Healthcare on English Islands

Bob Seely Excerpts

Wednesday 27th June 2018 Westminster Hall

[Mr Bob Seely (Isle of Wight) (Con)]

I beg to move,

That this House has considered the provision of healthcare on English islands.

It is a pleasure to serve under your chairmanship, Mr Hanson. I thank the Speaker’s Office for granting this debate and the Minister for coming to respond to it.

I will outline three arguments. First, I will explain why I believe Isle of Wight health services remain underfunded compared with the mainland. My trust believes that that underfunding ranges from £5 million to £8 million just for acute services. Secondly, I will ask why the Isle of Wight is the only UK island, separated by sea, without NHS-subsidised travel. I believe that is deeply unfair to my constituents. Thirdly, I will suggest ways in which we can help both the Department of Health and Social Care to deliver better health and social care on the Island through the creation of a single public services authority for local government and health, and the Island to become a national leader, as it has done in the past, in improving Government services by combining them.

By way of background, I start by paying tribute to the Island’s NHS staff, who do a wonderful job delivering NHS healthcare provision. We greatly value their professionalism and dedication. I also acknowledge the work of the Island’s NHS leadership in the clinical commissioning group and the trust, and the work of Maggie Oldham and Vaughan Thomas specifically. Along with their wider teams, they do a challenging job in difficult circumstances, and I am hugely grateful for their work and that of everybody in the health services, including medics and ambulance staff, and our public services.

I have called this debate both as Member for the Isle of Wight and as chairman of the all-party parliamentary group for UK islands. The purpose of the APPG is to promote the needs of island communities within Great Britain and Northern Ireland and to advocate for their economic and social wellbeing, the provision of high-quality, accessible public services, and affordable transport arrangements, which are particularly pertinent to the Island I have the privilege of representing. The issues I am raising today focus directly on those matters.

Today’s subject follows earlier debates that I or the APPG have called on the economies and public services of UK islands. Due to devolution, this debate is largely focused on English islands, meaning primarily the Isle of Wight, whose population is approximately 140,000, and the much smaller Isles of Scilly, which I believe have a population of about 1,500.

As I have previously raised, there are additional costs associated with providing public services in island communities. The University of Portsmouth has issued a peer-reviewed report showing that the extra costs of providing local government services on the Isle of Wight are some £6.4 million a year. Coincidentally, that is similar to the amount of money that Orkney, Shetland and the Western Isles get, despite having much smaller populations.

Those principles work for healthcare provision as well. I believe there are significant additional costs to providing services on the Isle of Wight. As I have said, we have a population of 143,000. That is half the size of a population that would usually have a district general hospital, so we are very grateful to have such a hospital and its great staff. However, because our helicopters do not fly 24 hours a day and sometimes the ferries do not go at night, the Island needs a maternity unit. Women cannot give birth in a helicopter. We need paediatrics and we need A&E. Our funding is naturally and obviously skewed by our environment, and because of that there is an argument that we are unable to properly fund some of the other services we need.

An additional problem is that if the trust has a full-time consultant on its books and pays them for their expertise while, in effect, using them only three days a week, or if the maternity consultant is not being used to his full capacity because, although we do need a maternity unit, ours is not as active as that of the average district general hospital, those consultants are not getting the required hours on their ticket, to put it in layman’s terms. That causes diseconomies of scale. One solution is to work much more closely with Southampton and Portsmouth. That is critical to our future, and it is going to happen.

Our costs are also exacerbated by the demographic profile of Isle of Wight residents. We have a lot of young people, as the Isle of Wight festival proved, but it is also the case that 24% of our population are aged over 65, and that percentage will increase. As the Minister and I discussed before the debate, there is an argument that NHS funding for those over 80 is not generous enough, because of the more focused health requirements of people of those advanced ages. Given that a fair chunk of our population are over 80, we have significant pressures. More than 2,700 residents are living with dementia, which is double the national average per constituency.

