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May I say what a pleasure it is to serve under your chairmanship, Mr. Atkinson? I am grateful to have the opportunity to raise concerns about health services in Buckinghamshire, particularly in Chesham and Amersham.
When I applied for the debate, I did so not only in the interests of my constituents, but on behalf of my colleagues who are sitting here with me. I was the lead name for the debate, but I applied for it on behalf of my hon. Friends the Members for Aylesbury (Mr. Lidington) and for Wycombe (Mr. Goodman), and of my hon. and learned Friend Mr. Grieve. Unusually, I will also make some remarks on behalf of John Bercow who, as you know, Mr. Atkinson, presides over the House and is unable to participate in such debates. Nevertheless, he feels just as passionately as we do about health services in Buckinghamshire and, with your permission, Mr. Atkinson, I have some speaking notes that I intend to deploy on his behalf.
I welcome the Minister and my hon. Friend Anne Milton, who speaks on health matters for the Conservatives, to the Chamber. I am delighted to see the Minister, because we did some sterling work together during the course of this Parliament on the Autism Act 2009. When that provision was just a raw Bill, the Government, in the shape of the Minister and his colleagues, chose to oppose it. However, with persuasion and after winning the vote on Second Reading, the Minister and his colleagues saw the light.
We were able to exhibit-and I say this in a spirit of generosity to all the other parties-the House at its best and put an Act in place. I give notice to the Minister that in the interests of my constituents in Buckinghamshire I shall be holding his feet to the fire. I am looking forward to a wide and thorough consultation on the Autism Act, which will be part of our health care service. I hope that the Minister will bring the enlightenment that he eventually brought to the debate on the services provided to people with autism to this debate, which covers the wider health care services in Buckinghamshire.
After more than a decade with Labour in power, it is fair to say that the NHS in Buckinghamshire is facing a crisis. We have called this debate to find out just what the Minister and the Government are going to do about that. There is no time for warm words; the stark reality is that the health service in Buckinghamshire is fast approaching breaking point.
Buckinghamshire has one of the lowest-funded NHS systems in the country: it receives some 17 per cent. less per head than the UK average. Last year, we had the only primary care trust with a deficit of some £7.5 million. Although we have relatively good health, we have only average care-those are not my words; they are the words of health care management professionals. Are we 17 per cent less in need or 17 per cent. healthier than other areas? I think not. Sadly, we have poor dental access and poor ambulance times, because of the size of the county. We also have a higher number of delayed hospital transfers and an ageing population. All our constituents are living longer, so the disparity between the formula that is adopted and the outcomes is starting to widen and become greater. I believe that my colleagues may allude to that matter in more detail.
The financial situation is becoming dire. I believe that the Buckinghamshire Hospitals NHS Trust must find an efficiency saving of 3 per cent. annually, which is some £11.5 million. In addition, the PCT is now paying the hospitals trust at 25 per cent. of the tariff for the rest of the year for over-performance against most in-patient and follow-up out-patient work, which adds another £5.2 million of income loss and takes the total savings that have to be found to about £17 million by the end of March.
In fact, in Buckinghamshire, we are unable to fund the care records service, which amounts to some £2.4 million, or Maternity Matters, which is about £700,000. Our health service leaders have had to pull together a summit plan-in other words, an emergency plan. Given the hospitals trust's financial position and the PCT's structural deficit, more than £20 million has to be taken out of the health service in Buckinghamshire between now and the end of the financial year.
Remedial action has been taken to try to plug that gap. Attempts are being made to curb our urgent care demand, and our health service is aiming to make 100 fewer admissions a week and reduce the number of accident and emergency attendees by 30 per cent. I must tell the Minister that, after my last meeting with the hospitals trust, there is no indication that there have been any major shifts in that pattern at all, which means that the projected cost savings will not be made. We are also trying to reduce our GP referrals to hospital by 50 a day.
Our GPs and other NHS staff are working like Trojans to see more patients, as well as offering community services and trying to reduce the elective and out-patient demand. They are trying to balance the books, but they are doing so against almost impossible odds. We are trying to move from one model of care to another far too rapidly, which is causing big problems. One could consider the scarcity of funds to be a positive challenge-indeed, many people who work in health service do, because they regard the glass as half full, not half empty. In the long term, we all want better care closer to home, and we want people to receive the right treatment at the right time. I believe that the administrators who head up our services are doing the very best that they can to deliver them. However, what we are experiencing on the ground is the alarming effect of a pace of change that is almost impossible to achieve. Buckinghamshire will be the first area virtually to tip over, not least because of the historical financial deficit.
