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I hope that right hon. and hon. Members will not mind that, having taken so many interventions, I have taken so long. It is important to tease out the issues.
It is true that as the Government, through the Secretary of State, appoint the Royal Cornwall Hospitals NHS Trust board and chief executive, they are responsible for the climate in which the board operates and the decisions that it takes. The Secretary of State should face those 300 people to explain to them that they are losing their jobs because of the direct relationship between that extremely bad news and the decisions that she takes.
If I had time, I could explain why payment by results has a distorting effect, adds to trusts' administrative costs and does not help with greater efficiencies. The target culture also has a distorting impact. I understand that we must seek incentives to meet the need for desirable outcomes, but hitting targets often means missing the point. Although performance against targets seems okay, actions taken have been at variance with the intention of those goals. Ambulance waiting times outside accident and emergency units show that patients are not brought inside because of the fear that they will reach the four-hour waiting time limit. An admissions netherworld has been created in which people are taken out of accident and emergency units and put into clinical decisions units before they are eventually admitted. I am not sure that those situations are entirely clinically acceptable.
The target culture also distorts clinical priorities and patient safety. Ambulance response time targets are met by co-responders and volunteers. That is fine, and we appreciate the efforts of those volunteers, but often that is simply a ploy by which to address the need to meet ambulance response time targets. Targets also encourage a culture of cynicism and manipulation of data, as shown in the article by Gwyn Bevan and Christopher Hood in the British Medical Journal on
All that raises questions, and I have given the Minister notice of some of the issues that I shall raise. In my view, local authorities, because of the budgetary constraints and strictures on them, are, in effect, agents of Government. If that is true, certainly primary care trusts and acute trusts are agents of Government.
How can we explain the overspend in Cornwall? What assessment have the Government and the Minister made of the appropriateness of the funding formula for places such as Cornwall? What opportunity will there be to vary the formula? If the problem is management incompetence, the Secretary of State should step in, but if the problem is not incompetence or bad management, there must be another explanation, which must include questions of formula funding. Does the Minister accept that some of the largest proportionate deficits are experienced in the poorest regions? Does she accept that targets in respect of the new so-called private sector disciplines have an impact in terms of increased management costs?
The situation in Cornwall is extremely serious. I am sure that the Minister understands that 300 people will lose their jobs. Patients in Cornwall, who need better services and better access to services, need proper answers. The mayor's parlour campaign team in Cornwall is asking for a review of health spending in Cornwall. I hope that the Minister will consider these questions seriously. The problem is not only national; in some areas, there is a particular focus and a particular acute need. The acute need in Cornwall needs to be addressed by the Government undertaking a review of funding and spending and of the provision of hospital and acute services.