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.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 15th January 2013 Commons Chamber

[Mr Hunt]

We believe in the clinical networks, including the network for cardiovascular disease. We have increased the funding for those networks by 27%. However, we want them to include mental health and maternity services. We think that it would be wrong to do what the Labour party wants, which is to concentrate that funding on cardiovascular disease and cancer, and deprive of the clear benefits of such networks the 700,000 women who give birth on the NHS every year and the nearly 1 million people who will be diagnosed with dementia.

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

Given that the majority of vascular interventions are acute in nature, following trauma or cardiac episodes, is it not reckless for NHS Lancashire and NHS Cumbria to be talking about moving vascular services away from the Morecambe bay area, meaning that people from the south lakes and north Cumbria will have to travel as far as Preston, Blackburn or Carlisle to receive treatment? Will the Secretary of State meet me, other local MPs and local consultants to discuss how we can put the matter right for local people?

[Mr Hunt]

We are very keen to ensure that all reconfigurations of services have strong local, clinical support. We are making good progress in this area. There is always a trade-off between access, which I recognise is extremely important in a rural constituency such as the hon. Gentleman’s, and the centralisation of services, which sometimes leads to better clinical outcomes. I am happy to arrange for him to meet me or one of my colleagues to discuss his concerns in more detail.

Vascular Services (Wycombe Hospital)

Tim Farron Excerpts

Monday 14th January 2013 Commons Chamber

[Steve Baker]

My hon. Friend raises an important point about transport, which will be an issue for many of our constituents, not least because they will not have cars.

People in need of vascular care will include those with abdominal aortic aneurysms, a life-threatening weakness of the main artery that must be repaired, and those who have had strokes or mini-strokes—transient ischaemic attacks. After a stroke, drugs are administered immediately, but they need to be followed up with a procedure to clear the carotid artery, called a carotid endarterectomy or, mercifully, a CEA. Other people requiring care will include those with poor blood supply, including smokers and diabetics, who might endure serious complications that might even lead to amputation.

Wycombe hospital provides the full range of services. It is proposed to move them all to Oxford university hospitals on the basis that the present arrangements are “not sustainable”, but I have yet to see evidence that supports that assertion. Leaked documents suggest that Oxford provides worse outcomes and is struggling to be ready.

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

I am extremely grateful to my hon. Friend for giving way and congratulate him on securing the debate. Further to the point raised by my hon. Friend the Member for Lancaster and Fleetwood (Eric Ollerenshaw), in the north-west the number of units will go down from four to three. Folks in Morecambe bay will no longer be able to go to Lancaster but will have to go to Carlisle, Blackburn or Preston. Does my hon. Friend the Member for Wycombe (Steve Baker) agree that the majority of vascular surgery these days is not elective but acute, following road traffic trauma and incidents such as coronary emergencies? We are talking not about elective surgery but about acute emergency provision, so it is vital that the services are close at hand.

[Steve Baker]

My hon. Friend is possibly inviting me to stray beyond my expertise, but perhaps the Minister can deal with that point. The concern in Wycombe is about elective treatment of aneurysms, and particularly the treatment that goes with stroke services. The key concern is that it is an excellent service that will be degraded if it is moved to Oxford, according to the clinical evidence.

I am grateful to Dr Annet Gamell, chief clinical officer of the Chiltern clinical commissioning group. She has given me a clear explanation of the position in Buckinghamshire, which is that things are waiting on the outcome of the review in 2014. Once a new theatre is open at Oxford, it is proposed that all complex elective vascular surgery will go there. It is planned that outpatient and diagnostic services will remain at Wycombe. CEA services would be subject to review in 2014, and I understand from Dr Gammell that the group would support moving CEAs to Oxford only if results indicated that patients would benefit from it. The Chiltern clinical commissioning group would take into account the impact of such moves on other services. Dr Gammell points out that if it is agreed to transfer CEAs to Oxford, there would be another local consultation, but on the basis of recent experience it is not clear to me what end that consultation would serve. The decision would have been made and it is clear that there is vast momentum to take services in that direction, despite the clinical evidence.

The key performance indicators for the south central cardio-vascular network show that in the first two quarters of the 2012-13 reporting year, Wycombe performed 17 aneurysm repairs and Oxford 16. Wycombe carried out 31 carotid endarterectomies to Oxford’s 47. Almost half of patient records at Oxford did not provide the dates of patients’ symptoms. Eighty per cent. of CEA patients at Wycombe received the procedure within two weeks of referral. At Oxford, the figure was just 23%, although patients seem to have received their treatment within 48 hours of symptoms. At Wycombe, 58% of patients were treated within 48 hours. Oxford achieved a ratio of total vascular interventions to amputations of 4.55:1, whereas at Wycombe the ratio in the period was 8:1, which shows a considerably greater degree of success in maintaining people’s limbs in very difficult circumstances.

