Unavoidably Small Hospitals

Debate between Maria Caulfield and Kevin Hollinrake

Tuesday 6th September 2022 Westminster Hall

[The Minister for Health (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. I thank my hon. Friend the Member for Isle of Wight (Bob Seely) for securing this really important debate. Small hospitals are often the Cinderella service of the NHS, and their value is not always recognised. We have heard cross-party support from Scotland and Northern Ireland, and if Welsh Members had been present I am sure that they too would have recognised the challenges that unavoidably small hospitals face.

I reassure colleagues that the ministerial team recognises the worth of small hospitals. As my hon. Friend the Member for St Ives (Derek Thomas) said, it is not just about the value they bring to their local communities, but the pressure they take off the wider health service in their regions, which we have seen particularly clearly in recent months and years. When we had covid hot and cold sites in the NHS, smaller hospitals were able to work and function and take some of the pressure off larger hospitals that had large outbreaks of covid. While I acknowledge that small hospitals are more expensive to run, their added value cannot be underestimated. My constituency does not have a hospital, so my constituents have to travel. We do, however, have the Lewes Victoria Hospital—it is a small community hospital, not an unavoidably small hospital—and my constituents really value its work. If they did not have it, they would have to go to the big hospitals in Brighton, Eastbourne or even Hastings, so I am on the same page as many of the Members here.

My hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) and my right hon. Friend the Member for Richmond (Yorks) (Rishi Sunak) touched on this. When trusts run a portfolio of hospitals, it is often tempting for them to move services to a much more cost-efficient, bigger site, but what then tends to happen is that, once the consultant-led maternity service goes, it becomes difficult for the anaesthetists to keep up their skills, and all of a sudden the hospitals become unsustainable. That is a risk. As my right hon. Friend highlighted, and as I saw when I visited the constituency of my hon. Friend the Member for North Devon (Selaine Saxby), there has been a resurgence in interest in small hospitals and their values. We are putting in surgical hubs and investment because we recognise that they can do specialist work, sometimes more easily than big trusts that have the pressures of big A&E departments, trauma centres and wards that are struggling with capacity.

Smaller hospitals can deliver in different ways, but there are no doubts that they face unique challenges. My hon. Friend the Member for Isle of Wight touched on the significant issue of funding. I will come back to that, but I will first touch on some of the other issues they face. On the Isle of Wight, for example, having a smaller hospital can sometimes produce better quality of care for patients. The ambulance handover delays on the Isle of Wight are minimal. The average handover for emergency conveyancing is less than 15 minutes, and their record on 60-minute breaches is often better than that of some of the larger centres.

The quality of care can also be a significant factor, but that also takes intervention and support. It is not just about the funding and the staffing, which we have also touched on, but the system itself. The recovery support programme that has evolved from the special measures programme is working with small hospitals to provide a systems-focused approach to support them and address some of those challenges. As my hon. Friend the Member for Isle of Wight has said, the hospital there went into special measures in 2017 and it is now rated as good. That resulted from a lot of support from the national systems, but also from the hard work of local clinicians and managers. It is a testament to their hard work.

Retaining workforce is difficult. We know that GPs, dentists and nurses are more likely to stay where they trained. That is difficult for smaller hospitals, because traditionally they do not have their own training programmes. People train in large teaching hospitals and often stay there and develop their practice further.

Health Education England is working on changing the traditional nature of training. Blended learning programmes use a combination of technology, online learning and the apprenticeship model to make it easier for small hospitals to train their own staff of nurses, healthcare workers and doctors. There is also the apprenticeship model, with apprenticeships now available in a number of healthcare organisations. Existing staff can take apprenticeship routes, stay in their workplaces and not have to travel long distances to universities miles away. That is important, whether it is for the registered nurse degree apprenticeship, healthcare assistant practitioners or the new medical doctor degree apprenticeship. That will make it easier for smaller hospitals to train and develop their own workforce and, crucially, to upskill the existing workforce. Traditionally, if someone wanted to take on an advanced nurse practitioner role or was an anaesthetist wanting more training, they would often have to leave their small hospital and go to a bigger teaching hospital to take such courses. The blended learning programme will make recruitment and retention easier for smaller hospitals, and will be a lot more rewarding for staff.