Clinics at Amersham hospital have been dramatically reduced, with many moving to Wycombe or Stoke Mandeville. That causes great difficulties for people who travel to get treatment. I can honestly say that some of the letters I have received are absolutely heart-breaking. Many of my elderly constituents find the journeys and the confusion of the changes almost impossible to deal with. Overall, more than 60 per cent. of the clinics can be maintained, but that means that there is a 40 per cent. reduction, which is an enormous drop by anyone's standards.
The PCT has given notice to providers of primary counselling services that their services will end early next year, which, when combined with other cuts to Mind centres and the managed services, means most of the counselling services in Buckinghamshire will be removed in the very near future. Our ambulance services, which do a fantastic job, do not operate on a level playing field. The per capita allocation of NHS funds reduces payments to the so-called affluent areas, such as ours. However, the cost per capita of providing ambulance services is much higher than in urban areas, which puts even more pressure on the service in Buckinghamshire.
With our services operating under such pressure, I am concerned about what will happen if we are hit by a flu epidemic and a harsh winter. Our senior managers have a mandatory duty to break even and deliver on budget, but they are not going to do so if it means jeopardising patient safety. There is a real possibility of a major problem if we are hit by a flu epidemic. I have been told by our senior personnel that the board of Buckinghamshire Hospitals NHS Trust takes seriously its responsibility for the stewardship of our finances, which ultimately are funded by the taxpayer, but that its commitment to patient safety and the quality of services is its top priority. That means, in my language, that our health care professionals-they cannot say this, but I can-will put people before their budgets and their careers, and that is true dedication. However, the years of unfair funding for Buckinghamshire are now coming home to roost. If there is a crisis this winter, what will the Minster do to help to deliver health services in Buckinghamshire, which are stretched to breaking point, to our constituents?
I understand that we in Buckinghamshire are not alone in feeling the effects of the unfair funding and that similar effects are being felt in Hertfordshire, Berkshire, Hampshire and, indeed, Oxfordshire. Perhaps the Minister would confirm that many of those areas are approaching a financial crisis. I believe that the financial crisis is felt right across our area, and I am certainly not convinced that the advent of the South Central strategic health authority, which was formed on
As I said at the beginning of my speech, I would like to make a few points on behalf of the right hon. Member for Buckingham, who has some specific concerns about his constituency. He has been contacted by several constituents concerned about the threat to mental health services and by people who are worried that the range of services might be reduced as a result of the planned review. He believes that the PCT might be planning to invest solely in cognitive behaviour therapy and wants reassurance that other forms of therapy will be recognised and receive investment.
The right hon. Member for Buckingham is also concerned about Buckingham community hospital, where doctors and patients are worried about the new contract and are concerned that the reduction in the number of hours of care would be detrimental to the hospital. That has already caused the transfer to Milton Keynes of patients who would have been treated in Buckingham community hospital. I understand that there is much anger about the downgrading of the community hospital among his constituents, and fears among the staff, who feel that the new arrangements are worse. Under previous arrangements, GPs could continue to visit their patients, but that is no longer the case. It is essential that the need for budget cuts does not result in a second-class service for the residents of Buckingham and the surrounding area.
Although unable to speak on the matter, the right hon. Member for Buckingham is no less concerned than my colleagues, who will speak in this debate, and me about the resources available for providing proper health care through the NHS to our constituents. I am sure that his comments would mirror some of my earlier remarks. I am particularly worried about the effect on NHS staff in Buckinghamshire. I have had talks, as have my colleagues, with the chief executive of the hospital trust and I know that it will try to reduce any redundancies to the absolute minimum. However, it has had to establish employee assistance and a redeployment bureau. Consultations with affected staff, although under way, mean that many of our dedicated personnel in the health service now fear for their jobs as we approach the Christmas season.
I therefore ask the Minister not to put on the rose-tinted glasses of office when he responds, but to realise that with our existing structural budget deficit, the need for productivity improvement, the financial downturn and the fact that Buckinghamshire received 17 per cent. less funding than the national average, we have an ever-increasing problem that will not go away. To deliver in this financial year and just break even, the cost improvement programmes equate to stripping out about £35 million in total. That would be asking a lot of any health service in any part of the county, but it is especially true in our area, where the demand is so high.
