Unavoidably Small Hospitals

Philip Hollobone Excerpts

Tuesday 6th September 2022 Westminster Hall

[Mr Philip Hollobone (in the Chair)]

Welcome to Westminster Hall, and to the debate on unavoidably small hospitals. I call Bob Seely to move the motion.

[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.

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[Several hon. Members rose—]

[Mr Philip Hollobone (in the Chair)]

Order. The debate can last until 11 o’clock. I am obliged to call the Front-Bench spokespersons no later than 10.37 am, and the guideline limits are 10 minutes for Her Majesty’s Opposition and 10 minutes for the Minister. Bob Seely will then have two or three minutes at the end to sum up the debate. There are six highly distinguished colleagues seeking to contribute. I do not wish to impose a time limit, but if everybody limits their remarks to eight minutes, everybody will get in.

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[Rishi Sunak (Richmond (Yorks) (Con)]

It is a pleasure to speak under your chairmanship, Mr Hollobone, and thank you for accommodating me at a late stage in the debate. I had not planned on speaking, but this morning I saw the Order Paper and it turned out that I had more time on my hands than I had anticipated! It is a pleasure to be here with my hon. Friend the Member for Isle of Wight (Bob Seely) to discuss this very important topic.

I am here to speak about the Friarage Hospital in Northallerton, in North Yorkshire, which is in my constituency. It is one of the smallest district general hospitals in the country, serving a rural population of over 100,000 people and covering an area of a thousand square miles, stretching from the North York Moors at one end to the central Pennines at the other, bordered by York in the south and Darlington in the north. When I was first elected in 2015 and when I was campaigning before that, I told my constituents that the hospital would be my No.1 priority.

The reason for that is simple. Of course the NHS is the country’s most prized public service but, as we have heard in all the contributions from hon. Members today, the accessibility of healthcare in rural areas specifically is an issue of acute anxiety and the pattern over several years had been in a negative direction. Indeed, as I was being elected, my local hospital had lost its consultant-led maternity unit. Shortly to follow was the loss of paediatrics. That had an enormous impact on the local community. They feared for the very future of our beloved local hospital and I committed to do everything I could to reverse the flow of services away from it to ensure a bright future for the Friarage.

As my constituency neighbour, my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake), rightly pointed out, when healthcare organisations look at such things they tend to think about centralisation, because it looks very efficient on a spreadsheet wherever they might be sitting, but it does not work for our constituents. One thing I will say to the Minister is that she should send a strong message to trusts, particularly those that cover large urban centres and smaller rural hospitals in the same area, to always think about accessibility when they make their plans, which I do not believe they always do as well as they could. Secondly, I echo my hon. Friend’s recommendation about booking appointments. That is a simple, practical thing and trusts can do a good job of it when members of the public have the option to travel to smaller hospitals nearby or to others further away and to get the timing of those appointments right. That has an enormous impact on people’s ability to access the healthcare that they need.

Shortly after I was elected, I had to deal with a challenge that we have already heard about today—the downgrading of our A&E. However, that marked a turning point and I say to the Minister that what followed can serve as an example of what the future of small rural hospitals can look like. Under the leadership of Dr James Dunbar and his team, at the Friarage we pioneered an innovative new model of an urgent treatment centre that is open 24 hours a day and is consultant-led, with a clinical decisions unit. That means that it can provide a far greater range of healthcare to my constituents, including far more care for children than would typically be found. The unit is staffed superbly by nurse practitioners. It is working brilliantly and all I will say to the Department of Health and indeed to trusts where there is a similar challenge is to look at the model and see how it can be replicated around the country because, as I say, it is working brilliantly and has saved the loss of all emergency services at our hospital.

My other recommendation to the Minister and the Department is on recruitment and staffing issues, which we have heard a lot about already. It was clear during the work that I did that often the guidance from the royal colleges exacerbates some of the issues that we have heard about. My hon. Friend the Member for Thirsk and Malton said that anaesthetists are a case in point. A specialisation has occurred over decades, whereby anaesthetists used to be generalists and now we have sub-specialties. It is very difficult for small hospitals to accommodate those sub-specialties, and we need to look with the royal colleges at what safe staffing models might work to ensure the sustainability of our services.

I must commend the South Tees trust, because after repeated efforts from my hon. Friend the Member for Thirsk and Malton and me, it has focused fully on ensuring the future of the Friarage. I thank Simon Stevens for visiting the hospital in his previous capacity and understanding the challenges, and the pervious Health Secretary, my right hon. Friend the Member for West Suffolk (Matt Hancock). Since then, thanks to the philanthropy of the late Sir Robert Ogden, we have a new Macmillan cancer centre, which is providing fantastic care, a new diagnostic centre, an MRI scanner, a dialysis unit and an ophthalmology unit, all of which save my constituents a round trip of up to four hours to the much larger James Cook hospital. They are all delivering fantastic care closer to home.

I will give the Minister another example of innovation from the local team. James Dunbar came up with a new ambulatory care unit, which means that we can do emergency treatment on the same day. In the first year of its operation, it saved over 4,000 overnight stays, so it is not just a model for rural hospitals but a beacon for how the NHS can work more broadly to reduce the pressure on our bed capacity.

Most recently, I am delighted that the Government and the Minister responded to my long-running campaign to get new investment in our operating theatres. They date back to the second world war and are in urgent need of refurbishment, so I am delighted that the Government have said that they will provide £30 million of investment to refurbish all the operating theatres to the latest and greatest standards. That will have several benefits. Most importantly, it will send a very strong signal to my community about the future of the Friarage. It is very clear that the Friarage is not going anywhere and people can have confidence in its future, which helps with recruitment and retention, as we have heard. People are attracted towards working at smaller hospitals when they know that their career will be something they can bank on and that there is interesting work to do. This investment will absolutely secure that and ensure that we can attract the nurses, doctors and other staff that we need.

The Friarage also serves as a model for how we will tackle the backlogs more generally, because the hospital will be a new surgical hub with all the associated auxiliary services that are required. That means that we can now double the amount of elective surgery and do it closer to people’s homes. In the scheme of what the NHS spends, that investment will provide a very high rate of return by increasing the amount of surgical throughput. The doctors and nurses I saw just the other day—chief medical officer Dr Mike Stewart, chief surgeon Matt Clarke, and theatre nurse Sarah Baker—are all incredibly invigorated by what they can now do for our community, and that will help more broadly serve us to get the backlogs down faster, which I know is a Government priority.

I say to the Minister that it is important that small hospitals are recognised, which is something that is said very clearly in the five-year plan. It is important that the NHS continues to deliver on that. My experience locally is that that is happening, and I ask her to take on board some of my suggestions. I will close by paying tribute to the incredible doctors, nurses and staff at the Friarage, and to the Friends of the Friarage charity. I said to them when I was first elected that they would be my No. 1 priority, and they will continue to have my full support.

[Mr Philip Hollobone (in the Chair)]

We now come to the Front-Bench speeches. I call Feryal Clark for Her Majesty’s Opposition.