debate, so I am sure that the words uttered in the Chamber today will not go unnoticed in Gloucestershire.
To help to tackle specific cases, each trust in the county has appointed an officer who can permit exemptions to the usual criteria. An example of that exception would be a frail elderly person who encounters difficulty in using public transport or has no family support. The cases highlighted by the hon. Gentleman--those of Mrs. Jackson and the 67-year-old patient with a leg injury--appear on the face of it to be the sort that should be taken up.
I appreciate that, after the implementation of the new guidelines in 1999, there was some concern about the impact of the measures on voluntary transport providers, who play an important role. Local trusts are currently discussing future opportunities with the South Cotswold volunteer service and Gloucestershire county council.
The hon. Gentleman expressed concern about the perceived poor allocation to his local health authority. I should explain that the Department of Health uses a national weighted capitation formula as the basis for allocating hospital and community health services revenue to individual health authorities. The underlying principle of the formula is to distribute resources as equitably as possible based on the health care needs of the local population. Under the current weighted capitation formula, Gloucestershire health authority should receive £377 million next year. However, the Government are allocating nearly £394 million for next year--a real-terms increase of 5.7 per cent. and more than £161 million more than the health authority received in 1997 under the previous Administration.
In addition to those allocations, Gloucestershire health authority has benefited from a number of initiatives under the Government's investment in modernisation. Those include £100,000 to identify and implement service changes that will improve cataract services for local patients; £103,000 to help to reduce waiting lists; £407,000 for booked admissions projects--which will in themselves make it easier for patients to plan their journey; and more than £2 million to modernise the accident and emergency departments in the area. I am sure that the hon. Gentleman welcomes those investments and the many others that benefit his constituents.
The hon. Gentleman made clear his belief that the formula needs to be changed because it fails adequately to cover the costs of providing health care in rural areas. In November 1998, we announced a wide-ranging review of the formula used to make cash allocations to health authorities and primary care groups and trusts under the auspices of the Advisory Committee on Resource Allocation. The aim is to produce a new and fairer formula that reflects the way in which the new NHS is managed and uses its resource.
The review includes assessment of the health care needs of rural populations and identification of any unavoidable extra costs associated with providing health services in rural areas. Although there can be no guarantees about the outcome of the review, I am aware that this is not the first Adjournment debate in which Members of Parliament representing rural areas have expressed their view that the way in which resources are allocated should be changed.
We know that the announcement of large and complicated reviews can cause a period of uncertainty; therefore, at the time that we announced the review, the Government announced a freeze on further changes to the existing formula. That will help to maximise stability and certainty for health authorities and primary care groups, while allowing the wide-ranging review to take place.
The hon. Gentleman also touched on the subject of the poor public transport infrastructure serving his constituents. All of us know that that problem did not start in 1997; it is rooted in the more distant past. I trust that he welcomes the announcement by my right hon. Friend the Deputy Prime Minister of considerable increases in funding for rural bus services, from £90 million over the past three years to £136 million over the next three. This year, Gloucestershire received nearly £800,000 to help to provide 36 new and enhanced services in Gloucestershire. Next year, there will be an increase of more than 20 per cent. in the rural bus subsidy grant for Gloucestershire, taking it to more than £1 million; that will be followed by a further 15 per cent. increase the following year.
Not all rural areas are alike, and traditional transport solutions are not always appropriate in some of the most remote areas. The rural White Paper also announced our intention that smaller communities should benefit from a new £15 million special parish fund. Parishes will be able to apply direct for up to £10,000 for small-scale projects such as buying a minibus, setting up a social car scheme or a car or moped pool, or paying a bus company to divert a route through an outlying village, which I know has been most helpful in some areas. That will give them more freedom to decide on the sort of help that they need.
I understand the hon. Gentleman's concerns about patient transport, which is a matter that we take seriously. However, the hon. Gentleman raised the question of medical needs and their assessment. We have to draw a distinction between vulnerable groups and patients who really need hospital transport so that their condition does not deteriorate, and cases in which the problem is inability to pay. Therefore, I draw the hon. Gentleman's attention to the hospital travel costs scheme, which supports low-income patients and allows some reimbursement of such costs.
It might not be strictly relevant to today's debate, but, in connection with funding, will the Minister take into account the fact that her Department has recently altered the coverage criteria for the south-east living allowance to include Bristol and Swindon? That is causing great problems with recruitment of nurses and doctors in Gloucestershire because in many areas, including the Cotswolds, the cost of living is higher than in Swindon and the rest of Gloucestershire. When a formula is changed, problems always arise at the margin, and that is what has happened as a result of the changes to that allowance. Will the Minister consider whether anything can be done to solve that problem?
That problem has been raised in this Chamber before. We continuously examine those matters, because we know that wherever a line is drawn, some people are left on the other side.
In addition to expressing specific concerns about patient transport in his constituency, the hon. Gentleman has stated his belief that we must give the elderly the respect that they deserve and must treat them properly. In that context, I hope that he welcomes yesterday's launch of the national service framework for care for older people. It is designed to provide a blueprint for care and to tackle problems of age discrimination throughout the NHS.
Everyone has a right to first-class treatment in the NHS. In every part of the service, whether in urban or rural areas, we need to identify and meet the needs of those who may be vulnerable. I hope that today's debate will enable the hon. Gentleman to take up individual cases involving decisions that he believes were wrong, although I believe that the overall framework is the right one.