We are experiencing a growing financial challenge. Our CCG is £19 million above its target funding. The Island overall receives £233 million to fund its healthcare services. The CCG and the trust are seeking to make £19.1 million savings this year, which will still leave cost pressures. The rise in our funding has been marginal compared with that in trusts and CCGs elsewhere in the UK. Those very small rises in funding are now having a very negative effect, and I would appreciate the Minister looking closely at that.

Financial modelling undertaken as part of the acute services redesign shows that even if services are reconfigured to the maximum extent, there will still be a gap between the costs of funding services for the Island population and the amount of money its NHS receives. Our trust believes that the cost, even under our most ambitious plans, is between £5.3 million and £8 million. That is just for the delivery of acute services, if I understand correctly.

My first suggestion to the Minister is that he accept that there are additional costs associated with providing those services on the Island. This is not a case of special pleading; it is merely an acceptance that the Island’s healthcare structure has exceptional circumstances by dint of being separated from the mainland. The Minister could build us a fixed link, at a cost of about £3 billion, or we can argue about the extra millions needed to properly fund the NHS.

I strongly welcome the Secretary of State’s recent announcement of a new long-term funding plan for the NHS, which is a clear sign of our party’s commitment to ensuring that the NHS continues its world-class provision—but I want to ensure that some of that funding comes my way. I would be grateful if the Minister would continue that conversation and meet our Island NHS leadership, so that he and his officials can understand the extra costs in detail.

I also want to propose a way that we on the Island can work more effectively with the integration of public services. I hope that idea will be attractive to the Minister and his officials. As I have said, we are not looking for special treatment, but we are looking for fairer funding. I place emphasis on both provision and access because we want to provide as many services as possible on the Island, but we also need access to the mainland for when some of our Islanders need to go to Southampton or Portsmouth for specialist services such as radiotherapy. There will be a small decrease in the number of visits to the mainland, but a small rise in the number of more specialised healthcare appointments there.

As the Minister may know, the NHS trust has laid out a series of options for the future of healthcare on the Isle of Wight. I seek Government support for its more ambitious aim of taking back more bread-and-butter acute services to the Island, thereby requiring fewer trips to the mainland, rather than the current option of slightly fewer services on the Island and slightly more on the mainland. We will discuss that at length.

The local care finance system has undertaken a detailed assessment of how to strike the appropriate balance between providing services within the shores of the Island and enabling access. However, there are increased patient safety risks associated with any shift of more services to the mainland, particularly for patients who may be frail and in need of swift access to services.

My constituents have made it clear, through a range of public engagement exercises, that they wish to see the maximum retention of services on the Island, and they join me in asking the Government to ensure that that is recognised in any future funding. As recently as two weeks ago, the Isle of Wight County Press and Isle of Wight Radio hosted a question time event with representatives of the Isle of Wight NHS at which the Island-mainland split in services was debated. My constituents’ views were clear: where possible, the retention of services on the Island should be a priority. I therefore urge the Minister to carefully examine the funding arrangements in place for healthcare, to ensure that those needs are met.

I also ask that we examine the issue of patient travel and how visits to the mainland from the Island are funded. As I have said, the Isle of Wight is the only UK island with no subsidised ferry travel to support local residents in accessing specialised services on the mainland. I will not dwell on arrangements for Scottish islands, because they are part of a wider mechanism and their arrangements are devolved.

The National Health Service (Travel Expenses and Remission of Charges) Regulations 2003 set out that any resident of the Isles of Scilly not entitled to payment in full of NHS travel expenses in accordance with low-income criteria will pay a maximum of £5 for their travel costs. A document from the Cornish CCG, NHS Kernow, also sets out that residents of the Isles of Scilly have to pay only £5 towards the cost of NHS-funded patient transport to the mainland. Furthermore, if it is deemed necessary that the patient needs an escort, a further maximum payment of £5 will be applicable.

