Unavoidably Small Hospitals

Kevin Hollinrake Excerpts

Tuesday 6th September 2022 Westminster Hall

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

I beg to move,

That this House has considered unavoidably small hospitals.

Thank you very much, Mr Hollobone; as ever, it is a pleasure to serve under your chairmanship. I thank the Minister for being here, and I wish her luck in any coming reshuffle. I also thank colleagues from Yorkshire, Devon, Cornwall and other parts of the United Kingdom for being here. Indeed, we have two Members from Yorkshire—my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) and my right hon. Friend the Member for Richmond (Yorks) (Rishi Sunak). It is a delight to see them both. I saw one quite recently on the Isle of Wight, but sadly not both.

The debate was originally granted prior to the covid pandemic. Clearly, much has changed since then, but I also wonder whether the fundamentals of unavoidably small hospitals have changed. The reason why I called the debate back then, and why I want it now, is that I fear they are still the poorer cousins of larger district general hospitals.

I will make two points. Clearly, I am going to talk specifically about St Mary’s Hospital on the Island, because it is in my constituency, but there are broader points to be made about unavoidably small hospitals throughout the United Kingdom. I want specifically to ask the Minister to put as much information as possible about the funding processes for unavoidably small hospitals in the public domain. We were talking prior to the debate, and she said that some of that information rests with the new integrated care boards. That may well be the case, and that is fair enough, but they are not elected bodies. We know that the NHS can be rather top down and bureaucratic in some of its behaviours, and the more information she can put in the public domain to help Members with unavoidably small hospitals understand the situation, the better.

Before I address that further, let me put on record my thanks not only to staff at St Mary’s but to GPs on the Isle of Wight and their staff, and to the pharmacists, the dentists and all the staff in care homes, who do a no less valuable job. Some of the problems we are facing are because of a lack of integration with our adult social care system; the inability to find a home for the elderly and vulnerable that that system looks after puts additional pressure on hospitals.

Let me also put on record my thanks to the Government for the £48 million additional capital spending on the Island. Indeed, I suspect that the former Chancellor, my right hon. Friend the Member for Richmond (Yorks), deserves thanks for that, as well as for the fair funding formula reference for the Isle of Wight. I am delighted and very grateful that he did both those things. That £48 million was part of getting a better deal for the Island, which is clearly an ongoing project.

In England and Wales, there are 12 unavoidably small hospitals, which are defined as hospitals that, due to their location and the population they serve, and their distance from alternative hospitals, are unavoidably smaller than the “normal” size of a district general hospital. In the Isle of Wight’s case, we are about half the size—about 55% to 60%—of the population needed for a district general hospital.

I would argue that the pressures on these small hospitals are greater than elsewhere. They are smaller, so they are more easily overwhelmed due to their size, and they are under greater economic pressure, because the NHS funding model—we recognise that there has to be a funding model—is designed for an average-sized, “normal” district general hospital, rather than an undersized one. You cannot give birth on a helicopter or a ferry; on the Island, we need to run our maternity services and our A&E 24 hours a day, seven days a week. However, our income is based on national tariffs that do not equate to the size of our population. As the Island’s trust says,

“the Island’s population is around half of that normally needed to sustain a traditional district general hospital.”

The third pressure on unavoidably small hospitals is because they exist outside of major population centres. Without a shadow of a doubt, they are in some of the loveliest parts of England and Wales, but because they are outside of those major population centres, recruitment and retention of staff becomes more difficult, which adds pressure on the staff who are there and adds costs in terms of locums and agency staff, which can have a highly significant effect on budgets. Ferries aside—with the partial exception of the Scilly Isles—the pressures at St Mary’s on the Isle of Wight are shared by other unavoidably small hospitals. I think that helps to explain why, in the last decade, a number of unavoidably small hospitals have been put in special measures or have sadly failed, despite the best efforts of those people who work there.

Our hospital, St Mary’s, is classed as 100% remote, which is unique even by unavoidably small hospital standards, because it is accessible only by ferry—although, as far as I can see, accessibility by sea is not a factor in the definition of an unavoidably small hospital. On the Island, our need for healthcare is arguably higher than elsewhere in the United Kingdom. We struggle to get the national standard, but our need for that national standard is greater because over a quarter of our resident population is aged over 65 and, by 2028, over-65s will be one third of the population. Indeed, we have a particularly large cohort of 80 to 84-year-olds.

