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Health Services (Gloucestershire)

Volume 447: debated on Monday 12 June 2006

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Michael Foster.]

Mr. Laurence Robertson (Tewkesbury) (Con): I rather regret the need for this debate, but having said that, I am pleased to have secured it and thank the Minister for attending. I want to set out the picture regarding health services in Gloucestershire and seek clarification from the Minister on a number of issues.

There are three primary care trusts in Gloucestershire and one hospital trust. Cheltenham and Tewkesbury primary care trust, which covers most, but not all, of my constituency, is in surplus, but other trusts have been in deficit. The result is that across the county, there are some £40 million-worth of deficits. All the trusts together are proposing cuts in health services amounting to some £30 million, as things stand.

There is of course great opposition in Gloucestershire to this proposal. I have a petition with more than 2,200 names on it, which I hope to present to the House in the next few days. That constitutes a high percentage of the population affected. Indeed, there have been rallies and marches across Gloucestershire. My hon. Friend the Member for Forest of Dean (Mr. Harper), who cannot be here tonight, initiated a debate in the Chamber on 25 May, and he has been very active in opposing the cuts. Indeed, there is united opposition to them throughout the House. Members from the Conservative and Liberal Democrat parties, and from the Government party, will seek to catch your eye to contribute to the debate, Mr. Deputy Speaker, and it might be helpful if I confirm that they have approached me to ask for permission to do so.

I should say at the outset that we of course have no disagreement with organisations balancing their books; every organisation must do that. Also, no one is going to accuse the Government of having cut spending on the health service, as that is not the case, so I hope that the Minister will not defend the Government against charges that I am not going to make.

I turn first to my main, particular and most immediate concern—I shall come on to others shortly—which is the proposal to close Winchcombe hospital. It was built in 1928, with a lot of the funding provided by local people and benefactors. It provides a caring and comfortable convalescence for people, especially older people, recovering from operations or other treatment. It also provides a very helpful minor injuries unit in a rural area where public transport is not particularly useful.

The White Paper on community hospitals issued some while ago made it clear that community hospitals should not close

“in response to short-term budgetary pressures.”

Sensibly, it recognised the value of, and need for, such hospitals—as, indeed, do I. I was recently treated at Tewkesbury community hospital within five minutes of having had a rather nasty car accident. The staff were excellent, and I pay tribute to them, and place on the record my thanks to them. The alternative to that treatment would have been a long car journey and delayed treatment, thereby putting additional pressure on staff at, say, Cheltenham or Gloucester hospital. So although the White Paper opposes such closures, that is exactly what is being proposed in Gloucestershire.

People in Winchcombe are united in total opposition to the proposed closure of their hospital; they value it and they need its services. If it closes, they, too, will have to go to Cheltenham or Gloucester for immediate treatment, and those who are currently being treated or operated on in one of those hospitals will, presumably, have to be sent home early if Winchcombe hospital closes.

I acknowledge that there is a debate going on about how long people should stay in hospital, and I accept that nowadays, some people can go home earlier than they might have done in the past. Often, home is the best place for people to recover, but not always. A while ago, my daughter was sent home from hospital after a major operation the very next day, even though she had no one to look after her and had two children to look after herself. That is unacceptable these days, but if we close hospitals and reduce bed numbers, it will become common practice, which I would greatly regret.

Have the people who make these decisions considered the knock-on costs—to social services, for example? Have they calculated when people need help at home? In the light of meetings that I and others have had with Gloucestershire county council, which would have to provide many such services, it appears that those knock-on services have not been costed. According to the local primary care trust, they have not been costed. Its director of finance said today, when asked about the future alternative proposals:

“we have not calculated detailed costs yet.”

How does it know that the books will balance even after the cuts have been made, if those cuts have not been thoroughly thought through or properly costed? What that director did confirm was that closing the hospital will save only an estimated £240,000 a year. How can that be right? How can that make financial, let alone clinical, sense?

I am also concerned by the lack of joined-up thinking about the knock-on costs, and generally. For example, just recently the doctor’s surgery in Winchcombe closed, and it was proposed that another one be built outside the centre. Why was no consideration given to moving the surgery to the hospital, and expanding the services available there instead of cutting them? The surgery would have remained in the centre of the town, where many old people live, and there would have been no need to build another one.

If the hospital is not needed, why are local health chiefs considering buying in several beds, for the very purpose of convalescence? We already have 22 beds at Winchcombe hospital, so why lose them and buy in beds from elsewhere? I totally oppose the proposal to close the hospital, but other cuts across the county also worry me.

For example, Delancey hospital, which is just outside my constituency and in that of my hon. Friend the Member for Cotswold (Mr. Clifton-Brown), is also proposed for closure, but it provides a good service. St. Paul’s maternity wing in Cheltenham general hospital was opened just 10 years ago at a cost of £6 million, and that is proposed for closure. The overnight facilities at Battledown children’s ward, also in Cheltenham hospital, will be closed, and other hospitals in neighbouring constituencies are closing. Mental health units are being proposed for closure, and further cuts are being “considered”, but are not confirmed yet.

