Kentmere Mental Health Ward, Westmorland General Hospital

Tim Farron Excerpts

Monday 13th June 2016 Commons Chamber

[Tim Farron (Westmorland and Lonsdale) (LD)]

Kentmere ward is the 12-bed adult mental health ward at Westmorland general hospital. It provides essential in-patient acute mental health services to people in South Lakeland and beyond. Four weeks ago, the Cumbria Partnership NHS Foundation Trust, which looks after mental health in the county, proposed to close the ward by the end of June, with new admissions ceasing at the end of May.

This is the second time in my time as our Member of Parliament that the ward has faced the threat of closure. Ten years ago, similar proposals sparked a huge outcry from local residents. Thousands of people signed petitions and wrote to health bosses, and about 3,000 of us marched through Kendal town centre in pretty shocking weather to voice our opposition.

The campaign took many, many months, but we won. Our victory in saving the ward was a hugely important moment for our community. Mental health is often a taboo, so the suffering of those living with mental health conditions, and of their families, often happens in silence and in private. In the face of a threat to the services that those with mental health conditions rely on, far too many people would choose to look the other way—but not in South Lakeland. The campaign showed that local people were prepared proudly to stand up in solidarity with those living with mental health conditions and with their families. I am therefore extremely proud of my community. In the face of this latest threat, the character of our community is once again shining through.

Westmorland general hospital is the main hospital serving the Lake district, the western Yorkshire Dales, Kendal and much of the rest of rural southern Cumbria. I have learned over the years that the tendency to overlook the health needs of rural communities such as ours means that I need to be permanently vigilant in my defence and promotion of our hospital. The campaigns we have run to win new cancer services, to prevent the closure of the hospital itself and to increase surgery at Westmorland general are testament to the fact that ours is a special community, which will fight with unique energy and tenacity for mental and physical healthcare that is high quality and accessible. Once again, it appears that we must roll up our sleeves and fight to defend our services.

As I said, the ward provides 12 beds, the majority of which are usually full at any given time. The people occupying these beds are often suffering from the most serious mental health conditions. For much of the time, the majority of patients staying on the ward are under section.

The apparent trigger for the proposed closure came after the Cumbria Partnership NHS Foundation Trust was inspected as part of Care Quality Commission’s comprehensive inspection programme last November. Its report, which was published in March, awarded a rating of “requires improvement” to the Kentmere ward. In particular, the CQC highlighted concerns relating to privacy, access to outdoor areas and the internal physical structure of the ward. Having visited the ward myself, most recently on Saturday, I have to say that the quality of staffing and patient care is absolutely outstanding. In fact, the CQC itself was surprised that the trust’s response to the report was to close the ward, believing that the upgrades needed to meet required standards were perfectly feasible. Let me be clear: this ward is providing excellent care from outstanding staff in a physical setting that requires some improvement. It most definitely does not require closure. Indeed, the CQC has been clear that it did not recommend closure, or anything of the sort.

As I said, the ward is situated in Westmorland general hospital. The partnership trust that is responsible for mental health in Cumbria is a tenant of University Hospitals of Morecambe Bay NHS Foundation Trust. The hospital is a fairly modern building, with plenty of car parking and a beautiful setting looking out towards the Lakeland fells and the Howgills. Put bluntly, if you have to go to hospital, I cannot think of anywhere more pleasant you could be, and that is not unimportant when supporting people living with mental health conditions. The hospital building is not full. There is a great deal of space on the site, with ward space that is not used or under-used. There are enormous opportunities, with a little bit of imagination, to seek more spacious, more suitable, better-quality accommodation elsewhere in the hospital.

It is clear, then, that Kentmere ward needs upgrading. It is not ideal that it is on the first floor. There could do with being more space for the unit as a whole and greater privacy for the patients. There will be projected costs of a completely new building to meet the requirements of an upgrade. The Minister may have seen those projections. They will no doubt be expensive, and the conclusion that he is probably meant to draw from whatever scary numbers he has been given is that the only affordable solution is to close the ward. He is expected to read his brief and fob me off. However, I know him well, rate him highly, and know that he has much better judgment than that.

The reality is that the needs of patients in South Lakeland could be met on the current Westmorland general hospital site. An immediate project should be launched, alongside the hospitals trust, to ensure that there is a larger unit with ground-floor access that has greater levels of gender segregation, greater privacy, greater dignity, and greater safety. If there is a will, then the way is staring us in the face. Whatever the challenges, which we acknowledge, in upgrading this unit, it is obvious from my conversations with patients, their families, staff, the CQC and the trust that there are serious concerns about the incredibly detrimental impact that closure will have on patients’ conditions.

[Rachael Maskell (York Central) (Lab/Co-op)]

What the hon. Gentleman is saying very much echoes what happened in York when the hospital closed nine months ago. The consequence has been loss of life to my constituents. It seems that primacy in decision making is given not to clinical need, but more to the physical environment, and that has to be wrong, does it not?

[Tim Farron]

I am extremely grateful to the hon. Lady for her intervention and wish to express great solidarity with her in the campaign that she is running in York. It is of great concern to me that the CQC will make recommendations that will require improvements, and potentially not offer solutions to maintain a plausible and sustainable provision instead. The judgment we have to make is, “Is a good service that is not perfect better than no service?”, and of course the answer is going to be yes.

As I said, the quality of care in Kentmere ward at Westmorland general hospital is excellent, as stated in the report, and the staff are excellent. The ward needs upgrading—that is a given—but its closure would harm the health of some of the most vulnerable people in our community. It is utterly unacceptable that those people will have to be shipped off to Barrow, Whitehaven or Carlisle rather than being treated much closer to home in Kendal. What is more, there is no guarantee that those far distant wards will have the capacity to accommodate them. Already, patients sometimes face the immense journey to Manchester, for example. For many less well-off residents, a round trip to these alternative wards of up to 100 miles, with many hours on the bus or train, will put family and loved ones beyond easy reach. It is the patients who would be harmed if they were cut off from their families and friends and missed out on all-important visits. Instead of the reassurance of familiar faces and surroundings, they would face this dark time alone and in an unknown place.