All the evidence and common sense suggests that that has a disproportionate effect on healthcare: older people, and especially the very old and frail, need healthcare more than young people. We on the Island are struggling—as, potentially, are other USH areas—to provide quality for that ageing population. In addition, the Island’s population doubles over the summer, because we have lots of lovely visitors. That impacts demand, which means that our A&E can be close to overflowing at times, even as efficiently run as it is.

I suggest that there is an additional factor: the impact of high levels of social isolation. People retire to the Island as a couple and one sadly dies, leaving the other isolated from family and social networks because they lived most of their life in other parts of the United Kingdom. That leads to increased reliance on statutory services.

All this has been noted. The former Health Secretary, my right hon. Friend the Member for West Suffolk (Matt Hancock), confirmed his concerns to me in July 2019, telling the House:

“As for Island healthcare costs, my hon. Friend is right to say that the Isle of Wight is unique in its health geography, and that there are places in this country—almost certainly including the Isle of Wight—where healthcare costs are”—[Official Report, 1 July 2019; Vol. 662, c. 943.]

increased.

I am not saying that we are the only place like that. There is isolation in other parts of the country, including Yorkshire, Cornwall, Devon and Cumbria, but in the Island’s case the situation is cut and dried because of our separation by sea from the mainland. In its January 2019 sustainability plan, the Isle of Wight NHS Trust estimated that the annual cost of providing a similar—I stress to the Minister that this is the critical element—standard of healthcare and provision of 24/7 acute services, including maternity and A&E, on the Island to that enjoyed by mainland residents would be an additional £9 million. These are 2019 figures.

The estimated cost of providing additional ambulance services, including coastguard helicopter ambulance services, was about £1.5 million. In the Scilly Isles, patient travel is funded out of the clinical commissioning group—now the ICB—budget. Ours is not. Our patient travel budget comes from ferry discounts and council contributions, and it was estimated to be £560,000. In total, one is looking at between £10 million and £12 million at 2019 figures.

Either because they were going to do so anyway or, hopefully, because of representations from myself and others, the Government have recognised since then that unavoidably small hospitals need a funding model that serves them, because there is no alternative but to keep those hospitals open to serve those populations in a way that is ethical and, frankly, legal nowadays.

I am proud of our efforts to highlight the plight of unavoidably small hospitals to the Government, and I thank them for listening and for trying to put in place a package of support for them. I say to the Minister that this is where I would welcome more facts being put in the public domain. I have trawled through NHS documents for the last couple of days, and the last figure I can see for the unavoidably small hospital uplift for St Mary’s on the Isle of Wight is that from 2019, when we received £5.3 million. That is roughly half of what we think we need to run a national level service, so we are grateful that the Government have recognised the need for an uplift for unavoidably small hospitals. Will the Minister please update me on how much money St Mary’s has had as an unavoidably small hospital since 2019, given that we have clearly had issues with covid?

According to page 13 of the NHS “Technical Guide to Allocation Formulae and Pace of Change” for 2019-20 to 2023-24, that money was given in 2019 due to

“higher costs over and above those covered by the”

market forces factor. I cannot see other figures in the public domain. I do not quite understand how the Government could calculate that figure in 2019 when the advisory committee said in January 2019 that it was

“unable to find evidence of unavoidable costs faced in remote areas that are quantifiable and nationally consistent such that they could be factored into allocations”.

That is from the NHS England document “Note on CCG allocations 2019/20-2023/24”.

The Government say that they cannot work out how much extra to give unavoidably small hospitals, while at the same time a different NHS document says, “We are going to do some calculations, and here is the rough calculation.” Can the Government work out the additional costs or can they not? They are basically saying the same thing in two separate documents.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

I congratulate my hon. Friend on securing this important debate. May I give an example of how the Government might calculate the figure? A hospital in my constituency in Scarborough is run by the York and Scarborough Teaching Hospitals NHS Foundation Trust, which tells me that it has to pay extra to get consultants to travel to Scarborough and stay overnight, as well as paying their hotel bills. However we factor this stuff in, we have to be able to make a calculation that allows those trusts properly to fund these hospitals.

[Bob Seely]

I thank my hon. Friend for that valuable intervention. We have exactly the same problem. I will come on to how we are trying to solve it, but we have the same issue getting consultants over from Portsmouth, although we are very close to Portsmouth and Southampton. It is difficult for a consultant with a speciality to work in a small NHS trust, because there is no opportunity to practise that speciality effectively enough to keep their ticket to do their very valuable and worthwhile job.