What is particularly worrying is that the problem will be exacerbated in future. With a forecast increase of only 5.1 per cent. next year and little or no increase in the budgets thereafter, there will be reductions in funding in real terms, which will mean real cuts to our health service that cannot be concealed or dressed up by fancy words. They will come as a result of the actions that have been taken by the Government in power at the moment. Will the Minister tell me how he can help us in this financial year, how he will ensure that people in Buckinghamshire continue to receive a high-quality, safe and accessible health service and how it will be sustainable in future years? I am sure that he would not want his legacy in government to be the fact that people in Buckinghamshire do not get a decent national health service. I hope he can rise to the challenge and will not produce the usual official script.
I congratulate my hon. Friend Mrs. Gillan on securing the debate. I should also declare an interest in two respects. Since I might refer to mental health services, I declare that I am an honorary vice-president of Buckinghamshire Mind. I should make it clear, moreover, that my family and I have been using local health services in the county throughout my time as a Member: all my four children were born at Stoke Mandeville hospital and, because of family illness, I have had occasion to visit the accident and emergency department at Wycombe general hospital, and both the accident and emergency and in-patient wards at Stoke Mandeville hospital within the past 10 days.
My hon. Friend set out clearly in her speech the financial challenge the local NHS faces. Some of the problems we have faced over the years in persuading officials and Ministers to take those challenges seriously arise from the misleading impact of average statistics for the country, which show Buckinghamshire as being prosperous, healthy and therefore able to cope with significantly less than the average per capita funding for England. Of course, those averages sometimes conceal the fact that there are certainly pockets of poverty, both in Aylesbury and in High Wycombe, as I am sure my hon. Friend Mr. Goodman will say later. Certainly, anyone who visits Southcourt or Quarrendon in my constituency would not regard those estates as prosperous. There is a disparity in the county between the south, where the population is ageing rapidly, and the Aylesbury area, which is one of the fastest-growing parts of England and has a young population.
It is wrong to assume that old people are passive these days. When I speak to GPs in my constituency, they say that elderly patients come in, describe their symptoms and then explain that they have looked their condition up on the internet and discovered that some new treatment is available. They then tell their doctor, in forthright terms, that they want that treatment and are unwilling to take no for an answer. They have high and increasing expectations that a previous generation of retired people did not have.
I had a case exactly like that in my surgery as recently as yesterday. A constituent had been told by his GP to look up what could be done for his condition, and he went back with what needed to be done. The GP would very much like to recommend the treatment but, of course, would be running against an ever-diminishing budget.
My hon. Friend is right, and all of us are finding such cases arising in our constituency work load. I do not know whether she recalls this, but I believe that it was the first of the strategic health authority's trinity of chief executives who questioned in a valedictory memorandum whether the current level of funding for Buckinghamshire was sufficient to maintain a core service at the level which local people are entitled to expect.
My hon. Friend put it well: there is little argument today about how health services are evolving and ought to evolve in this country. I am certainly not going to stand here and say that there cannot ever be change, and I believe that most of my constituents want health services to be delivered to them at home or as close as possible to their home. Trends in medical science and the trend toward concentrating specialisms-the treatment of particular cancers or particular types of heart attack-in a limited number of hospitals where all the experts and the best equipment can be brought together are certain to continue and will provide better patient outcomes.
The model for the future of a wide range of local, usually community-based services and in-patient stays in hospital reserved for serious conditions, for as short a time as possible, is one that I would endorse. However, my real fear about what is happening in Buckinghamshire is that although we are seeing that reconfiguration happen, it is driven not by clinical developments and priorities but by the urgency of making the books balance in a short period of time.
The Buckinghamshire Hospitals NHS Trust and the Buckinghamshire primary care trust have agreed a financial plan that involves cutting the number of hospital admissions by 100 a week, and securing a 30 per cent. reduction in admissions to A and E. That all has to be achieved by the end of the current financial year, and we are already seeing the results. I had a letter from a constituent the other day in which she complained that she had received a letter offering her an appointment at Stoke Mandeville hospital for treatment for which she had been referred by her GP, but then she had a telephone call to say that the offer was being withdrawn because her case no longer fitted the new criteria that the PCT had imposed for financial reasons.