[Jim Shannon (Strangford) (DUP)]

Does the hon. Gentleman know whether any issues have been raised by veterans’ organisations or by veterans themselves? Ex-soldiers and former service personnel are clearly—

--- Later in debate ---

[Jim Shannon]

Does the hon. Gentleman know whether there is a need to address that issue? A lot of veterans in my constituency need help. Does his constituency have the same problems as mine?

[Tim Farron]

The hon. Gentleman draws attention to an extremely important matter, namely the plight of so many veterans. It seems that we are happy for brave women and men to provide loyal service and to put their lives on the line for us, but they are often dropped when they return from duty. There are incidences of mental health concerns for them and their families in the years after their return, and I am not clear that we as a general community provide the support that we should. That support can sometimes be provided by the community, but sometimes it needs to be provided in a physical setting as well. I am grateful to the hon. Gentleman for his intervention.

A recent Government report showed that the closure of this ward in South Lakeland would leave our part of the world with among the worst access to mental health services in the entire United Kingdom. Out of the 6,688 open ward stays in adult acute mental health in-patient care in England alone over the past year, only 263 patients —4% of them—received care 30 miles or more away from where they lived. The closure of the Kentmere ward would leave vast numbers of South Lakes residents—including all of Kendal, as well as many other rural areas—even further away from those services, as the closest alternative in-patient ward is in Barrow, 35 miles away from Westmorland general. The most likely alternatives are further away still: Carlisle is a 45-minute drive, at best, and Whitehaven and Manchester are both more than 70 minutes away, if the traffic is kind.

The provision of replacement community support, which has been offered to compensate for the closure of the ward, would be inadequate. More community support would, of course, be welcomed, but that must be in addition to, not instead of, the 12-bed unit. Increasingly, the majority of patients in the unit are under section, and one cannot section people in the community.

By the way, when people are sectioned, there is an immense impact on our local police force. Closure of the unit in Kendal would mean that our local police force, which is already heavily stretched, under-resourced and under pressure, would have to take patients vast distances across Cumbria to far-off mental health units, taking officers off the beat and threatening the safety and security of our rural communities.

The last time I spent a night out on the beat with our local police force, I was stunned by how much of its time was spent dealing with various kinds of mental health issues. Indeed, that was pretty much all it did on that occasion. Anecdotally, police officers locally tell me that up to half of their workload can involve dealing with people living with mental health conditions. Their dedication and compassion in being the first line of support for incredibly vulnerable and often distressed people and their families is overwhelming, and I am proud of them. However, our police are already working beyond their physical capacity; the closure of Kentmere ward would just add to that pressure. It is unacceptable.

Local people recognise the damage that closure of the ward will have on patient welfare and are once again uniting to make their concerns heard as we stand together to fight to put a stop to the proposed closure. There has been an overwhelming response from local people to the campaign, and as of today our petition has reached 5,500 signatures.

Last week, we were encouraged, in the face of such massive public opposition, as we were able to secure a much welcome but temporary victory: the trust announced that a final decision is to be postponed while it looks at whether the ward can be upgraded and improved to meet CQC standards, which means that it will now stay open and continue to admit patients over the summer. The vulnerable patients I met over the weekend continue to get treatment close to home. If we had not achieved this victory, they would already be being carted off to Barrow or Carlisle—far from home, and far from loved ones. News that new admissions will continue to be made throughout the summer is also welcome.

I am grateful to the trust for listening to our concerns and thinking again. I personally thank every single one of the thousands of local people involved in our campaign. Between us, we forced the trust to hold back on closure. I am especially grateful to volunteers from South Lakeland Mind, and to the local media outlets that have shown such strong support to the campaign. This is only a temporary reprieve for Kentmere ward, and our work is far from complete. My message to the people of South Lakeland is that this is the moment to step up our campaign, energised and encouraged by this success and spurred on by victories in campaigns for our hospital over the last few years. My message to patients and their families is: we will stand with you and we will not give up, because we must not give up.

It has been very clear from my discussions with the trust over the last few days that its default position is still to close the ward. I have one very specific request of the Government this evening. Will the Minister clearly instruct the Cumbria Partnership trust not to close this vital ward? While the trust looks at upgrade options and alternatives, I ask him to make it very clear, right here and right now, that closure is off the table.

I have spoken to many local residents about the matter over the past few weeks, but a conversation I had with one lady struck me particularly hard. She is regularly treated for her mental health condition at the unit, and she was clearly extremely distressed by the thought of having to trek miles from home to receive care if the ward were to close. Her condition has been visibly exacerbated by the tangible threat from this proposal. A decision by the Minister to instruct the trust, tonight, not to go ahead with closure could directly alleviate the worry and anxiety of that lady and many more like her.

The long-term effects of closing the unit would be far greater than the short-term savings. If the Government are serious about mental health, they must put words into action and prove it by stepping in and preventing the closure of this vital ward. The closure of the ward would be a serious backward step for mental health care in South Lakeland, and the Minister has the opportunity to prevent it. On behalf of the people of the South Lakes, I ask him now to take the opportunity to save Kentmere ward.

[The Minister for Community and Social Care (Alistair Burt)]

There is no pressure here, then. I thank my friend, the hon. Member for Westmorland and Lonsdale (Tim Farron), for securing this debate and for his vigilance in raising such an important subject, which matters a great deal to his constituents. I put on record my appreciation for the work done by the NHS in Cumbria and I thank the staff for their hard work and commitment to patients. In doing so, I acknowledge what the hon. Gentleman said about the police. As we in the Chamber who know about these matters are aware, the police do a great deal of work in this area. The crisis care concordat, which was piloted by the right hon. Member for North Norfolk (Norman Lamb), has made a considerable contribution to the way in which we look after those with mental health issues at times of crisis, and the police have been intimately involved. I fully accept what the hon. Gentleman has said about the amount of such work that the police in south Lakeland are involved in.

I am fond of South Lakeland. Bury Grammar School had a house at Helsington, near Brigsteer, which I am sure is in the hon. Gentleman’s constituency. I remember the place extremely well. It is a beautiful area, and its constituents are entitled both to good service from an MP and to the best quality services.