I have talked about the matter with my hon. Friend the Member for St Ives (Derek Thomas), who represents the Isles of Scilly. I am delighted that residents of the Isles of Scilly benefit from such an arrangement, but why is it not available to my constituents as well? Although some on the Isle of Wight meet the narrow definition of being on a low income and would benefit from having such costs met, many other residents have to regularly access healthcare treatment on the mainland—such as those with prostate cancer, who may need 40 trips —and face difficulty in affording the associated and oft repeated costs. I believe it is inequitable and unfair for one set of English islands to enjoy such a benefit when others do not. It is yet another example of the Isle of Wight’s not being treated fairly.

The arrangements for Isle of Wight residents travelling to the mainland for operations and medical appointments are much less generous, and exist only due to the co-operation of our three cross-Solent operators. Red Funnel offers a special return ferry fare; Wightlink offers a discount for both vehicle and foot passengers plus a patient escort; and Hovertravel offers a 20% discount on day returns. I am grateful to those operators for putting those arrangements in place, and to the NHS on the Isle of Wight for negotiating them, but the reality is that even with such discounts, the cost of trips to access healthcare on the mainland can place a great financial burden on patients, which is at odds with the NHS’s founding principle of being free at the point of delivery.

I therefore ask the Minister to amend the 2003 regulations to extend that statutory requirement to the Isle of Wight, as well as the Isles of Scilly. That would be a significant step forward and would have a transformational effect on the lives of many of my constituents who go to the mainland for treatment. Around 32,000 return visits are undertaken a year. Under option 3, that would be about 30,000, while under option 4 it would be about 27,000 or 28,000. We are talking about numbers in the low tens of thousands, and funding those visits would require relatively small amounts of money.

However, as those visits are in the tens of thousands, and because our CCG is struggling for money, I ask that any such arrangements do not have a budgetary impact, either on Cornwall’s or the Isle of Wight’s CCGs, and that the cost of funding the discount comes directly out of the NHS budget. That would be recognition that English islands should be treated similarly to Scottish islands, and of the cost of going to the mainland from the Isles of Scilly or the Isle of Wight. Under this plan, patients and their escorts would pay no more than £5 to travel to the mainland for treatment. I believe that to be a fair and reasonable gesture for the Government to make, and I ask for that change to be brought forward, along with the changes to the 2003 regulations to allow the Isle of Wight to benefit from statutory obligations.

There is also the issue of travel for families. Staying overnight in a mainland hospital brings about financial pressures for my constituents. I appreciate that the 2003 regulations do not provide for support in these cases, but if the Minister was generous enough to consider those changes, and to find the small amount of money to fund directly the £5 fare for people seeking treatment, my hon. Friend the Member for St Ives and I could go back to the ferry companies serving our respective islands and see if they would be generous enough to make similar provision for patients’ visitors. Someone from Ventnor, Cowes or Ryde who was going to hospital in Southampton on the mainland would pay £5 to get to the hospital, but their families often pay full whack on the ferries. That is not cheap. If we changed those arrangements, we could talk to the ferry companies about providing properly recognised and organised support to families visiting their loved ones in hospital. That would be a generous gesture to the Isles of Scilly and the Isle of Wight.

I am grateful to the Minister for listening, and I will raise one other issue. To recap, the Isle of Wight is not properly funded, and my folks—my constituents—are hard done by when traveling to the mainland. Do not get me wrong: we love being an island, but we seek fair funding to mitigate the effect of the Solent, which is often overlooked by the Government. However, I am here not just to ask, but to offer. We on the Island are already committed to integrating health and social care as much as possible, and I believe that Islanders would be delighted, with Government support, to lead the way in delivering best practice in the integration of council, health and adult social care services.

For example, we have the “My Life a Full Life” programme, which is a collaboration between the Isle of Wight CCG, the NHS trust and the Isle of Wight Council. The programme works in partnership with local people, voluntary organisations and the private sector to deliver a more co-ordinated approach to the delivery of health and social care for older people and people with long-term conditions on the Island.