I fear that community services, primary care and preventive services not only will not be developed in time to meet the demands of the new model of health care but are actually under acute strain at the moment. Let us look at what is happening with the PCT. I have been told by local GPs that the health visitor service has been cut, and moved from GP surgeries into a central office location. When I visited a GP surgery on one of my most deprived estates the other week, I was told by the nurses and other staff that it is sometimes difficult to get hold of a health visitor because health visitors often do not know from one day to the next where they will be based or which people they will be able to see. Comprehensive coverage by health visitors of the poorest areas of Aylesbury may still be an aspiration, but it is not happening in practice.
The same is true for district nurses and the school nurse service, which is desperately stretched. The truth about primary care in our county is that anything that is not the subject of a specific Government target is liable to be squeezed and cut.
There is little scope for GP innovation that would push up the standard of service. GPs tell me that they feel frustrated when they come up with a new idea but are then told by the PCT that unless it can afford to fund the innovation throughout the county, no practice is allowed to provide it. That undermines professional responsibility and stifles the possibility of some real improvement in the quality of health care locally.
I have already referred to the pressure on Wycombe and Stoke Mandeville hospitals to cut admissions and attendances at A and E, but we have learned recently that there is to be a further regional review of hospital capacity, which will involve Berkshire and Buckinghamshire and possibly Oxfordshire as well-my understanding is that the John Radcliffe hospital is also under acute financial pressure. Local people will greet the prospect of a further hospital review with horror, and there will be fear that another round of hospital cuts is on its way.
If we are to move to the new model of health care, it is clear that an effective ambulance service will be important. Paramedics need to be able to reach patients quickly and to stabilise their condition, and we need an effective ambulance service if more patients are to be transported significant distances to the specialist hospitals and units of the future. However, the South Central Ambulance Service NHS Trust is already struggling to meet its targets. Yesterday, I had a letter from the chairman of the trust, who said that services in rural areas of the south-central region in particular were under huge strain.
The other element that is missing from the discussion about the new model of NHS care is the place of county council social services. As the Minister will know, Buckinghamshire county council is already a floor authority, and news has just come through that it will again receive the smallest grant increase of any shire county in England for the next financial year. The eligibility criteria for access to social care are being tightened year on year. My fear is that, inevitably, that will mean that more elderly and disabled people, and more people with a chronic illness who are unable to qualify for care that they might previously have received, will fall over or have accidents. They will be admitted to A and E, and possibly for an in-patient stay in hospital. Paradoxically, that would increase rather than reduce the financial pressures that some of the reductions and reconfigurations in service have been designed to achieve.
In conclusion, I want to leave the Minister in no doubt that those are not just my views as a politician. The view of nearly every doctor and nurse in my constituency to whom I have spoken is that the local health service in our county is struggling, and that, yes, there needs to be a coherent look at the configuration and pattern of health care in Buckinghamshire, but that that needs to be linked to an examination of the funding system to ensure that people get the quality of service they are entitled to through payment of their taxes.
I congratulate my hon. Friend Mrs. Gillan on securing this debate. Despite her heavy commitments elsewhere, she has proved again this morning that she is a relentless and doughty champion of the health care and other interests of her constituents, as all of us in Buckinghamshire try to be. It is worth putting on the record once again that our colleague John Bercow cannot be with us, but my hon. Friend spoke for him.
I cannot rival my hon. Friend Mr. Lidington in my use of the local NHS, although I have been through Wycombe hospital accident and emergency and in a ward there for a brief period, so I have had some personal experience of the NHS in Bucks, as well as the constituency experience that my hon. Friends have had as Members of Parliament. However, I do not want to start a Monty Python-type competition, where colleagues and others compare their experiences of woe, especially-on a more serious note-given the experiences of some of my constituents, which I have heard about in my surgery and outside it over the past eight years. Given that I am leaving the House at the election, I shall speak at least partly in a valedictory spirit.
In my eight years as a Member of Parliament, undoubtedly the most important constituency issue has been health care: no other single issue compares to it in terms of the interest, concern and anxiety it arouses. In those eight years, the cuts and closures at Wycombe hospital-the loss of our children's ward, maternity ward and full A and E service-have created a huge ruction in Buckinghamshire. I want to make three simple points about that whole experience.