All that represents short-term thinking. Where will it end? The proposed closure of those and other services is extremely worrying. Why are we having those cuts at all, and whose fault are they? People are taking a stand not only because of the present proposals, but the further ones that they fear. We are not a third world country—we are supposed to be the fourth largest economy in the world—so why do we face those cuts? Are we not entitled to expect enhanced, more efficient health services, not just services cobbled together to match the particular budgetary pressures at the time?

On 6 April 2005, the Prime Minister said from the Dispatch Box:

“It is correct that we raised national insurance to pay for extra investment in the national health service.”—[Official Report, 6 April 2005; Vol. 432, c. 1409.]

My constituents have paid the extra tax, but where is the money going? All they are seeing is cuts. Yes, they are getting vague promises from local health chiefs about better provision being on the way, and that health care will be provided in a different way in future. Well, we will believe it when we see it. If there is a better way to treat patients, why was not that way pursued before? Why does it take budgetary pressure to force decision-makers to follow the correct clinical path?

Who is to blame? It is an interesting question. No doubt the Government have increased funding, but have they increased their requirements from trusts to the extent that the extra money has been swallowed up in extra costs? Or have the local health chiefs mismanaged the extra expenditure? I would like the Minister to give me her view of Gloucestershire, because I do not necessarily blame the Government. I want to explore tonight exactly where the fault lies. Who is to blame for the deficits? What is the Minister’s view? How do we sort the deficits out? It could be done by closing front-line services and making patients suffer, but it could also be done more sensibly, given a little more time.

The question that I would most like the Minister to answer—it is a crucial question that has been raised before—is about the balancing of the budget. The local trusts claim that they have to balance their books for the whole of this financial year, including making up historic deficits within this financial year. I quote from their consultation document published just today:

“PCTs have to achieve in-year balance and recover 2005-6 deficits”.

They say that they have been told, unequivocally, that they have to do that. They told hon. Members that that was the case just last Friday. However, the Secretary of State, in a letter to my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), said that trusts would be expected to make improvements this year and achieve month-by-month balance by the end of the financial year. That is quite a different thing.

In a statement last week, the Secretary of State said again:

“We are aiming for all organisations with deficits to reach monthly balance of income and expenditure by the beginning of April next year.”

She went on to say that in some cases, the worst ones will be allowed even more leniency. Who is right? Do the trusts have to achieve total balance for the year, including historic deficits, or do they have to achieve monthly balance by the end of this year? Because if the Secretary of State is right, the consultation paper in Gloucestershire has been launched on a false, even dishonest, premise.

The hon. Gentleman knows my position on this issue, but an answer to his question would greatly help the strategic health authority. When I saw Trevor Jones, the chief executive, 10 days ago he made it clear that if the strategic health authority was given guidance that the aim was a month-by-month balance, it would change its interpretation of the strategic framework. It is vital that my hon. Friend the Minister provides some guidance, because we may be working on false premises.

I am grateful to the hon. Gentleman, and I know that he shares my concerns. He makes the point well: the strategic health authority is in touch with the primary care trust and providing instructions—I nearly said guidance—but we do not know whether they are correct. If we go by what the Secretary of State says—and that is in writing—the SHA’s interpretation is wide of the mark. I hope that the Minister will clarify the situation. I reiterate that the trusts should balance their books, but how long have they been given to do it? If it can be done over a slightly longer period, the cuts might not be necessary.

I wish to make a further point about top-slicing. The PCT covering most of my area in Cheltenham and Tewkesbury was actually in surplus last year. However, it is cutting front-line services to help to balance the books of others. That, it seems, is the penalty for achieving better financial management. As if that were not bad enough, the Government are forcing the Gloucestershire trusts to bail out the others under the same SHA to tune of more than £6 million.

In her statement last week, the Secretary of State said that

“that money will not be lost to those communities. It will be repaid, normally in the three-year allocations period.”

However, she went on to say:

“I have stressed to the health authorities that the areas with the greatest health needs should be repaid first”.—[Official Report, 7 June 2006; Vol. 447, c. 254.]

So Gloucestershire will actually lose that money, and if the hospitals are closed anyway they are not likely to re-open within that three-year period.

Does the hon. Gentleman agree that there is added nonsense in the concept of repayment in that particular case, of which the Minister may not be aware? For Cheltenham and Tewkesbury PCT to ask for the money to be repaid to it by Cotswold and Vale is a nonsense, because the two will merge in any case. So the money lost to Cheltenham and Tewkesbury will never be repaid.

Indeed, this becomes more complicated because the three trusts are merging into one. I am not making a point about one area against another, and west Gloucestershire makes up a large part of my constituency. However, it does appear that good financial management is being penalised by that top-slicing.

In fact, Gloucestershire loses out in the first place when it comes to funding. We receive only 88 per cent. of national average funding. That is supposed to be because we are healthier, but—as local health chiefs point out—healthy people live longer, and older people cost the NHS even more money. So where is the joined-up thinking in that particular philosophy? Where is the joined-up thinking about the NHS generally?