Let me turn immediately to the subject of the debate. Cumbria Partnership, the provider trust, announced in May its decision to close Kentmere unit following information from the CQC that highlighted the environmental constraints on the unit. Kentmere is an old mixed-sex unit with no access to outdoor space. The hon. Gentleman’s concerns and comments about the decision have been widely reported. As he knows, and despite what he said at the conclusion of his remarks, this is a matter for the local NHS. Neither I nor any other Minister have a role in the decisions that are taken. The hon. Member for York Central (Rachael Maskell), who spoke forcefully about Bootham Park in York, also knows that well.

However, I understand, as the hon. Gentleman rightly says, that the NHS now says that the unit will not close as announced and that decisions will depend on further work. It is, therefore, worth setting out the background and indicating the interest that I have in making sure that the best possible services are provided, while recognising that the old levers of Ministers and the NHS are not quite as they were.

Mental health services for Cumbria are commissioned by the NHS Cumbria clinical commissioning group. Cumbria Partnership NHS Foundation Trust is the provider of mental health services for patients in Cumbria. The CCG has been working on a new mental health strategy for Cumbria for some time. It is fair to say that one of the problems that the NHS, in common with other public services, faces in Cumbria is the geography. The largest towns are at the northern and southern ends of a region that covers a large area, and it is difficult to travel between the smaller towns because the roads are often slow. This means that the NHS has to make difficult decisions about where and how to provide services. To put it bluntly, everything cannot be available in every local community. While cost is a real factor, the main problem is maintaining quality. It is not about saving pennies; it is about making sure that the quality of service is high.

Like everyone else, NHS clinicians learn and improve through experience. Skills that are not being used will decline. Facilities seeing only a few patients tend to lack the patient throughput needed to ensure that services remain of high quality. The cost of employing staff is the main factor driving the cost of services, and providing services from a greater number of locations means that more staff are needed. There are only so many staff to go round. The NHS invariably finds that larger units do better in terms of patient outcomes, but the question is where those larger units should be located. Inevitably, decisions taken by the NHS will disappoint those areas not chosen.

NHS services in Cumbria overall—not just mental health services—are facing a range of challenges, and in many cases the reasons are the same. The northern part of the area is part of a success regime aimed at improving all patient services; the issues at the University Hospitals of Morecambe Bay NHS Foundation Trust in recent years are well known. It is against this background that the NHS is considering what should happen at Kentmere and what is best for the hon. Gentleman’s constituents. Cumbria Partnership announced on 17 May that the Kentmere unit would close from the end of June 2016. At the same time, it was announced that the adjoining health-based place of safety would close at the end of May. The trust said that the decision was a result of quality and safety concerns raised by the Care Quality Commission. The CQC had inspected the unit in November 2015 and its report was published in March. However, the CQC says that the decision to close the ward and the health-based place of safety is not a necessary outcome of the findings of the CQC inspection, to which the hon. Gentleman referred. In short, while it did identify problems, the CQC report did not recommend the closure of the unit.

The report clearly highlighted concerns about the ward environment, which it said placed service users at risk and did not support good care and treatment. Something does need to be done about those concerns. The unit, which treats men and women, does not meet minimum standards on single-sex accommodation and has poor access to outside space. As I understand it, one issue is that privacy for bathing and sleeping cannot be guaranteed on the mixed ward. That poses an obvious risk to patients.

On 25 May, the trust gave a reassurance that the closure would be temporary and that timescales for the closure would be reviewed. I now understand that, following discussions with the CQC and with commissioners, any decision on closure will be delayed to allow further exploration of what improvements can be made. More needs to be done, and I will say a bit about that later. It says here that the trust accepts it did not get its messages right on the closure, and I think that hon. Members will probably agree strongly with that. Many hon. Members will be aware of similar experiences in other areas, and I think the NHS needs to think carefully about how it communicates with patients and the public, particularly when the news is not good. The facts need to be clearly set out, and it is important not to rush to announcements prematurely.

These circumstances reminded me of the closure last year of Bootham Park Hospital in York, in the constituency of the hon. Member for York Central. There are differences, in that the CQC recommended the closure of Bootham Park on patient safety grounds, which is not the case here. But the report produced on the closure by NHS England makes a number of observations about how difficult processes such as this need to be handled by the NHS. I have discussed this matter with the hon. Lady and I would be happy to discuss these matters further with the hon. Gentleman if we get an opportunity to do so. These are difficult decisions to get right—safety considerations really matter and when things are identified as needing to be put right, they must be put right—but the question then becomes how to do it, on what timescale and what the options are. I will come to that in a moment. The difficulty of handling such decisions, and the way in which they have not been handled well at Bootham Park, reminds us of the importance of getting such decisions right. The report on Bootham Park, particularly in relation to owning and communicating decisions, has been made public, and I have placed a copy of the report in the Library.

As I have said, in relation to Kentmere ward, we have moved in the space of a few weeks from a permanent closure to a temporary closure, and then to the unit remaining open while more work is completed. The safety of patients has to be the primary concern, and we would be failing patients if the NHS continued to tolerate the risk to the quality and safety of care that the environment at Kentmere places on local services. Something needs to be done, and it is up to the local NHS to decide what that is, but I do not think it will do so on its own. That is where the hon. Gentleman and his friends come in.

The CCG recognises that mental health services in Cumbria need to improve and it has already involved service users, their families and carers on this project. Much of the work so far has shown, not surprisingly, that patients want better services closer to home in their local community. Later this year, NHS Cumbria CCG will therefore be consulting about the future configuration of adult in-patient mental health beds across Cumbria. That will ensure it has the right beds in the right place, with a sustainable service that the local NHS can staff for the future. The CCG has already said it will not support any permanent service change at Kentmere without full public consultation.

In preparation for this, the CCG is looking at the current configuration of adult in-patient mental health beds, benchmarking how it is managing mental health needs across Cumbria with other mental health providers and advising on areas where the NHS needs to develop services to meet future needs. The CCG also needs to make sure it has the right kind of beds in place—for example, facilities for children and young people, older adults and psychiatric intensive care beds.

[Tim Farron]

There is not much time left, and I am very grateful to the Minister for giving way. I want to point out to him, first, that there is not a single tier 4 adolescent or child mental health bed in the whole of the county of Cumbria, and secondly, that the 12 beds on Kentmere ward are nearly always full and the majority of them are for people under a section, so there is no opportunity for community options. It is not the case that there is a lack of demand.