My hon. Friend the Member for Isle of Wight talked of funding. I am the first to acknowledge that smaller, more rural and coastal hospitals have greater expenses because they cannot get the scale of efficiency of a larger teaching hospital. A lot of work is going in to supporting the funding mechanism. NHS England is responsible for allocating funding. It goes down to the new integrated care boards, which were established in July. Funding allocations for this financial year were published earlier this year. If my hon. Friend cannot find that information, I am happy to provide him with the figures and the algorithm used to achieve them. The formula seeks to acknowledge geographic and demographic distribution, which can vary, as a number of hon. Members have said. Some areas can have an older population, and it is important that the funding formula reflects that. The discussion is between NHS England and the integrated care boards. There has been a change in the formula to take account of the higher costs of providing emergency services in particular in sparsely populated areas, with an adjustment for costs that are unavoidable due to the small nature of the hospital.

If my hon. Friend and other hon. Members feel that the changes to that formula and the relationship between NHS England and the local integrated care boards are not delivering some of the funding measures we had hoped for, I am happy to discuss that further and to sit down with colleagues so that they are clear about the funding formula and allocation. It should not require trawling through pages of documents to find that out. I am happy to help my hon. Friends with that, because it is important to recognise.

I want to touch on urgent and emergency care. It is important for emergency care to be available locally, but that can be a challenge for unavoidably small hospitals, because they see a much smaller number of trauma cases or cardiac arrests. Highly skilled staff, such as anaesthetists, with the support of their royal colleges, need a number of such cases to keep their skills in place, and we need to support them.

I want to reassure colleagues that we are committed to keeping smaller hospitals. The investment in the Friarage surgical hub is a case in point. We have also recently seen investment in North Devon. I also hear the call for the 40 hospitals programme. We are committed to that, and it is important that staff have that reassurance and patience, because it is about not just the services that are technically on a site, but the quality of care. As smaller hospitals often know their patients well, they get a quality of care that they sometimes do not get in larger hospitals with hundreds of patients coming through a department.

[Kevin Hollinrake]

One of the Minister’s predecessors wrote to me on 28 October 2019 and said that a new community services formula was being used for hospitals such as Scarborough Hospital in my constituency, and others that have been mentioned. Will the Minister write to tell us exactly what impact that has had on funding since 2019 so that we can understand what extra resources have been made available?

[Maria Caulfield]

I am happy to write to all colleagues on that. It is important to understand the difference that that formula will make and to assess whether it is working in practice, and Members of Parliament will be able to pick up quickly on whether it is making a difference locally. I also encourage colleagues to meet their integrated care boards—if they have not already done so—which will have a relationship with NHS England and will supply the information on the demographics and geographical variations that make the formula work. The integrated care boards came into force in July, and now is a good opportunity to have those conversations so that ICBs are clear that Members of Parliament and their local communities value smaller hospitals and that that must be considered when decisions on funding and services are made.

We have had a good debate. I want to reassure colleagues that small hospitals are a vital part of the NHS family: they take pressure off some of the larger services and provide good quality service for local residents, who really value them.

Access to NHS Dentistry

Debate between Maria Caulfield and Kevin Hollinrake

Thursday 10th February 2022 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Ms Ali. I congratulate my hon. Friend the Member for Waveney (Peter Aldous) on securing the debate and I am pleased that he is seeing a local improvement after we met recently. I also thank the hon. Member for Bradford South (Judith Cummins) for securing the debate.