The clear clinical evidence in that period is that Wycombe outperforms Oxford, and it does so with fewer clinical staff. All this is not mentioned in the “Oxford University Hospitals Review of Phase 1 of the Centralisation of Vascular services”, which has been sent to me under cover of a letter dated 12 August from the chief executive of NHS Berkshire. It was among a number of documents leaked to me. The report describes the resignation of a vascular consultant, Mr Peter Rutter, following significant difficulties associated with the move from Wexham Park to Oxford. Those difficulties including antiquated theatre instruments, poor quality theatre lighting and patient safety issues.

Mr Rutter observed:

“Vascular surgery is not very important in Oxford and would take 5 years to bring up to standard.”

He also said that vascular had no champion at Oxford, which is confirmed in other documents. Other remarks in the review include, for example,

“Many outlying district general hospitals have better endovascular facilities”,

“Oxford is not a modern endovascular hospital”

and

“Oxford has no culture of multidisciplinary working”,

which is essential when vascular supports those other specialties. Furthermore,

“Little thought had been given to the effect on Interventional Radiology in DGHs”

and very worryingly, an

“Oxford senior surgeon threatened to make Bucks vascular surgeons redundant unless they toed the line.”

A comment in the review implies that Wycombe’s excellent interventional radiologists would join Oxford University Hospitals only if CEA and bypass surgery stayed at Wycombe, which has been rejected. Presumably, these valuable experts who make the excellent service possible will resign and go elsewhere.

In summarising, the review explains that the impression had been given that OUH had not properly thought through the implications of centralisation. In discussing theatre upgrades, it concludes that

“there remain concerns about the quality of lighting, ventilation, anaesthetic facilities and sterility.”

I am only a humble aerospace and software engineer, but it seems to me that these are fairly basic concerns. Despite all this, the review clearly states:

“It will not be possible for carotid surgery to remain in Wycombe as CE and CAS will not be commissioned from Wycombe beyond 2013.”

Surely this is a matter for the commissioners.

The reviewers are clear that it is not viable for Wycombe to keep carotid surgery and bypass, but they do not state the evidence for their assertion beyond the new status of vascular as its own specialty. Before making recommendations, the review says:

“OUH practices Vascular Surgery more like a DGH than an important Teaching Hospital. Several of the surrounding DGHs, currently being centralised into Oxford, probably provide a better endovascular service.

Vascular surgery at OUH seems to be safe but has not developed in the way that it has in other hospitals in the United Kingdom. It seems to be positioned about ten to fifteen years behind the best.”

Notwithstanding the evidence of superior performance at Wycombe and shortcomings at Oxford, the review insists that vascular services must transfer, ultimately on the basis that it is inevitable that vascular services will be co-located alongside Oxford’s major trauma unit. That is a blatant rejection of the principle that is constantly used to justify centralising services away: clear clinical evidence. All the time that Wycombe provides better care and the team can provide it sustainably, in its opinion, and while local commissioners are prepared to buy it, why surrender to Oxford’s desire to be the Thames valley super-hospital, whatever the cost to patients?

Any responsible Member would admit that the trend in health care is towards specialisation. When my hon. Friend the Member for Bracknell (Dr Lee) was describing his Thames valley super-hospital proposal in Marlow, he said that any politician who claimed that they could restore A and E to a district general hospital would be a liar. I am grateful that I have not fallen into that trap, but it illustrates a point. Politicians are accountable to their electorates and businesmen are accountable to their customers, but managers and clinicians in the NHS who follow rules and guidelines seem to account seriously only to one another and, significantly, to do so on the basis of who carries the greatest authority through prestige.

In the midst of all that, senior NHS executives keep circulating. Stewart George and Fred Hucker—irrespective of their individual merits—who chaired the Bucks and Oxfordshire PCTs, became joint chairmen of the cluster. Mr George is now moving to the CCG, and Mr Hucker to Buckinghamshire hospitals trust. A new era of openness, accountability and genuine public involvement seems unlikely, and continuity seems a dreary inevitability, but all that ought not to be.

Vascular services in the Thames valley appear to be not so much sleepwalking into disaster as positively driving towards it. Vascular services in Wycombe are not some ditch and gatepost operation to be salvaged by the great Oxford University hospitals, as Wycombe outperforms them with a smaller team. In this regard, it is the John Radcliffe that needs saving.