My aim is to keep as many young people on the Island as possible, to build an economy for them, and to get a university and improve our education system. However, at the same time, it is critical that we become a leader in ensuring quality of life in later life. We are naturally drawn towards integrating our services, because we are a small island, so we have the potential to be a national leader in this. “My Life a Full Life” is a great idea, but it arguably has not reached the point that it should, because we still have siloed organisations. There are bureaucratic hurdles to overcome in combining the leadership of those organisations, but ensuring their full integration could save a considerable amount of money on appointments, which could then be put back into frontline services.

I would like to acknowledge the work of all those involved on the Island in delivering some really good programmes that we have for integration, but particularly Councillors David Stewart and Clare Mosdell, along with professional officers such as Dr Carol Tozer, the director of adult social care. They have established a local care board, and it is already bringing the services together as part of our One Public Service vision for the Island, but it is still not combined structurally and in terms of leadership and governance.

At the moment, the Government provide one pot of money to local government on the Island, another to fund the Isle of Wight NHS, and another to the CCG. Does it have to be that rigid? Can we aspire to a situation in which one combined funding pot is made available for public service provision on the Island, thereby increasing the requirement for deeper and more meaningful integration? Such circumstances may require combining the governance and leadership of public services. It is important to explore that, and there are questions about the role of experts, certainly in healthcare and adult social care provision.

I ask the Minister to explore, with his ministerial colleagues, whether there is an appetite for creating a unique public authority on the Isle of Wight that combines traditional local government functions with those of NHS trusts, the CCG, adult social care, mental health services and so on. If such a fully combined and integrated approach can work anywhere, it should work on the Island. Such a step would be a natural progression from the integrated way in which we are trying to work; we are trying to overcome those siloed, bureaucratic, financial hurdles. Clearly, if we achieved that, we would ensure that the input of healthcare professionals was still very much at the forefront of decision making. I urge the Minister to work with us as closely as possible on that, because that could be a valuable exercise that could be repeated elsewhere, perhaps in more isolated communities, and in places where the combination of healthcare and public service could achieve real public good and address public need.

I will not talk for much longer; I will just make a couple of other points briefly. I am grateful to you, Mr Hanson, for allowing me to speak at length.

I want to talk about digital solutions. Again, we are not the only part of Britain that is isolated, but clearly the Solent is a boundary and border for us. I find the situation slightly ridiculous. Yes, if people need to go to Southampton for an operation, that is great, but do they need to go there for every pre-op appointment? Do they need to go to Southampton or Portsmouth for every post-op appointment? We were talking about this earlier. We need to find the greatest centres of expertise in Britain and be able to buy in those services. Perhaps people can have their appointment in Southampton, Reading, London or Portsmouth, but can have their pre-op using digital technology—telemedicine. We need to be much more efficient in how we use that.

Again, we are not the only isolated part of Britain. However, I am offering the Island to NHS England as a pioneer in not only integrated services, but how we use advances in telemedicine and all those other wonderful things. Also relevant is data collection. The NHS does not use data terribly well, if I understand correctly. In relation to data for preventive medicine, we are small enough to be manageable. Social scientists love us because we are geographically isolated; we are clearly, in a very geographically obvious way, measurable. And for relatively small amounts of money, a great deal of learning could be done on the use of data in relation to preventive medicine, telemedicine and integration—the combining of health and adult social care.

As well as saying, “Please look at our funding”, because we have funding problems on the Island, we have special needs that have never, ever been recognised. I find the situation shocking, frankly. The Government, with the best will in the world, try to be fair. They fund the Scottish islands via the Scottish Government; they give them extra money. Anglesey has a bridge; the Scilly Isles have a small population anyway. However, the Government permanently function without taking into account my constituency. I know that they do not mean to do that, but our circumstances are unique, in that we are isolated by water, and that has never been recognised. When isolation factors are looked at, we never seem to qualify.

We are not properly funded, but we would like to be, and I would like the Government to look seriously at the struggle that some Islanders face in paying for the travel to the mainland when they go for treatment. I am offering the Government suggestions of ways in which the Island could be used as a test case, as a national leader, to integrate services better, to use data better and to combine all these functions, using telemedicine, to create a world-class service on the Island. That could be used not only to deliver great healthcare to my residents, but as a national role model for others.