[Alistair Burt]

I take the hon. Gentleman’s point. I cannot be as au fait with the situation as him, but I fully understand the point in general. Whereas there is a tremendous move towards improving community services, which is important and vital in its own right, that cannot be a total substitute for the in-patient acute beds that are needed. I understand his point, and that is my view and the Department’s. Getting the right balance is important, but the one is not a cheap substitute for the other. Such services are an important component, because it is important that more is done in the community to keep people away from acute beds and make sure they do not need them, but I entirely take his point.

NHS Cumbria CCG is working with its providers—mainly the foundation trust, as well as clinicians, service users and carers—to help develop the model of care it will need in the future to deliver its vision of improved mental healthcare and sustainable services. I am told that public consultation will be carried out in line with best practice and the latest Government guidance. There will be sessions for stakeholders and the public to share their views, ideas and concerns in communities around the county. I spoke to health service chiefs this afternoon in preparation for this debate, so I know how seriously they take the point about the need for consultation, as well as that they recognise the communication difficulties in relation to how they have got to where they are and that they are open to such a consultation. I therefore urge the hon. Gentleman and his constituents to involve themselves fully in that consultation, which will shape whatever happens to Kentmere in the long term.

Tempting as it is to follow the hon. Gentleman’s suggestion that I should decide on the configuration of services, I am afraid that I cannot do so because that would be outside my authority. I wish him, the hon. Member for York Central and other Members in the House good night and good luck.

Question put and agreed to.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 5th January 2016 Commons Chamber

[Mr Hunt]

The inquiry has only just started, but I thank my hon. Friend for her interest in it. The important conclusion that we have drawn from what happened at Southern Health is that this issue is much broader than one trust. We are not as good as we need to be at investigating unexpected mortality in the NHS. Southern Health is perhaps an extreme example, but the problem is much more widespread. A cultural change is needed, and we are determined to do something about it.

[Tim Farron (Westmorland and Lonsdale) (LD)]

Will the Secretary of State undertake to support Morecambe Bay, the other hospital trust in Cumbria, as it moves out of special measures, by confirming the commitment made by the coalition Government to underwrite the capital costs of a radiotherapy unit at Westmorland general hospital and to support the uplift in tariff needed to sustain that unit?

[Mr Hunt]

I will happily look into that. I cannot give the hon. Gentleman the answer now, but we would want to do everything we can to support that trust. It has been through a very difficult time and has made huge progress. We want to help it on its way.

Maternity Services (Morecambe Bay)

Tim Farron Excerpts

Tuesday 3rd March 2015 Commons Chamber

[Mr Hunt]

I do not know the answer to the last question because we have received the report only very recently, but we will do this work as soon as possible. Indeed, if we have cross-party support, it may be that we can expedite the process. The hon. Gentleman worked very closely with James Titcombe and is absolutely right to talk about the seriousness of what happened. As with the Francis report, however, I would caution against the idea that this problem will be solved if a few more nurses are struck off. We need accountability—that is incredibly important—and where there is wrongdoing, people must be fully held to account. The big lesson is the lack of openness, transparency and trust. It is quite possible that the reason some people did not speak out about poor care is that they were frightened of the consequences of doing so. They thought they would not be listened to. Other industries, such as the nuclear industry in which James Titcombe worked or the airline industry, have managed to create a culture of trust where people on the front line who make mistakes feel able to speak out and be supported if they do so. That is the most important lesson we need to learn from today’s report.

[Tim Farron (Westmorland and Lonsdale) (LD)]

I, too, want to the thank the Secretary of State and the shadow Secretary of State for their entirely appropriate contributions, both the statement and the response, on this immensely sensitive and deeply personally upsetting series of circumstances. I want especially to pay tribute to the families who lost loved ones as a result of what Dr Kirkup referred to as

“serious failures of clinical care”.

He refers to the report as a damning indictment.

The dignity and determination of parents such as James Titcombe and Carl Hendrickson have led to this awful truth being laid bare today. Those parents are an inspiration to me, and they should be to all of us. I want to pick up on one point in particular that was raised during the Secretary of State’s statement. Dr Kirkup expresses disquiet that the NHS and the parliamentary ombudsman chose not even to investigate what has now been shown to be the needless deaths of at least 11 babies and at least one mother. May I press the Secretary of State to go further than he has in his statement and do everything in his power to ensure that the watchdog for patients is not a lapdog for senior managers? Patients need a powerful, effective independent investigator who listens to those who grieve, like the Morecambe Bay families, and not one who dismisses them without even an investigation.

[Mr Hunt]

My hon. Friend is absolutely right. There were, clearly, very serious flaws in the way the Parliamentary and Health Service Ombudsman operated, particularly in the case of Joshua Titcombe. My hon. Friend will know that the PHSO is accountable to this House through the Public Administration Committee, and not through the Government and the Department of Health. The Public Administration Committee is considering this issue in a great deal of detail to see what lessons need to be learned. I think one of the issues is the level of expertise within the PHSO and, with the greatest of respect, a certain lack of confidence in its ability to understand when there has been a clinical failure. I think everyone agrees that one of the things we need to do is to ensure that it can draw on medical expertise. It needs to make sure that its culture is as open and transparent as the culture it would like to see inside the NHS.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 13th January 2015 Commons Chamber

[Mr Hunt]

Let me tell the hon. Lady what we are doing—[Interruption.] This is what I think is so shocking: Labour Members are not actually interested in what is happening to avoid precisely the kind of things that the hon. Lady mentioned. We are putting £4.6 million of extra support into the North West ambulance service this winter, and that money is being used to employ more paramedics, to train people so that they can see and treat patients on the spot, and to help more people on the phone so that they do not need an ambulance. The hon. Lady should perhaps have listened to the earlier question, because where Labour is running the ambulance services, results are even worse.

[Tim Farron (Westmorland and Lonsdale) (LD)]

Does the Secretary of State agree that the rules for commissioning ambulance services need to be looked at again to ensure that ambulances serving rural areas such as South Lakeland which do not have an acute centre of their own and therefore export their ambulances further afield need to be compensated with additional ambulances to take account of the fact that so many of our vehicles are out of county most of the time?

