Devon shares a challenge with many other rural parts of the country. We can safely say that the things we are asking and lobbying for have a general application. From the Minister’s perspective, something that has a more general application will be much more acceptable.
We have an above average number of over-85s with complex co-morbidities, as do many other rural areas, because people like to retire to such places. We know that travel distances in Devon are particularly acute. We have been compared to Denmark in terms of the numbers of roads that we have.
It is absolutely right to raise the recruitment challenge, but it is not a simple question of not being able to get people; there simply are not enough people to get. Previous Governments have inadequately provided for training. In addition, we have the challenge of attracting people to work in a rural location. Rural locations are fine if someone is retiring there; young individuals want to live in cities; and that is the challenge. On top of that, the cost of living also makes a post in a rural area unattractive.
Perhaps the most difficult problem is the one-size-fits-all approach that previous Governments have focused on. The model for funding and for structures is built around an urban model where there are numbers and therefore productivity. The challenge we have is the lack of footfall, except in tourist times. We need to tick the box not only for the funding formula but for the new integrated models of care that look at integrating vertically and horizontally across primary and secondary care. The multi-specialty community provider and primary and acute care systems will simply not work where we are, which means that we cannot use the same solutions as other areas.
Devon is a prime example of all these problems. We have three different reviews going on. We have the success regime in north Devon; the consultation on primary care, which last year took place in south Devon and is now taking place in Northern, Eastern and Western Devon; and the sustainability and transformation plans, which have been relatively recently brought into play. As has already been mentioned, Angela Pedder, the leader of our STP, will look at combining all the reviews.
The real challenge that we face is the speed at which implementation of the changes is being considered. As other hon. Members have said, it makes it almost impossible to put in place the needed care in the community. Of more concern to me is the fact that nowhere have we really addressed the need for a proper strategy for rural healthcare. I have read the five-year plan, and the word “rural” appears three times. I have been frustrated, when I have written to the Minister’s predecessors to ask about a rural strategy, because they have told me that there is one, when the truth is that there is not. There is an urgent need for a proper review of examples from around the world—Australia and New Zealand. There are plenty of examples. Even China has a proper strategy, and other countries think about such things in a very different way. That, to me, is crucial.
The other day I attended a workshop with the Nuffield Trust, the ambulance service and a number of hospital trusts, looking at what is happening and what we need to do. In rural areas things are at crisis point. Care homes are closing and are not being replaced with new ones—at least not in rural areas. They tend to be developed in city areas. The result will be a change in the population mix in rural areas, which will lead to economic deprivation and then social deprivation. We need to accept that rural communities are different. They need to be supported; otherwise, the consequences will not be as simple as whether we lose a hospital. The taxes raised in this country are generated predominantly in the city, but we accept that they should be spent across the country; equally, that is how we should deal with our rural communities.
We should review and amend the funding formula. I am pleased to hear of the changes in allocation which are coming shortly. However, the issue is more fundamental than the funding formula. One of our challenges is the fact that the needs are different in each rural area, but training regimes have become increasingly specialised. There are many individuals who specialise, in a number of different specialisms; the current regime structure requires a certain number of specialists, in each of those specialisms, to get a tick in the box to say that an area is safe. We need more generalists, not more specialists. Several royal colleges are already considering the generalising of training, but we need conversations to happen not just within those royal colleges but between them, and Government should sponsor and support that. We also need to get acceptance within the trusts that recruit the individuals. If they will not accept the new generalists, we shall have a problem.
We need more generalists and we need more geriatricians. We also need to think carefully about how to deliver urgent care. Urgent care and accident and emergency are not entirely the same. Some of the models used in other parts of the world, such as Australia, are very interesting. It is wrong to say that if there cannot be an A & E department the hospital must go. There are many different ways to provide what we need, and we must look at that. We must also review the regulatory criteria. Regulators say, “You need a person with this job description and this expertise and training.” At the moment regulators will not allow an organisation to accept someone with the right skill mix but without the specific tick-the-box qualifications. That needs to change.
As to the care home sector, we clearly need hard measures, but we need soft measures too. The human side of social care is as important as the technical side. A challenge with respect to the agenda for integrating health and social care is to scrutinise the commissioning of social care in the same way as the commissioning of NHS care. At the moment that is not happening. I do not think I am wrong if I say that there is now a bit of a lottery, based on where people live, for how much money is allocated and therefore how good the care is.
My final plea is about the long-term plan. With increasing development and population—whatever happens about immigration—we need to ensure that we plan. At the moment, the NHS is not a statutory consultee in the planning process; and that needs to be rectified.