--- Later in debate ---

[The Minister for Health (Stephen Barclay)]

It is a pleasure to serve under your chairmanship, Mr Hanson. I pay tribute to my hon. Friend the Member for Isle of Wight (Mr Seely) for raising the issue in the way that he has. He has used Westminster Hall exactly as it should be used—to bring the concerns of his constituents front and centre before the House. He set out not only the challenges faced, but the ways forward and a number of solutions for different issues. In short, he raised issues of funding that relate to population and geography, travel, the potential for further integration, and also a way forward involving digital and data. I will address each of those in turn.

This is also a timely debate, as the shadow Minister mentioned, following the Prime Minister’s announcement at the Royal Free Hospital last week of a significant funding boost to the NHS. Alongside that, NHS leaders are drafting a long-term, 10-year plan on services, which will look at many of the issues he cited in his speech. As we start that journey with NHS leaders, bringing the issues of the Isle of Wight front and centre is timely and helpful.

I would segment the funding formula issue into two: the challenges that the Island has in common with other parts of the country, such as those posed by the over-80s and by the significant number of constituents with dementia, and those that are unique to it. Indeed, few hon. Members feel that their constituents’ circumstances do not merit being higher up the funding formula than they currently sit. It is valid to raise those issues, and NHS England will look at them on the advice of the Advisory Committee on Resource Allocation, which advises on the funding formula. Those decisions are common to other areas, but they need to be made in respect of the Island. If my hon. Friend wishes, I am happy to facilitate a meeting with NHS England so the funding pressures pertaining to the demography of the Island can be raised. He will recognise that the setting of the funding formula is an independent process.

There are specific issues about the geography that my hon. Friend raised very well, not least about maternity services and paediatrics. The Island needs to supply those services and that will have an impact on its funding. I am happy to look at those issues. Integration is one way that headroom will be facilitated to meet those challenges. As he said, the Island was a vanguard site that has received £8.4 million of extra funding since 2015 to facilitate the transformation of services. That funding recognised some of the Island’s specific geographical challenges.

Although geography can be, and is in certain areas, a disadvantage and a driver of cost, it is also a driver of opportunity, as my hon. Friend set out. The Island has a strong sense of place and identity, and there are strong personal links between key decision makers and stakeholders. As the shadow Minister rightly said, the move towards greater integration between health and social care—as is reflected in the name of the Department—is also an opportunity to drive integration between the council and health services. My hon. Friend alluded to the bureaucratic obstacles to that, and I am happy to work with him to overcome them. As patients present with multiple conditions and as we move away from silos of care to a more holistic approach to patients and their wellbeing, the Island offers a huge opportunity for greater integration.

On my hon. Friend’s point about data, I had an interesting meeting yesterday with the chief executive of the Christie in Manchester, which is one of our outstanding trusts. I was struck by the fact that 19% of its patients take part in medical research programmes. The chief executive set out how that is hugely beneficial to the trust and to the patients, who get access to cutting-edge drugs and the latest thinking. He has also been able to attract some of the world-leading figures in research because he has a population that researchers can work for, which is very attractive to them. That is a real win-win, and the demographics of the Island offer an opportunity in that regard.

[Mr Seely]

One point that I did not make was that when it comes to looking at dementia, the Island would be very open to becoming a national leader or a place where academics and researchers could investigate how we can live better with dementia in this country. We have double the national average of people with dementia, so it would be a natural fit for us.

[Stephen Barclay]

I am keen to work with my hon. Friend on that, because the Government have prioritised their research and development budget, as I know from my time at the Treasury. A significant investment has also been made in health R&D. The NHS has an opportunity to combine its patient data with our world-leading universities and R&D to attract researchers, drive forward the most innovative approach on healthcare and translate that cutting-edge research into day-to-day care. That can be a frustration for our constituents; it is fine to have the research, but we need to roll it out to scale in a way that is meaningful for patients. The challenge of the Island’s geography is also a huge advantage to it. I do not know what percentage of its patients are taking part in research, but that may be an area for him to explore and for the Department to work with him on.