Although I am delighted that the previous Conservative Government recognised the additional costs and gave the Isle of Wight nearly £50 million in additional capital expenditure, my trust assesses that the funds given are roughly half what is needed. I stress that we are not just sitting on the Island saying, “We want money.” We understand that we need to sort out these problems for ourselves. Our trust was in special measures and is now rated good, due to some fantastic hard work by Maggie Oldham and other health leaders, who have come in and turned our hospital around, really helping to make a difference. I thank everybody, from the cleaning staff to the most junior nurse and the most junior doctor, for the great work they have done.

We are now rated good and have been looking at ways to provide better services on the Island, without just waiting for the Government to provide funding. We are integrating. We have deepened our relationship with Portsmouth general hospital, our university hospital, the idea being that when it hires a consultant, we share that consultant for 10% or 25% of their time. A world-leading consultant in an area of medical expertise will therefore spend some of their time looking after folks on the Isle of Wight.

We have reformed our mental health services, and we are reforming our ambulance service too, to ensure that we have more ambulances out there to treat more people, more quickly. Along with everywhere else, we are integrating adult social care as part of the Government’s plans. We want to be pioneers in that. Because of our age demographic, we want to be at the front of the queue. I have sadly learned that, if the Island is not first, it tends to be last, because it comes as an afterthought. I always want to ensure that the Island gets to the front of the queue, so that when the Government look to test pilot schemes, they come to us first.

We are looking at chances to pilot new schemes. We did it with Test and Trace, and we are adopting telemedicine as fast as we can. We are working with the University of Southampton to pilot using drones to deliver cancer care. The drone testing started during covid and, as of a couple of months ago, it is now a regular service that brings just-in-time cancer medicine to the Isle of Wight. That is a really good way to see that advanced technology is helping folks on the Island and, indeed, helping the NHS to provide a better-quality service.

I will round up, as I am mindful that other people want to speak on this issue and it is important that the Minister hears other voices. In January 2019, the NHS long-term plan set out a 10-year strategy for the NHS in England. For smaller acute hospitals such as St Mary’s, the plan stated that the NHS will

“develop a standard model of delivery”.

It would be great to hear from the Minister what has happened to that plan for a standard model of delivery. Is that now the funding formula that is included in the new integrated care boards? If so, will the Minister please outline how that funding formula works and is calculated, as my hon. Friend the Member for Thirsk and Malton and I have asked? It is in the public interest that the formula is as transparent as possible.

Will the Minister please explain why, if someone travels from the Scilly Isles to the mainland for care, it is paid for out of a central budget? If someone has prostate cancer or another form of cancer, they often need to be treated in Portsmouth or, occasionally, Southampton. That funding does not come from the Government. Why is that? Why is there a double standard that affects the Isle of Wight negatively?

Finally, the Minister mentioned before the debate that the funding formula details are held by the new integrated care boards. For the 20 Members of Parliament in England and Wales who are within the remit of an unavoidably small hospital, those figures should not be held at ICB level but should be shared between Ministers and interested Members, so that we can all see how these very important institutions in our communities are funded. By doing so, I hope that we can increase the funding for them or at least increase the Government’s understanding that just because such hospitals are the smaller cousins of larger district general hospitals, they should not be treated worse but should be given extra care and attention to make sure that folks in our communities can have the same standard of care as other people throughout the rest of England and Wales.

--- Later in debate ---

[Kevin Hollinrake (Thirsk and Malton) (Con)]

It is a pleasure to speak in this debate with you in the Chair, Mr Hollobone. I thank my hon. Friend the Member for Isle of Wight (Bob Seely) for tenaciously following up on this very important issue, which I and my right hon. Friends the Members for Scarborough and Whitby (Sir Robert Goodwill) and for Richmond (Yorks) (Rishi Sunak) have been following closely over the years.

My hon. Friend concluded in exactly the right place. The issue is not hard numbers in terms of cash, deficits or whatever; this is about patients and patient care. We have experienced two challenges in respect of Scarborough Hospital and the Friarage Hospital in Northallerton in particular. Yes, as my hon. Friend set out, there is the issue of funding and the extra costs of delivering services in places such as Scarborough, but there is also the fact that these hospitals are run by trusts that run a number of hospitals, and the small hospitals are, of course, not necessarily their largest hospitals. Because the trusts are faced with the extra costs of running the smaller hospitals, there is a natural tendency for them to try to centralise care in one of the other hospitals. When they talk to the public—they tend to talk to their customer base before they make changes—they ask them, “Would you be prepared to travel for better health outcomes?” Who would not say yes to that? Of course! But it is a leading question.