Let me ask the Minister some specific questions. Is the Chiltern CCG able to insist that it will purchase vascular surgery from the Bucks health care trust at Wycombe despite national guidelines? What are the roles and authority of the NHS Commissioning Board, the local health and wellbeing board and the south central vascular network? Crucially, has the elevation of vascular surgery out of general surgery and into a specialisation of its own led to such things as turf wars, demarcation disputes and office politics? What formal influence are locally elected representatives—councillors and MPs—supposed to have?

Wycombe has had its own hospital since 1875. The current hospital was not founded by the NHS; it was built in 1923 with donations from local people, which were mostly given in pennies, as a memorial to the men we lost in the great war. The public are therefore right to be incandescent with rage at changes that appear to be driven by remote sectional interests, not local patient care.

Recently, my right hon. Friend the Secretary of State said:

“I need to say this to all managers: you will be held responsible for the care in your establishments. You wouldn’t expect to keep your job if you lost control of your finances. Well don’t expect to keep it if you lose control of your care.”

What is needed is real accountability. Let us get health under the control of the people who pay for it and start by keeping vascular at Wycombe for all the time that that remains in patients’ best interests.

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

I congratulate my hon. Friend the Member for Wycombe (Steve Baker) on securing the debate and raising issues that are pertinent not only to his constituents but to those of my right hon. and learned Friend the Attorney-General, who has been sitting next to me on the Front Bench listening to the debate and who shares a number of my hon. Friend’s concerns.

Before I discuss the substantive points about Wycombe, I should address my hon. Friend’s point about failing management in the NHS. He is right that there is a tendency to recycle failing managers in the NHS, and I am sure that the House will return to that point when my right hon. Friend the Secretary of State responds to the concerns raised in the Mid Staffordshire inquiry, following the Department’s receipt of the report.

It is worth paying tribute to the dedicated health care workers in Wycombe and the surrounding areas of Buckinghamshire, because my hon. Friend has a number of excellent clinicians. He highlighted several local successes in delivering high-quality care through vascular surgery, and I know that there are good outcomes locally in specialties such as carotid endarterectomy. He has many excellent doctors and nurses and other front-line health care professionals, and also some very good managers, who have the best interests of their patients at heart and deliver high-quality health care outcomes for local patients on a daily basis, 365 days a year.

My hon. Friend rightly highlighted some local concerns about the ongoing loss of services at Wycombe hospital, and it is worth reiterating some of his words. He said that the hospital had lost A and E, consultant-led maternity—retaining a midwifery-led unit as a concession —and paediatrics, and this year the emergency medical centre was downgraded to a minor injuries unit, resulting in a repeat of much of the local outcry at the loss of A and E, and now he has highlighted eloquently the concerns over the potential loss of some of the vascular services at the hospital.

It is worth pointing out that I was reassured today before coming to the debate by local health care commissioners in the Wycombe area that there is a strong future for Wycombe hospital. There is no threat of the hospital being downgraded to the point of closure. Commissioners today reassured me—and I hope that this reassures my hon. Friend—that in many areas Wycombe provides a very good site further to develop health care services the better to meet the needs of the local population. It is an excellent satellite site, combined with Stoke Mandeville, for providing high-quality, close-to-home health care. From discussions that I have had, I believe that there may be the possibility of improving further some of the cardiac care that is offered.

I come specifically to the issues that my hon. Friend raised about vascular services, which are particularly important in Wycombe, which has a large Asian population, among whom, as we all know, there is a higher rate of cardiovascular disease. It has a higher rate of diabetes and many cardiovascular illnesses. My hon. Friend highlighted eloquently the number of local vascular services provided, and particularly referred to amputation services. We know that one of the complications of vascular disease and diabetes is the higher rates of amputation among some patients. It is quite right that he wants to make sure that high-quality services are provided locally to meet the established need for patients who require vascular services, and that those patients have a holistic service that looks not just at their immediate medical needs but provides high-quality surgical care.

We know that as lifestyles, society and medicine change, the NHS must continually adapt. The NHS has always had to respond to patients’ changing expectations and to advances in technology. When we do change and reconfigure services, it must be about modernising facilities and improving the delivery of high-quality patient care. In that context, it is also important that while we have to recognise that some services are better provided in larger centres of care— for example, the John Radcliffe centre, which can offer super-specialist services—where the clinical outcomes for patients are better, we must also provide high-quality local services, particularly for older people. We know that the majority of vascular patients often fall into an older age demographic, and it is important that when there is any service reconfiguration, those day-to-day outpatient clinics for vascular patients are maintained locally. I am reassured that in the potential reconfiguration, bread-and-butter outpatient clinics and continuity of care for vascular patients will be maintained.