[Mr Hunt]

My hon. Friend makes an important point about the way targets are set up. It is possible for ambulance services to hit their targets while not delivering a satisfactory service to the most rural areas, and we have discussed that issue a number of times. Because we are in the middle of a challenging winter, we do not think that now is the right time to review the issue, but he should rest assured that we are keeping it under review.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 21st October 2014 Commons Chamber

[Norman Lamb]

I absolutely recognise the problem. I have commissioned an up-to-date prevalence survey so that we have evidence that can help services around the country. If the hon. Lady wants to talk with me further about the problems in her area, I would be happy to do so.

[Tim Farron (Westmorland and Lonsdale) (LD)]

A local report on mental health and emotional resilience among young people in South Lakeland found that the stigma surrounding mental health and the lack of sufficient resources over time mean that distressed and panic-stricken families often do not know how to begin to access the support that their children desperately need. How can my right hon. Friend help us get swift, clear and obvious access to mental health care for young people?

[Norman Lamb]

I welcome the study that has been undertaken in my hon. Friend’s area. The brilliant “time to change” campaign has done an awful lot to tackle stigma in mental health. We confirmed recently that the funding for that will continue in 2015-16. I accept that we need to do much more to improve access to children’s mental health services.

--- Later in debate ---

[Mr Jeremy Hunt]

I am very happy to pay tribute to Eilish Hoole, to the many cancer campaigners and to the many people who have survived cancer and put their lives back together again. There is still a huge job to do in getting earlier diagnosis. I think there is agreement across the House about the need for much earlier cancer diagnosis, particularly for ovarian cancer, which makes a huge difference. I know that we would all like to pay tribute to her work.

[Tim Farron (Westmorland and Lonsdale) (LD)]

NHS England has identified south Cumbria as one of just three places in England where travel times to receive radiotherapy are unacceptably and debilitatingly long. Will the Secretary of State meet me and NHS England to talk about how Kendal hospital can be the place for a new radiotherapy centre this autumn?

[Jane Ellison]

I would be happy to meet the hon. Gentleman and discuss this important issue for his constituents.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 1st April 2014 Commons Chamber

[Norman Lamb]

I understand the issue that the hon. Gentleman is raising. If he wants to discuss it further with me, I shall be happy to meet him. Clearly, local opinion and the making of decisions locally are what our reforms are all about.

[Tim Farron (Westmorland and Lonsdale) (LD)]

Rural surgeries such as Ambleside, Coniston and Hawkshead in my constituency are under threat because of a combination of historical funding difficulties and the removal of the minimum practice income guarantee. Will the Minister agree to look into the setting up of a strategic small surgeries fund, so that rural surgeries have a confident future?

[Dr Poulter]

My hon. Friend and I have discussed the issue before. As he is aware, price premiums are already built into the funding formula to support rural practices. NHS England has already identified about 100 practices that may need additional and special support. Commissioners will be looking to provide that and work with those rural practices and others that may have challenges.

Minimum Practice Income Guarantee

Tim Farron Excerpts

Wednesday 26th March 2014 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is a huge pleasure to serve under your chairmanship, Sir Roger. I am extremely grateful for the opportunity to raise the problems caused by the removal of the minimum practice income guarantee. The removal of the minimum practice income guarantee is not the sole cause of the crisis facing some of England’s rural surgeries, but it has unveiled the failure over several decades to provide a sustainable basis for funding GP surgeries in rural communities. The coming crisis, which could have the unintended consequence of closing dozens of rural surgeries, will be immensely costly to our communities and to the taxpayer. Taking intelligent, targeted and swift action to prevent those closures will be extraordinarily cheap by comparison.

Over the past few months, I have been working with our communities in and around Hawkshead and Coniston in my constituency, whose surgeries are undoubtedly at risk. Last August, 500 local people filled the school hall at John Ruskin school in Coniston at a public meeting. Five hundred people is an impressive turnout in any community, but when we realise that the total number of patients listed at Coniston is just 900, we see how important the issue is. Those 500 people turned up because they know that it would be impossible for them reasonably to access another surgery, given how remote and isolated they are. My job today is to convince the Minister—I hope it will not take much doing—that my constituents are right and he should take action to help them. Let us be clear: unless a specific decision is taken to provide new and additional support for small rural surgeries, there will be a series of surgery closures that will be hugely damaging to our communities, harmful to patient safety, costly to the taxpayer and utterly embarrassing for Government.

In my constituency, two practices stand out as being in need of immediate aid from NHS England and the Department of Health: Coniston and Hawkshead, two communities in the central Lake district, which are about as remote as one can get in England. Both communities have a GP surgery, and both surgeries are at risk because of unsustainable funding. If you would care to have a look at your Ordnance Survey map of the Lake district, Sir Roger, you will see that if either of those surgeries were to close, the next nearest surgery would be on the other side of at least one lake, not to mention a couple of mountain ranges.

Across the country, there will, of course, be some small practices that should amalgamate with others, predominantly in urban areas where access and sparsity are not such an issue. The number of small rural GP surgeries, such as Coniston and Hawkshead, which are facing up to falling off the funding cliff is relatively small. At the last count, there were 36 in the whole country. Therefore, although intervention is vital, it is manageable and affordable. It is not a big problem to solve if we do it now, but it will become an enormous problem if it is not tackled. The evidence is clear that for that to happen, there will need to be strong and unmistakeable political leadership. In other words, Ministers must state unequivocally that they want NHS England to protect small, strategically vital GP surgeries, and that they expect a formal fund to be set up to make that happen—a small strategic surgeries fund—just as our Government have successfully done to protect small, strategically important schools in rural areas. It will cost little, but it will save a lot.

A couple of weeks ago, controversially, our Government fought to permit the Secretary of State to have the right to intervene in local trust matters when there is a patient safety issue. They were right to do so, because elected Governments should involve themselves to ensure that strategic priorities are met. Here is one such example. It is strategically vital that people in rural areas across the country, including Coniston and Hawkshead, have the same rights to access health care as anyone else.

[Dr Sarah Wollaston (Totnes) (Con)]

As somebody who has worked in a small rural community, where there are high levels of deprivation in an area of relative affluence, the difficulty is that many people cannot access transport to get to services in other locations. I agree with my hon. Friend that we must prioritise access in small rural communities and recognise the problems of rural poverty.