First, when I arrived as a new candidate in 2000, I visited Wycombe hospital and spoke to a gentleman called Roy Darby, who had been the chief executive there-Wycombe and Stoke Mandeville had recently been merged into a trust-for at least 10 years and, I think, longer. The NHS has always been primarily a nationally orientated and directed service, but the structures were reasonably stable and people such as Roy Darby knew their way round the local NHS backwards and exhibited a particular sense of responsibility, ownership and knowledge of it.
Since my being elected our regional health authority has been merged, as my hon. Friend the Member for Chesham and Amersham said. The three primary care groups that existed at the time of my election became three primary care trusts, some of which had deficits-as my hon. Friend the Member for Aylesbury is fond of saying, no one has ever found the balancing surpluses-and then became a single Bucks-wide primary care trust. The mental health trust has been merged with Oxfordshire and the ambulance trust has been merged. Wycombe hospital had just gone in with Stoke. We have experienced a kind of permanent revolution, as in Mao's China. Local people undoubtedly feel that their ownership of the service, which was never particularly strong, has been compromised in the past eight years, and that when cuts and closures have been put on the table, besides some of the improvements that have taken place, they have not had any say in what has happened.
Secondly, on the cuts and closures, as I have said, good things have happened and are happening at Wycombe hospital. I have good relations with the management team there and with the PCT, as my colleagues do: we try to work together. However, in 2004, when this wave of cuts and closures was announced and rippled through large parts of the country-including in substantial areas of the south of England, where Government Members of Parliament appeared to be less well represented than Conservative and Liberal Democrat MPs-there was a feeling that managers had been sent in from outside to ram these changes through.
Thirdly, the main substance of my hon. Friends' speeches is the problem with the funding formula. In a rational dispensation, spending would be related to need, meaning that spending would largely be related to age. As my hon. Friends have said, we have an ageing population in Buckinghamshire, particularly in south Buckinghamshire. In a rational dispensation, deprivation funding would be allocated from a separate budget. Under such a system it is unlikely that Buckinghamshire would receive 17 per cent. less per head than the national average, which is the case. I am sure that my hon. Friend Anne Milton will say more about this later.
Essentially, given the pace and scale of change that my hon. Friends are describing, in Buckinghamshire we are like the Red Queen in "Alice's Adventures in Wonderland", who had to run to stand still. Given the funding disadvantage, our NHS staff and managers have to climb a steep incline to get on top of their deficits and manage the restructuring at a time of great change, because there is an enormous knock-on effect from our having 17 per cent. less funding per head. For example, there is a clear effect on my poorer constituents in areas such as Castlefield and Micklefield. My hon. Friend the Member for Aylesbury mentioned the poorer areas in his constituency, such as Quarrendon. In effect, our poorer constituents, because they are not surrounded by others who are as poor as they are, are disadvantaged compared with poorer constituents elsewhere living alongside those who are as poor as they are. That has had a substantial effect on communities in my constituency containing people who may not speak English as a first language, some of whom have recently arrived and many of whom may not always have grasped how rapid the pace of change has been and what effect these changes were having on their local services.
May I say how much my hon. Friend will be missed as his constituents' representative when he leaves the House? He has taken the headlines on many occasions, particularly in respect of health and health services, defending his constituents' rights to a decent service. Does he agree that this double hit on those people in our constituencies who are less wealthy and have less disposable income is exacerbated by poor public transport systems? Therefore, the changes that accompany this downturn in financial circumstances often mean moving out-patient clinics, even though people have established a pattern of travel and find it almost impossible to reorganise their travel arrangements to get to farther-flung clinics. They are disproportionately affected at a time when they are trying to be treated by the health service, and their poverty means that, in many instances, they are unable to travel to some of the changed services.
I agree. I will return to that point in a moment. As my hon. Friend the Member for Aylesbury rightly said, one effect of change being implemented is that transport has to take the strain, and that applies whether the ambulance service is involved, or whether poorer people are travelling who may not have access to their own private transport.
I have touched on the implications of the change for my poorer constituents. Obviously, in respect of the better-off ones, if they are elderly they are still entitled to such care. That group of people is more likely to need the NHS than others, as my hon. Friends have said.