I have a couple of examples of how it works in practice. A number of my constituents have written to me. One of them had to go to York Hospital from Scarborough. They did not have transport—they did not have a car—and they had to go for an appointment at 7.30 in the morning for treatment for a brain tumour, and were then discharged at 11 o’clock that night, without transport. It is not just that people have to travel for extra care and that they are deprived of local care for treatment that would have been available at Scarborough at one point; it is the fact that there is no real consideration of some of the challenges of living in a rural area. Some of my constituents have had to travel to York from Scarborough on the east coast—from Filey in my patch—to stay in a hotel overnight because there is no public transport to get to early morning appointments in York Hospital. Those are direct consequences of centralisation.

[Bob Seely]

The problem is clearly significant in my hon. Friend’s patch, but does he understand that when people are separated by sea from the mainland it becomes an even greater problem? There are even greater logistics if people need a car and then a ferry to the bus and so on.

[Kevin Hollinrake]

My hon. Friend is absolutely right. His challenge may be even greater than ours in rural parts of North Yorkshire.

Centralisation is a natural tendency for any organisation, of course. A person sat in a larger hospital in York will think, “Let’s have all the services over here. It is easier and cheaper to employ consultants over here.” Centralisation is easier, but it is much worse for patients. It is not fair on them, given the complexity of travel and the effect on local communities.

The principal trust that runs the hospitals in my area is the York and Scarborough Teaching Hospitals NHS Foundation Trust, which runs Malton Community Hospital, Scarborough General Hospital and St Monica’s Easingwold, which is a small cottage hospital. It is easier for the management to centralise things, and it is cheaper, given that it is more expensive to provide healthcare in more remote locations. I said earlier that because remote hospitals have difficulty recruiting people, they tend either to close services down or provide additional remuneration for the consultants who work there, so there is a double whammy of cost.

The other issue in my constituency is that it is 40 miles from Scarborough Hospital to York, and on a good day it takes an hour to travel on the A64 all the way to York as it is a single carriageway for most of its stretch and is often logjammed with traffic. The dualling of that carriageway has been the subject of many pleas to the former Chancellor, my right hon. Friend the Member for Richmond (Yorks), and many others, and hopefully we will get that in the not-too-distant future. This is serious stuff, of course, for anyone who needs emergency treatment.

The stroke unit at Scarborough was relocated to York some time ago, so if someone has a stroke in Scarborough, they have to get to York, and they might be in an ambulance for two hours on that road. It is unfair. I understand that they may get better treatment at the hyper-acute stroke unit at York, but nevertheless there are potentially direct impacts on people’s healthcare when services are centralised in distant locations.

It is not just stroke care that has been centralised in other hospitals, but outpatient physiotherapy, dermatology and pain clinics. Breast cancer oncology was moved away from Scarborough some time ago owing to the difficulties of recruitment. It is easier to employ consultants in a hospital that has more money than to incentivise them to go to more remote locations. The A&E unit at the Friarage Hospital in Northallerton, in the patch of my right hon. Friend the Member for Richmond (Yorks)—he will talk more about it—was downgraded to urgent care treatment, and we were told that one of the reasons was that it was difficult to recruit anaesthetists.

Services are being closed down. The Lambert Hospital in Thirsk in my constituency, which provided respite and elderly care, was completely closed down because it could not recruit in that location. Our suspicion was that the trust did not really try all that hard to recruit people because it is more difficult to run services in remote locations.

On costs, I can give my hon. Friend the Member for Isle of Wight a direct comparison. When the York and Scarborough Teaching Hospitals NHS Foundation Trust took over Scarborough back in 2012, it was given £10 million a year for the extra costs of providing services in that location. That ended in 2018. A small amount has been provided to make up for the loss of £10 million—£2.6 million of funding through the clinical commissioning group—but, as a consequence, services are diminishing.

There is some good news: my right hon. Friend the Member for Scarborough and Whitby and I campaigned, and the Health Ministers were very supportive. There has been £40 million of extra investment in the A&E at Scarborough, but nevertheless there are some real concerns about the services, which are reduced as a consequence of underfunding. I would like to hear from the Minister exactly what we are doing about it now and what we will do in the future to improve the situation.

--- Later in debate ---

[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.