I agree with my hon. Friend the Member for Stroud (Siobhan Baillie) that we have seen a level of interest in and concern about the matter across the Chamber, and that we need to ensure that we take some of the politics out of it because there are some difficult steps to take to improve dental services across the board. I welcome the contribution from my hon. Friend the Member for Mole Valley (Sir Paul Beresford), whose clinical experience is so helpful in the debate. I reassure colleagues on both sides of the House that since I came into post in September, dentistry has absolutely been a priority for me. I have been working night and day to try to make some short and long-term improvements, because I am live to all the concerns that have been raised.

We have set up some joint working, which was not happening before, between NHS England, the chief dental officer and the Department, and I meet the BDA regularly because we are serious about reform. I say to any dentists watching the debate that I absolutely understand the problems that make delivering an NHS contract unbelievably difficult. The contract is the No. 1 long-term issue that we have to deal with, and we are starting progress on that as soon as possible. I will come to some specifics shortly, but first let me mention covid.

I know that there has been some concern that covid is a lame excuse but, as my hon. Friend the Member for Mole Valley said, it has had a significant impact on access to dental services in the past 18 months. When lockdown happened, services were immediately reduced; only urgent services were allowed. That continued for a significant period. It was not until 8 June 2020 that practices were allowed to open for up to 20% of normal activity and it was not until last year that that went up to 60% and, towards the end of the year, to 65%. Although dentists were compensated for their loss of income during that period, the backlog that that generated is shown in all our postbags right now.

I place on record my thanks to dental teams up and down the country. Urgent appointments went back to pre-pandemic levels in December 2020, but with only 85% of activity allowed the backlogs will only grow. We need to be honest about that; the impact is significant. I completely understand the pressures that that is putting on dentists. We are keen to support dentistry where we can to get it up to 85%. It has been difficult during omicron with staff sicknesses and patients having to cancel when they become covid positive, and I absolutely recognise the stress and strain that covid has put on the system, but we have to be honest. I think it was the hon. Member for Bootle (Peter Dowd) who mentioned this, and I am happy to accept the difficulties we face. There were problems before covid and there are those same problems post covid, and we are absolutely focused on starting to tackle them.

Let me make a couple of points. There is no patient registration system for dentistry—that is one of the myths. It is not like GP practices, where someone signs up and is then on the list. Patients can go from dentist to dentist if there is one available, and we are making sure that we open up capacity where it exists.

We have written to all dentists to ask them to update their capacity so that we can put it on the website mentioned by the Father of the House, my hon. Friend the Member for Worthing West (Sir Peter Bottomley), and we have also asked them to run a cancellation list. If someone cancels, the practice will be able actively to contact the next person on the list. Capacity is being generated by that, but I am aware of the problems with capacity across the board. We have talked about many parts of the country, such as Norfolk and Devon, that are experiencing capacity issues, but all parts of the country have experienced a squeeze in the number of appointments available.

A couple of weeks ago, we announced £50 million to help with some of those issues. I know that some Members have been quite dismissive of that this afternoon, but we know that it will cover the period to the end of this financial year to buy some urgent capacity for the system and to help deliver more than 300,000 appointments that currently cannot happen. There has been good uptake, even in the few weeks since the money was announced. Regions across the country are signing up and because the payments to dentists are much better than under the current contract, there is an appetite among dentists. That shows that if we remunerate dentists adequately they have an interest in taking on NHS work.

I encourage Members from all parties to contact their local commissioners, because we want to ensure that that money is used. If there is no interest, or if they are struggling to spend the money, they should let us know. NHS England has been in contact with local commissioners to get that feedback so that we can make the best use of the money and buy as much capacity as possible.

[Kevin Hollinrake]

Does the Minister think that it is acceptable for commissioners to take 20 months commissioning a service when we have dentists who want to take that work and take on that surgery?

[Maria Caulfield]

Absolutely. I will come on to that point, which is valid. We want to increase capacity and there are dentists who want to take on NHS work. When contracts are handed back, we have to do the whole procurement process, and when there is an interested party, even when they are ready to sign on the dotted line, that takes a considerable amount of time. In the Department, we are looking at how we can change the procurement process. It often falls in the lap of local commissioners, but they are stuck with the procedures they have to follow. I am keen to see how, when someone is willing to take up a contract, we can enable that to happen as quickly as possible.