The funding shortage is having a paralysing effect on change in the local NHS. Wycombe hospital and Stoke, in the trust, want to achieve foundation status. We support foundation status, as the Government do, but the deficit, and the shuffling of deficits back and forth between the hospital trusts and the PCT, is a millstone round the neck of the foundation status application. Our health service is prevented from moving forward by the deficit. As my hon. Friend the Member for Aylesbury said, not only can it not move forward; we are now faced with the hospital review to which he referred. I am sure that my constituents and our local paper, the Bucks Free Press, will look on that with a searching light.
I will not labour the point that my hon. Friend the Member for Chesham and Amersham made about transport, but if, at the same time as going through the changes, doctors are being told to look for ways of not referring patients, the stress on patients who are referred will fall on the transport system. The Chamber will have noted what my hon. Friend said about the ambulance trust.
All together, some good things have happened in the Buckinghamshire NHS Hospitals Trust, but the system is under great strain. With the approach of an election, in which I shall not be participating, many of my constituents will cast their minds back to 1997 and the claim of the then Leader of the Opposition, Tony Blair, that voters had 24 hours to save the NHS. They will look at their local NHS and acknowledge the many good things that have happened, but they will remember that in 1997 Wycombe had full A and E, a maternity unit and a children's unit. Although they will understand that change must happen, it cannot be forced through against a background of having, unfairly, 17 per cent. less funding than the national average.
It is a pleasure to be able to participate in this debate. I hope to do so briefly, because much of what I want to say has been said by my hon. Friends. In particular, I thank my hon. Friend Mrs. Gillan for securing this debate and opening it.
It might be helpful for the Minister if I try to step back a little from the immediacy of the funding issues that we have described, and go back to some basic principles. It will be widely acknowledged on both sides of the Chamber that NHS resources are not infinite. If my party has the opportunity of forming a Government, we will face exactly the same funding constraints, particularly in the current financial climate, that the Government must face. However, those constraints should not allow us to engage in propaganda exercises to pretend that something is when it is not. My hon. Friend Mr. Goodman rightly highlighted the extent to which the Government have met the promises that they made pre-1997, but it is impossible to reach that conclusion for Buckinghamshire as a whole and south Buckinghamshire in particular because of the extent to which services have been curbed or cut.
A live issue is the extent to which an area should receive funding in relation to its need or indices of deprivation. The county, including my constituency, is prosperous by national standards, so one can understand that the Government might argue that the population's health care needs are likely to be proportionately less. That may be correct, and the indices of overall health in Buckinghamshire do not seem to be very bad, but the difficulty that arises with that approach is that as services are progressively phased out, those who may need them will be unable to access any service at all. That is the hallmark of the problem that I face in my constituency. It consists of some people who are very rich, and some who are on middling incomes and who can manage, but it also has pockets of extreme poverty which is every bit as bad in one or two places as in inner-city areas in London.
One of my wards was, and still may be, ranked 13th in the indices of deprivation in the south-east, although that is not as bad as some of the wards in the constituencies of some of my hon. Friends here today. People there find that the services that they need and cannot access through the private sector are simply not available in the health service.
This is an old theme, and the second or third time that we have had a similar debate about the problem of funding of health services in Buckinghamshire. Returning to that theme, I well remember that as one of the Government's first actions when they came to office in 1997-I give this to the Minister by way of illustration of the problem-they removed the tax breaks for people of pensionable age taking out private health insurance. I remember that vividly, because the consequence was to create the first winter crisis after I was elected to Parliament. Those people could no longer access private health care, particularly in my constituency, or beds in private hospitals when they had pneumonia in winter, so they started to fill the hospital at Wycombe. I remember the administrators saying that they believed that that was the cause of that sudden surge, thereby making it even harder for those who were more deprived to obtain access.
How does the problem of chronic underfunding manifest itself? My hon. Friends have made some important points, and I do not want to repeat them, but I endorse what they said. I shall give the Minister some examples that may interest him in understanding what is going on. The first has been alluded to, but I am returning to it. It is the problem of the reverse turf war between social services and the health service. Generally in a turf war, people are told to get off someone else's patch, but throughout my time as a Member of Parliament since 1997 I have witnessed the struggle between social services and the health service in asking the other to come on to their patch and take over responsibility for the services that they should provide.
We have discussed acute services, and I want to move away from that a little. A matter that fills my surgeries weekly is arguments about elderly people with modest circumstances in hospitals-where they will go next to be cared for, what the element of nursing care should be and who should take responsibility for it. Leaving aside the fact that I am perfectly aware that individuals may have a financial interest because of the extent to which they must pay from their pockets, that happens even when people will never be in a position to make a contribution to their care if they move into a care home. It is a source of endless correspondence, and all because the PCT and social services want to pass responsibility round and round because neither has the resources to meet the need.