[Tim Farron]

I am grateful to my hon. Friend for making that strong and good point. What counts as poverty in rural areas is often very different from what counts as poverty in urban areas. It is poverty in terms not only of income but of access to services. The average age of my constituents is 10 years higher than the average age of the UK population, so isolation and lack of access to private transport, never mind public transport, make it physically impossible to access another service. That is why we need to intervene.

I have had many conversations with NHS England, our local area teams and the clinical commissioning group. In the nicest possible way, there is a sense that they are all seeking a lead from the top. They are all good people, but they seek direction from the top. To be fair, NHS England has identified some 90 GP surgeries as outliers—practices that will lose more than £3 a patient—and a further 200 or so that will lose more than £2 a patient. However, that process of identifying outliers does not tell us which practices will be sustainable and which will not. Crucially, although outliers have been identified, no resource has been identified to help to protect them. That is why the Government must take a lead and make it clear that surgeries such as Hawkshead and Coniston must be protected, and that funding must be set aside to ensure that they not only survive but thrive. I am concerned that many of the discussions and the media attention have focused around the minimum practice income guarantee when we should focus more directly on funding sustainable general practice in remote rural areas.

In south Lakeland there are vast differences in minimum practice income guarantee payments per patient. Coniston gets approximately £25 a patient, Hawkshead gets less than £1 a patient and Ambleside gets around £15 a patient. By comparison, Slaidburn in Lancashire receives £110 a patient, even though the Slaidburn practice is the same size as the one in Hawkshead. The proposed changes from April will begin to remove those differences. Arguably it is correct to do so, but it is not correct simply to leave it at that.

The process of removing the minimum practice income guarantee and redistributing the funds per capita is a staggeringly blunt instrument. It is the ultimate one-size-fits-all policy, which treats small rural practices the same as large urban ones. It is on a par with making the casual assumption that the local village shop will have the same business model as Tesco. Smaller practices do not have the economies of scale that larger practices do; for example, the core practice management costs are the same whether the practice has 1,000 patients or 5,000.

NHS England’s argument is that, because smaller surgeries are inefficient, they should merge with neighbouring practices to increase efficiency. That works in urban areas, where there are often multiple GP practices operating close together. In that case, it is safe and sensible to consider sharing resources more efficiently. In remote rural areas, however, it is not possible to achieve those savings without sacrificing patient safety. It is not possible physically to merge with a neighbouring practice if it is on the other side of a lake. Merging, say, Coniston and Hawkshead with a larger, more distant surgery in Ambleside or Ulverston will not change the fact that health care still needs to be provided in the heart of those communities.

The only way to get savings is by closing a surgery or downgrading the service significantly in one or more of the villages and asking the patients to travel to another one for their main GP service. That would, in fact, result in no savings at all. Consider the increased cost to the ambulance service, to the A and E units nearby—not that they are particularly nearby, by the way—and to social care that would be triggered by the removal of GP services from the heart of our community. The human costs of closure are immeasurable, but the financial costs are measurable. It would be extreme foolishness to let our surgeries close by accident.

NHS England suggests that the policy does not impact on large numbers of rural practices, and that a greater number of urban practices will lose out. It is correct: there are not a large number of rural surgeries at risk. However, the analysis ignores the fact that, for the rural surgeries, an alternative to the current service provision is simply not available. Patients cannot simply move to the neighbouring practice down the road, because there is no “down the road”.

The changes come on the back of an already diminishing level of income in general practice for small rural surgeries. Hawkshead’s 2013-14 income from the GP contract is down 5% on 2012-13, and that has absolutely nothing to do with the removal of the minimum practice income guarantee. We should therefore be careful not to allow the removal of the minimum practice income guarantee to mask the much wider problem of a lack of sustainable funding streams for a relatively small and very manageable number of rural surgeries.

NHS England states that the removal of the minimum practice income guarantee will be phased gradually over seven years, but only so much can be squeezed out of an ever-reducing funding stream. The core running costs of the premises cannot be cut, so all that is left to cut is staff. If the staff consists of barely a handful of committed professionals, all that is left to do is close.

Hawkshead is already at 50% of the national staffing average, which reflects its historical low level minimum practice income guarantee funding compared with similar practices. At the same time, the surgery has the highest patient satisfaction levels in the country. It is officially the best surgery in England, but, as things stand, its only options are to reduce service provision to a level that would never be tolerated in an urban area, or to close. I am sure that the Minister will agree that such unacceptable choices mean that we must intervene.

Unlike Coniston practice, Hawkshead will gain by a small amount through the proposed changes. However, it will be by only about £1,000 a year, when the historical funding shortfall is about £35,000 to £40,000. Coniston’s income will decline significantly—by around £25,000 to £30,000 a year—and, to put it mildly, both surgeries will be at severe risk.

The minimum practice income guarantee should be removed or phased out. That is not challenged by those of us in rural communities. The wide disparities between surgeries with significant minimum practice income guarantee grants and those that, like Hawkshead, get pretty much nothing, makes the case for us. Nevertheless, the removal of the minimum practice income guarantee provides an opportunity to ensure that, in the wider context of a fairer and more efficient funding model, there should also be an element in the formula that does what the minimum practice income guarantee was originally intended to do, only more efficiently, more effectively and less expensively.

A small strategic surgeries fund could cover the additional cost per patient of keeping the core expenses covered. As a basic need, Coniston must keep its current funding, and Hawkshead must rise to a similar level in order to sustain service provision. NHS England will argue that it has reverted responsibility for the decision-making process to local area teams. However, there is no ring-fenced funding to deal with the problem, so local area teams are limited in what they can do. Our local area team has given its support to ongoing service provision in Hawkshead and Coniston, and I am extremely grateful for that, but so far no additional funding has been identified to support the practices.

The Minister will know that strategic small surgery funds have been established in Scotland and Wales. They are ring-fenced at the centre to ensure that no surgery that needs to remain open is closed by accident. Rural communities in England suffer from poor funding in social care, secondary care and primary care. Far too often, people in areas such as Cumbria are forced to put up with services funded at a fraction of what is required in order to provide care equivalent to that on offer in urban areas.