We have also relaxed the upper tolerance threshold and increased activity from 104% to 110% of dental activity. The current contract penalises dentists if they go over their contracted work, which is a perverse disincentive when dentists have capacity and want to take on extra work.

Before I touch on the nub of the problem, I will mention prevention. I am pleased that prevention is being considered and that the Government’s proposals on water fluoridation are part of the Health and Care Bill. I hope Opposition Members will support us when the Bill comes back from the Lords. We are also looking at options for how to introduce supervised tooth brushing in parts of the country where there is the greatest need. I reassure hon. Members that the prevention and oral health element is as key as getting dental procedures done.

The dental contract is the crux of the matter, and we are absolutely committed to reform. I met the BDA this week to start negotiations. We are looking at some quick wins over the next 12 months and some long-term contractual reform to the UDAs. We have started informal negotiations, and the formal negotiations will start in April. We all—the BDA, patients, MPs and the Department —know the urgency. It cannot be a long, protracted negotiation. However, we are working well with the BDA. We are keen to get negotiations under way and to reach a resolution as quickly as possible. We have to make the NHS a better and more attractive place to work, because dentists have other options; I cannot remember which Member said it, but dentists are voting with their feet when it comes to where they want to practice.

On the recruitment, retention and training of dentists, Health Education England published its “Advancing Dental Care Review” in September. It is working through how we can train not just more dentists but the whole dental team, and on how we can upskill dental technicians and dental nurses. We will bring forward legislative changes to enable other members of the dental team to take on more roles. We are setting up centres of dental development in those areas of the country with the biggest shortages, which tend to be coastal and rural. I take the point made by my hon. Friend the Member for Broadland (Jerome Mayhew) about Norfolk—I think I heard that several times. We are looking at where in the country those dental deserts are and whether we can match them to centres of dental development.

Members may not realise that this week the Department announced a consultation with the General Dental Council on the registration of international dentists and whether we can put in place a process to recognise the qualifications of dentists from around the world, as my hon. Friend the Member for Mole Valley mentioned. The overseas registration exam, which they have to take, was suspended throughout the whole of covid, so we have a backlog of around 700 dentists waiting to take it. The first exams started a couple of weeks ago, and there are exams in place for the rest of the year to try to get through that backlog. We are confident that we can do that.

We need to work on how we recognise existing qualifications to remove the barrier of having to do an exam. Again, I encourage colleagues to respond positively to the consultation on the GDC website and to the developments it is making. My hon. Friend the Father of the House has written to me about international dentists having to take the exams within five years of their first attempt, and whether those rules can be relaxed. That is also part of the consultation. We very much recognise that covid has had an impact on those rules too.

I reassure colleagues that I am working on bringing NHS England, dentists and the BDA together so that we can make a difference as quickly as possible. The changes in the Health and Care Bill on integrated care systems and having accountable people for commissioning locally are crucial. Integrated care boards will be statutory from 1 July, and will have accountable officers. I strongly urge colleagues to speak to their ICBs or CCGs, because there are differences in practice across the country. Some commission dentistry really well, some not so well. Very often, if the money allocated to dentistry is not ringfenced, and if it is not spent locally, it goes into other healthcare provision and is lost from dentistry. I encourage Members to hold the feet of their local commissioning bodies to the fire on what they are doing with the money given to them. We are here to support them, and work will be done on dentistry commissioning going forward.

In the short time I have had, I hope I have been able to provide assurances that dealing with the situation is not without its challenges. There is no silver bullet that will resolve all the problems. There is not a quick-fix solution, but I am working at pace, as is the Department, to reform the contract. Work is starting in April on the formal negotiations, and I hope that will improve recruitment and retention in dentistry. We value the work that dentists do, which for too long has gone unrecognised and has been a Cinderella part of the service. The people who have suffered are not just the dentists, but the patients.