That is one example. The second is the PCT's approach to those who are, perhaps fortunately, a small minority but who, for one reason or another, need specialist provision that falls outside the competence of the Buckinghamshire Hospitals NHS Trust and Thames valley hospitals. I am sure that the Minister will acknowledge that what should be a reasonably rapid bureaucratic process, by which referral to a specialist London hospital that will provide what is sometimes life-saving care takes weeks, almost inevitably requires my involvement in writing letters to him, or to the head of the PCT or the regional trust trying to kick someone into acknowledging that specialist provision that can be accessed only at, for example, St. Thomas's hospital, should be provided.
There is a constant, underlying theme of difficulty in moving the bureaucratic logjam. Although 99 times out of 100 we will probably end up getting what we asked for because it is the right thing to have-I say that to reassure the Minister-in the meantime, the patient and their family can legitimately claim that the wait and delay have had a significant impact on the health of the individual. I do not regard that as acceptable.
Given the human condition, I know that we will never have a perfect service, and I do not expect one. However, the amount of time, effort and energy that is devoted to bureaucracy is worrying and must also cost money. In my role as an MP, I keep thinking about the amount of money that could be used in front-line services that is being squandered in shoring up the bureaucratic paper round. That process dilutes the amount of money that I and wealthy members of my constituency pay in tax, before the money can be translated into the service and used to the advantage of the person who needs it. Such bureaucracy adds to that process.
Mental health provision has been mentioned. It is a subject of interest to me, and in the past I have been involved with Mind, when I was vice-chairman of a group in London. Mental health provision in the county is, frankly, poor. That is not the fault of the professionals who provide it, and if I were to be optimistic I would say that it is perhaps on a mildly improving graph. There was a period about two years ago when mental health provision had become so bad that I thought it had reached the abyss.
My hon. Friends have highlighted the issue of counselling services, and I would like to pick up that subject to illustrate my point. Counselling services are accessed directly on referral by a GP. One of the features of the briefing that was helpfully provided by Buckinghamshire primary care trust, is that it wants to cut costs by lowering the number of admissions to accident and emergency and referrals to hospitals. We all know that mental health problems exist, and with the economic downturn and the various other financial pressures on families, I get the distinct impression that that trend will be rising.
Counselling and referral systems operated in the county very cheaply. Buckinghamshire PCT gave a £300,000 funding subsidy, which it is now withdrawing. Of that, £90,000 is being withdrawn from Bucks Mind which, as the Minister will know, provides a largely voluntary service. On the face of it, that is not a large sum of money, although I accept that in the context of the PCT this is probably an essential cut to try to meet budgetary constraints and to save money. However, if that service cannot be provided because the money has been withdrawn, what will the consequences be on the need to access more specialist services through accident and emergency or elsewhere?
This is a classic illustration of where by trying to make savings and cuts of this kind-particularly the virtual closure of a voluntary service that simply needs help with its overheads-we are likely to put greater pressure on the health service elsewhere. When the cut was proposed, it was suggested that the referral service for counselling to Buckinghamshire Mind was not a good system. However, Buckinghamshire PCT was clearly aware of Mind's effectiveness, as it had been happy to fund it without any difficulty for years in the past, arguing that it was extraordinarily good value for money. The fact that the PCT now believes that such funding will no longer be possible, illustrates that a series of warped priorities have been imposed on it due to the current problems that it faces.
I will not go on at great length, but I will conclude with another illustration of my point. The ambulance service has been mentioned, and we learn that although the apparent needs of the area are not as great as elsewhere, the service has seen an inexorable rise in volume demand by more than 6 per cent. per annum in recent years. It is currently running at 8 per cent. up on last year, and has pointed out that that is not sustainable given that only 60 per cent. of patients go to hospital when an ambulance is called out, and only 10 per cent. need extended hospital treatment on admission. That strongly suggests that the ambulance service is being used as a bottom-line safety net for the provision of primary care services to the local community-indeed, I know that to be the case.