It is understandable that civil servants in Whitehall and officials in NHS England should come up with funding mechanisms that, in the first instance, overlook the fact that it simply costs more money to provide equivalent care to rural communities. It may even be understandable that officials might be ignorant of the desperate social needs in rural communities caused by poverty, ageing populations and isolation. However, once those problems are made clear, it is not acceptable to shrug them off. Once we have brought them to national attention, it is imperative that we see action.

In summary, I want to make five quick points. First, a small number of small, rural surgeries in England are at risk, partly as a result of the removal of the minimum practice income guarantee. Secondly, Coniston and Hawkshead are two such surgeries, and there is no alternative to having a surgery in either of those communities that is either sensible or safe. Thirdly, rural communities have as much right to decent health care as anyone else. Fourthly, it will cost relatively little to come up with a strategic fund to protect those few dozen surgeries. Fifthly, such a fund will be created only if the Department of Health and NHS England agree that it must be, and then make it so.

My constituents deserve access to good local GP services as much as anyone in London, Birmingham or Manchester. Unless we tackle the problem I have outlined, my constituents will be put at unacceptable risk. On behalf of the people of south Lakeland, and all other rural communities, I ask for the Minister’s help in setting up a small strategic surgeries fund so that we can remove that risk.

--- Later in debate ---

[Dr Poulter]

Absolutely. As I have outlined, other parts of the formula recognises rural areas; they are already recognised in GP funding allocation. Therefore, on both counts, additional support is available for areas such as those described by my hon. Friend the Member for Westmorland and Lonsdale in his constituency, and indeed those in Totnes and in my own constituency. Rurality is already factored into GP contracts and funding for GP practices and health care.

What will happen with the money that is recycled and released from the MPIG is an important point. The money released by phasing out the MPIG will be reinvested into the basic payments made to all general medical services practices, which are based on the number of patients and key determinants of practice work load, such as the age and health needs of patients and the unavoidable costs of rurality.

Another factor that we all recognise—I know it is a factor in Totnes and, I believe, in Westmorland and Lonsdale—is that many older people choose to live in rural areas. Older people once used to retire to seaside towns, but they are increasingly retiring to predominantly rural areas. The changes and the freeing up of cash from the MPIG will benefit all practices. In the health care funding formula—not necessarily the GP funding formula, but how clinical commissioning groups allocations are allocated—there is a strong weighting for age which will bring broad benefit to rural areas, particularly those that have a high proportion of older people.

NHS England has been undertaking specific analysis of the withdrawal of the MPIG. Inevitably, a small number of practices will find themselves in more difficult circumstances. NHS England has been considering the small number of significant outlier practices, as my hon. Friend the Member for Westmorland and Lonsdale mentioned, for which alternative arrangements may need to be made to ensure that appropriate services are maintained for local patients. We appreciate that that is a matter of concern for some practices, and my hon. Friend has outlined concerns in his own constituency. That is why we have decided to take seven years to implement the change to the MPIG funding. Phasing in the changes over that period will allow the minority of practices that lose funding to adjust gradually to the reduction in payments.

NHS England has been looking carefully at how its area teams can support the practices that are most affected. It has invited practices that believe they will have problems as a result of the phasing out of the MPIG to raise that concern with their area team. In a small number of cases where there are exceptional underlying factors that necessitate additional funding, NHS England has asked its area teams to agree different arrangements to ensure that appropriate services for patients continue to be available. That includes looking at how services are funded.

Importantly, NHS England has suggested that practices with small list sizes could look at collaborating with other practices, for example through federating, networking or merging with nearby practices, to provide more cost-effective and better services for patients, a point I will come to in a moment. Practices can also identify other ways they could improve cost-efficiency, such as reviewing staffing structures, and they can review commissioning or contracting options.

[Tim Farron]

I am grateful to the Minister for that explanation. I simply want to point out that neither Hawkshead nor Coniston, despite both being put in an unsustainable financial situation in the future, technically count as outliers. Will he guarantee that NHS England will look at the sustainability of all surgeries, not just those that have lost the most from the withdrawal of the MPIG?

[Dr Poulter]

The answer is in exactly the point made by my hon. Friend in his speech: it is about local area teams working effectively with practices.

Let me provide my hon. Friend with an example of how collaboration between services and GP practices can work well, from not just a financial perspective but a patient care perspective. In Debenham, Otley and Grundisburgh in my constituency, all of which have important rural communities, there is a practice that works collaboratively and a practice that serves and looks after populations across a number of sites. That works well for local populations, because they have an accessible local GP service.

That practice model has also produced considerable economies of scale. It has allowed the practices to invest in additional services for the benefit of local patients. Where there are pressures caused by an ageing population and the complex needs of older patients, that has allowed more money to be freed up to focus resources appropriately. In some cases, it has also allowed greater flexibility in the use of the infrastructure—certainly, surgery buildings —to provide greater community benefits.

The model can work, and it is important that practices, even though they are small businesses, consider that they need to collaborate and work with neighbours, where possible—not to lose their independence or identity, but to make efficiencies where they can, so that more money can be directed into front-line patient care. That is part of the answer.

Providing a sustainable solution is about practices working well with their neighbours. Sometimes it might mean rebuilding relationships that have broken down in the past. We know that, with the best will in the world, we do not always get on well with our colleagues, although we all do our best to look after patients. Sometimes it is about practices setting aside past disagreements, working collaboratively for the benefit of patients and making efficiencies where possible.

[Tim Farron]

Of course, many surgeries will be able to find ways of surviving and thriving through different working arrangements. There will be some, however, that are essential and strategically vital for rural communities such as mine, which will have done everything they possibly can but cannot make ends meet. Will the Minister confirm that funding will be available through NHS England to support those surgeries?

[Dr Poulter]

That is a matter for area teams to look at. The first approach that area teams will take is to ask, “Where can we make efficiency savings that will mean there is more money for front-line patient care, such as IT, back-office services and administration costs?” Hospital providers have been doing well in reducing administration and freeing up money for patient care. Are there economies that can be gleaned through better procurement practices and surgeries working together?

That has got to be the first thing: surgeries looking to help themselves. Later on down the line, if everything else has been exhausted, the area team will have to make a decision about whether other mechanisms are in place to provide additional support.