My hon. Friend also raised the potential of digital. He will be aware that the Secretary of State has asked Dr Eric Topol, one of the world leaders on the use of digital in healthcare, to undertake a report for the Department. My hon. Friend is right that rather than a patient having to be physically present in all instances, as was traditionally the case, there is scope to use digital much more for them to see a consultant online and for information to be sent digitally. I recognise that if the clinical commissioning group is in deficit, finding the headroom to invest in that technology becomes a trade-off and a challenge, but that is one of the opportunities that will be opened up by the Prime Minister’s investment in the NHS and it is an area that the 10-year forward view will specifically examine.

In terms of timing, the Island has a chance to look at how it can become a leader, what has been done with digital enablers and early adopters in the NHS, and in which areas it can lead on in technology. I will come on to the challenges of travel, but reducing the need for journeys is a more sustainable solution than seeking to subsidise them. Our starting point should be how we can use technology to reduce the need for as many journeys, rather than how we can subsidise more journeys. That offers significant scope.

On travel, I heard my hon. Friend’s remarks about the cost and its wider impact on families. There is a correlation with a separate debate we have had about car parking charges. Clearly, there are specific challenges related to travel, but as he also set out, it is quite complex, because there are already arrangements with the ferry companies and national schemes for subsidies and assistance that can be given to people who are financially challenged. It is a question of looking at how we can fit in with the existing schemes and what agreements can be reached with the companies concerned. I am happy to meet him to pick up on that specific point to better understand our current approach and what can be done, given the challenges. Again, the challenge of distance is not unique to the Island, but as he mentioned, there are certain features of travel to the Isle of Wight and the Scilly Isles that pose challenges.

As my hon. Friend will be aware, the NHS healthcare travel cost scheme provides financial help for travel costs for patients on low incomes who are referred. The scheme is part of the NHS’s low-income scheme, under which people are also entitled to free prescriptions and glasses. Under the scheme, the full cost of transport can be reimbursed by the NHS to eligible patients. Schemes are in place, but I hear the wider points that he has raised and I am happy to discuss them with him.

In short, my hon. Friend has set out that the Isle of Wight is ideally placed to be at the vanguard of the NHS’s approach as we move forward with the 10-year forward view, in embracing digital and integration and in looking at how to deliver place-based commissioning most effectively. There are some specific challenges with regard to its population and its geography in terms of travel. The interplay of those two things is another challenge in terms of efficiencies of scale and the services that are considered essential on the Island, which may be dealt with at a larger-population level elsewhere.

In the NHS more widely, as we move to a hub-and-spoke model and to more flexible population sizes, and as we look at place-based commissioning, the Isle of Wight has huge potential to be at the forefront, as my hon. Friend has set out. I am very happy to follow up this debate by meeting my hon. Friend, and to facilitate a discussion between him and NHS England, to ensure that we deliver what he has campaigned passionately for—the best healthcare for residents of the Island—and that the significant investment set out by the Prime Minister is maximised for his constituents.

The shadow Minister quite reasonably asked whether we were open to changes to the legislation. As he will be aware, the Prime Minister said to the NHS leadership in her remarks at the Royal Free Hospital that we are open to such suggestions if NHS leaders feel that changes are necessary. As part of the workings of the long-term plan, those leaders will need to look at what they need, and whether much of the integration—I know that the Mayor of Manchester supports the integration that is taking place in Manchester—can be done under existing legislation, or whether changes are needed, and if so, what those are. That will be part of the discussions with Simon Stevens and others in the weeks and months ahead.

--- Later in debate ---

[Mr Seely]

Only to thank you for your chairmanship, Mr Hanson, and the Minister, the shadow Minister, and the officials for attending. Thank you so much.

Question put and agreed to.

Resolved,

That this House has considered the provision of healthcare on English islands.