The Government are also clear that the reconfiguration of front-line health services is a matter for the local NHS. Services should be tailored to meet the needs of local people, and the four tests laid down in 2010 by the previous Secretary of State for Health, my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), require that local reconfiguration plans demonstrate support from GP commissioners, strengthened public and patient engagement, clarity on the clinical evidence base and support for patient choice. If my hon. Friend is worried that these tests have not been met in the local reconfiguration, he has the opportunity directly to challenge them or to ask the local health scrutiny committee to refer them to the Secretary of State for review.

[Tim Farron]

The Minister rightly says that the NHS reforms allow local councillors to vote to refer such matters to Ministers. In my area of Morecambe bay, that opportunity comes on 22 January. Will he assure councillors that Ministers will take such referrals very seriously and look into them with great rigour?

[Dr Poulter]

Yes. I assure my hon. Friend that when a referral is made by a local overview and scrutiny panel the Secretary of State will look at it and decide whether to refer it to the independent reconfiguration panel. That is often the decision that is made in these cases, but it lies initially with the Secretary of State, who will then have to consider whether to refer it. I am happy to write to my hon. Friend further to outline these steps if that would be helpful.

It is worth highlighting the national parameters that are being set for the delivery of good vascular surgery by the NHS Commissioning Board, which takes over full responsibility for commissioning from April this year. The board published a draft national service specification for vascular surgery for consultation. The consultation commenced in December 2012 and will conclude on 25 January 2013. It identifies the service model, work force and infrastructure required of a vascular centre. It says:

“There are two service models emerging which enable sustainable delivery of the required infrastructure, patient volumes, and improved clinical outcomes. Both models are based on the concept of a network of providers working together to deliver comprehensive patient care pathways centralising where necessary and continuing to provide some services in local settings…One provider network model has only two levels of care: all elective and emergency arterial vascular care centralised in a single centre with outpatient assessment, diagnostics and vascular consultations undertaken in the centre and local hospitals.

The alternative network model has three levels of care: all elective and emergency arterial care provided in a single centre linked to some neighbouring hospitals which would provide non arterial vascular care and with outpatient assessment, diagnostics and vascular consultations undertaken in these and other local hospitals. All Trusts that provide a vascular service must belong to a vascular provider network.”

In essence, this is about making sure that we deliver high-quality vascular care. There are two or three circumstances in which someone would require vascular care. First, there is emergency care—for example, when there is a road traffic accident, or when someone has a leaking aortic aneurysm, which is a very severe and potentially life-threatening emergency. We know from medical data that such service provided in an emergency is much better provided in a specialist centre—an acute setting such as the John Radcliffe, which would be the hub and the central focus. There is also good evidence that trauma care in any setting, including the requirement for neurological specialists potentially to be involved, is better served in a specialist trauma centre. A specialist centre provides better care in emergencies.

At the same time, it is clear from those models that there can also be a strong role for other hospitals as satellites of the central hub at the John Radcliffe. My hon. Friend clearly made the case for the high-quality outcomes at Wycombe hospital for carotid endarterectomies and other vascular services. I would suggest that there is a role for challenging local commissioners if they wished to remove some elective procedures from Wycombe when there is a case that they can still be delivered in a high-quality manner and to a good standard for patients.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 27th November 2012 Commons Chamber

[Dr Poulter]

We have already highlighted in earlier answers the fact that under the previous Government health care rationing was far worse on varicose veins, which one of the right hon. Gentleman’s own Back Benchers mentioned, and elsewhere. This Government are very proud of our record whereby 60,000 fewer patients are waiting more than 18 weeks than under the previous Government and 16,000 fewer patients than in May 2010 are waiting longer than a year. Waiting times are coming down, infection rates in hospitals are coming down, and people are getting better care. This Government ended the worst health care rationing scandal of all—the fact that people with cancer were not getting access to the drugs they needed. Now, 23,000 people are getting access to that care. If he could not do anything about rationing, he should at least recognise that this Government have done something and have made a real difference to people’s lives, particularly patients with cancer, by reducing rationing.

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

Those of us who live in rural areas such as south Cumbria have faced the rationing of acute services for years—not rationing by price, but rationing by distance. Will the Minister encourage Morecambe Bay, which will undertake its review of the allocation of services in the coming months, to allocate accident and emergency services back to Westmorland general hospital, where they would be closer to the people whose lives they could save?

[Dr Poulter]

As my hon. Friend is aware, from next year the NHS Commissioning Board will have responsibility for commissioning local services and for setting the funding formula. I would be happy to raise his issue with the board, because it is true that, historically, the capitation formula has not recognised the fact that there are a lot of older people in rural areas and further distances to travel. The previous Secretary of State, my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), took steps towards reviewing the formula and I assure my hon. Friend that the Government will be looking into it further.