I am confident that, with a funding formula that recognises rurality, and a funding formula for CCGs that particularly identifies the importance of an ageing population, we have a formula that will support rural practices into the future.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 22nd October 2013 Commons Chamber

[Dr Poulter]

The right hon. Gentleman has perhaps misunderstood the information imparted on that occasion. It is very clear that the allocation formula is now independently set and NHS England has primary responsibility for it. There is legitimate concern. There is a 10% deprivation weighting for some of the poorest communities in-built into that formula. It is also important that we recognise that demographics and an ageing population are putting pressure on a lot of CCG budgets, but these are matters for NHS England.

[Tim Farron (Westmorland and Lonsdale) (LD)]

As Morecambe Bay trust seeks to recover from its financial crisis, one of the options put forward by clinicians is for a new, acute hub hospital to be created south of Kendal to improve safety, access and financial efficiencies. It is bound to involve a capital cost to start off with. If the new hub hospital is the option chosen by clinicians, will my hon. Friend give it his backing politically and financially?

[Dr Poulter]

My hon. Friend will be aware that this is a matter for local commissioners to decide and it is not for Whitehall to impose solutions on them. There are issues and efficiencies that Morecambe Bay trust can drive by better managing its estate and reducing temporary staffing costs. The hospital and trust will, of course, want to look into those issues in improving their financial outlook and the quality of care they can provide for patients.

Health Services (North-West)

Tim Farron Excerpts

Thursday 11th July 2013 Commons Chamber

[Mr Speaker]

Order. I thank the Secretary of State for his courtesy. I know the right hon. Gentleman well, and I know that he would not seek for one moment to mislead the House. He was trying candidly to respond to the right hon. Member for Blackburn (Mr Straw). For the avoidance of doubt, let us be absolutely clear. I can quite accept that the Secretary of State requested, within the Government machine, permission to make a statement today. However, the House will wish to be aware that I myself was aware of the request to make a statement only this morning. Let us be clear about that.

[Tim Farron (Westmorland and Lonsdale) (LD)]

There is a strong clinical case for the concentration of vascular services in Cumbria and Lancashire at three sites, but is it not ludicrous that the three that have been chosen are so geographically located that one is virtually on the Scottish border, then there is a gap of almost 100 miles, and then there are two that are nine miles apart? Does not that leave south Cumbria and north Lancashire dangerously under-provided for? Given the current difficulties, shall we say, at Morecambe Bay, does not robbing Morecambe Bay of those skills and that expertise make a difficult situation potentially even worse?

[Mr Hunt]

I know that my hon. Friend has campaigned, rightly, to represent the concerns of his constituents about the extra travel that they will have to undertake. I would like to reassure him that we considered that issue very carefully. The Independent Reconfiguration Panel recognises that travel is a consideration, but also believes that for his constituents, even for the people who have to travel further, there will be better clinical outcomes for specialist vascular surgery. We are not talking about routine surgery, diagnosis or rehabilitation work but about conditions such as aneurysms and carotid artery disease which require specialist care. Patients can get much better help if that is concentrated in specialist centres.

As to why those particular centres were chosen, it was a genuinely difficult decision. There is a bigger concentration of population in the south of the region and there is also more social deprivation and more unmet need. I know it was a difficult decision, but it was decided that that would be best for the 2.8 million people in the area and also better for my hon. Friend’s constituents.

Care Quality Commission (Morecambe Bay Hospitals)

Tim Farron Excerpts

Wednesday 19th June 2013 Commons Chamber

[Mr Hunt]

First, may I say I agree with what the hon. Gentleman says, and commend him on his work with his constituents and local families who have suffered so terribly from what happened? He is absolutely right to say we have created a system that is a nightmare for families who identify problems, and the real problem is a lack of clarity as to where the buck stops: where the buck stops in terms of the decision to say that a hospital is safe or not safe, and where the buck stops in terms of sorting out a problem when it is identified. Those are the areas where we are putting through big changes this year, as a result of the Francis report.

I completely understand why the issue of whether there is a continuing cover-up is a concern. All I can say is that I have total confidence in the new leadership of the CQC. They are on the side of the public. They understand that the CQC’s job is to be the nation’s whistleblower-in-chief. They absolutely get that, but changing the culture in the broader NHS takes more than the appointment of two new individuals at the CQC; it takes a complete change in the leadership so that people on the front line always feel supported if they want to raise safety concerns. That is a much bigger job. I do not want to pretend that we are going to be able to solve it overnight, but that is the big change we have to make.

[Tim Farron (Westmorland and Lonsdale) (LD)]

My constituents can be forgiven for wondering whether, when the watchdog chooses to muzzle itself, it is time to put it to sleep. The report shows that the CQC discovered the truth about the deaths of babies at Furness General, but chose to suppress the truth, and to seek to subvert the Freedom of Information Act—and this morning I have asked the police to investigate that point.

Grieving families like the Titcombes deserve to know who made these decisions, so will the Secretary of State agree to ensure the removal of anonymity for those guilty of putting institutional convenience ahead of the lives of mothers and babies?

I completely agree with my right hon. Friend about backing those on the front line, but we have a culpable ex-chief executive of the trust on a £200,000 payout while the excellent nurses and doctors in the trust are struggling under immense pressure, so will he agree to work with me and all colleagues across Morecambe Bay to help the trust recover, which includes agreeing not to now demand that the trust make £25 million-worth of savings by March, as that would further threaten the pursuit of patient safety?

[Mr Hunt]

I agree with much of what my hon. Friend says. He is absolutely right that accountability for what went wrong is crucial in this. I know that the CQC wanted to publish the report in full today, including the names of the individuals involved, but was given legal advice that it would be against the law to do so. However, the CQC is keen to have maximum transparency as soon as possible and is looking into how it can make sure that happens. There should be no anonymity, no hiding place, no opportunity to get off scot-free for anyone at all who was responsible for this. This is the problem we have to address in the NHS: all too often, people are not held accountable for what went wrong. However, the system also bears responsibility. This is not just about bad apples and how we root them out more quickly; it is also about creating a system that brings out the best in people—that plays to the decent instincts that got people to join the NHS in the first place, rather than making them think that targets at any cost matter more than the care and dignity of the patients in their trust.