All of us on this side of the Chamber are supportive of the Thames Valley air ambulance service, which is entirely voluntarily funded. One of its complaints is that it is being used for routine hospital transfers to save the ambulance trust cash. It resents that because it is a specialist emergency service that intervenes when somebody has to be transported rapidly from one place-often removed from a road-to a hospital. I hope that the Minister will forgive me this digressory tour to illustrate what is happening on the ground in our area.
I do not expect the Minister to be a miracle worker. I know that his Government have wrecked the public finances and now have to pick up the pieces, and I fully appreciate that the area I represent will never receive the same amount of funding per head of population as a place such as Liverpool or another great city that has higher levels of deprivation. However, we cannot go on in this way. At some point, this will all go badly wrong for the Government. Illustrations of serious failures will be visited on the Minister, which will be entirely due to a failure to do any creative, sensible, medium-term planning for how to secure effective services in health care for our constituents locally. It requires doing something more than submitting the poor old primary care trust-which in my view does its best-to an endless cycle of crisis management.
I congratulate Mrs. Gillan on securing this debate, and on getting a good turnout from her colleagues, who have all spoken passionately about the health needs of their county.
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 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.
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.
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 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? If the hon. Lady and the hon. and learned Gentleman lamented its loss, the clear implication is that they want it back.
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.
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 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. 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-
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.
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 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 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 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 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.
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?
In the nine minutes left for me to reply I want first to congratulate Mrs. Gillan on securing the debate. I also congratulate the hon. Members for Aylesbury (Mr. Lidington) and for Wycombe (Mr. Goodman) and 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.
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.
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; 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.
The route to financial health for Buckinghamshire, as for all parts of the NHS, lies not in questioning the funding formula, although I have heard the points made by the Opposition, but in radical action to improve the quality and effectiveness of local services. The NHS has faced long-standing financial pressures locally; that point has been made and I recognise it. However, it has told me that it is working to address those issues. Both the hospital trust and the PCT are working to break even for 2009-10. They believe that they are on the front foot in re-engineering health services; they have formed a Healthy Buckinghamshire leaders group-a joint plan of action to deal with current financial problems; and their summit plan is already making a difference. The new Buckinghamshire-wide out-of-hours service is already up and running, not least in the constituency of the hon. Member for Chesham and Amersham, and there are plans for a new GP-led centre based in Wycombe hospital. The hospital trust tells me it expects a 15 per cent. drop in demand for out-patient services in the next few years as care is increasingly-and rightly-delivered by GPs and other community services, as the hon. Member for Aylesbury remarked.
The way patients use NHS services means that demand drops for some out-patient services, and it is not a good idea to run half-empty clinics. That is why clinicians across the NHS in Buckinghamshire are exploring how to combine out-patient clinics to make the best use of available resources. A smarter NHS will mean more services coming out of hospitals and into the home or the community, although I recognise the points about concerns over rural ambulance services. I understand that the review is taking place in Buckinghamshire, and the final report will be presented to the South Central health overview and scrutiny committee in January 2010.
A point was also made about psychological therapies. The PCT's professional executive committee, led by clinicians, agreed the recommendation to refocus psychological therapy resources, totalling more than £4 million, on evidence-based therapies. As the Minister responsible for mental health I can tell Anne Milton that a 50 per cent. increase in funding for mental health services since 2001- a £2 billion increase-is remarkable and puts this country's mental health services at the forefront of those in Europe.
I have tried not to be too party political in this debate, but other hon. Members have made it so, and I therefore conclude by saying that when the Conservative party left office in 1997 the NHS was on its knees. Norman Lamb was right. In the past 12 years the Conservative party voted against every Budget, with record increases in NHS spending that brought benefits not least to Buckinghamshire. Finally, the Conservatives are approaching the general election pledged to abandon key criteria for waiting times, and to create an austerity Britain, with smaller Government. From what we have heard today it appears they intend to reintroduce tax breaks for private insurance schemes and abandon deprivation formula in the funding allocations.
On a point of order, Mr. Atkinson. Is it in order that when the Minister himself thought there was little time for the debate he should reduce it to a political diatribe although he has not answered the question of what will happen to my constituents in the event of a flu epidemic, given their straitened circumstances?
It was also a skilful attempt to use up time, as I describe the options at the next general election, which will be, for the people of Buckinghamshire, a fundamental choice between going back to the bad days when the Conservatives ran down the NHS, or looking forward to a period of further investment to support the health service in Buckinghamshire and across the country.