To follow up the point made by the hon. Member for Cheltenham (Martin Horwood), I should explain that when I was elected in 1997 there was one Gloucestershire health authority. At present there are three PCTs, but there is a proposal to revert to one; in other words, we are to go back to exactly where we were nine years ago, except that there is now another tier of bureaucracy—the pointless strategic health authority, which costs more than £5 million a year to run. Even that is being tinkered with, because it will cover a different area. The situation is ridiculous. A number of PCTs and hospital trusts, under a single SHA, are making far-reaching decisions. Those PCTs will not exist come October, and the SHA will not exist in its present form by the end of the summer, yet massive cuts are being planned by people who probably will not be in post to carry them out—or to carry the can for them.

I referred earlier to the consultation document published by the health chiefs today. They wanted a consultation period of only five weeks, but Members and some members of Gloucestershire county council managed to exert enough pressure to get the deadline extended to 12 weeks. That is still not a long time, but, farcically, it takes us to the point when the people making the proposals might all be seeking alternative employment. At the end of the consultation period, none of them might be in post, such is the nonsense of the situation.

As well as containing dubious phrases such as the one I quoted earlier, the document insults the intelligence of the people of Gloucestershire. Among other “motherhood and apple pie” questions, it asks:

“Do you think that helping people to stay fit and well is an important principle?”

For goodness sake, what kind of smokescreen, what kind of sham, is this public consultation exercise? Will the people be listened to or will their views be ignored, as they normally are?

There is an unhappy situation in Gloucestershire. We are paying more tax to fund the NHS, yet we are losing our hospitals. The Government are piling billions of pounds into the NHS, yet a quarter of the country’s PCTs are in deficit. Local health chiefs say that they have to balance the books within the current financial year, yet the Government say that they have to achieve a monthly balance. The Government claim that they are reforming the NHS, but in truth they are merely tinkering with its structures. The net result is that the people of Gloucestershire, especially older people, children, poorer people, the pregnant and the mentally ill—in other words, the vulnerable—all lose out.

As I said at the beginning of the debate, I do not seek to blame the Government; I am trying to bring home to the Minister the strength of opposition in Gloucestershire to the proposals being made across the county. Will she clarify exactly what she is asking trusts to achieve financially this year? If she only does that we shall have made some progress, but otherwise the most vulnerable and the most in need will lose out.

I congratulate the hon. Member for Tewkesbury (Mr. Robertson) on initiating the debate. This is the fourth such debate in which I have taken part over the last month: two of them were about health in Gloucestershire, the others were about maternity provision and community hospitals, which relate directly to my area, where I face the prospect of losing both.

Like the hon. Member for Cotswold (Mr. Clifton-Brown), I took part in the rally in Stroud on Saturday—I mentioned it to the Minister before we came into the Chamber. It is estimated that about 4,000 people were at the rally, at which both the hon. Member for Cotswold and I were able to speak. There was immense feeling about the proposals and I said that I would echo it in the Chamber—it could certainly have been heard at Westminster.

Earlier today, I took part in a meeting of the overview and scrutiny committee organised by the county council, which included representatives from the district councils. I have come straight from that meeting, which is why my brow is more furrowed than normal, and I want to raise with the Minister some points about the consultation on partnership trusts. As the hon. Member for Tewkesbury said, although we managed to extend the PCT consultation so that it takes place over 12 weeks, the consultation period for the partnership trusts—the mental health and learning disability trusts in Gloucestershire—will finish on 23 June, which is a mere five weeks. Without putting words into the mouth of the overview and scrutiny committee, it is fair to say that it is looking carefully into the discontinuity between the PCT consultation, which has yet to start formally, and the consultation on partnership trusts, which has reached the mid-way point, if not the final stage. I hope that the Minister will comment on that, as the situation does not make much sense; another £12 million has yet to be found from the PCTs and, given what they could later demand, that could have an enormous impact on the partnership trusts.

The hon. Gentleman raises an important point, because there is no reason at all for the dissimilarity—for the general consultation to take 12 weeks and the consultation on mental health partnerships to take only five weeks. The overview and scrutiny process for mental health partnerships should be just as long because the mentally ill need more time to adjust to the changes that will be brought on them and those making representations on their behalf need more time to make their case.

I agree and make no apology for concentrating on that point, because that is the most urgent consultation. On Saturday, the hon. Gentleman heard a lady make a most emotional speech about the implication of the proposals for her nearest and dearest. People feel very let down because they have been given almost no time or opportunity to make their case.

The Chamber heard the request of the hon. Member for Tewkesbury that the Minister clarify whether we are talking about a month-on-month balance or historical deficits that have to be cleared in a matter of months. We need an explanation, because that is the nub of the problem we face in Gloucestershire.

There is a second problem and I make no apology for continuing to labour the point, because it is important: the relationship between Gloucestershire and its partners in the SHA. It is hardly acerbic to note that Gloucestershire feels let down by the fact that it happens to be in a strategic health authority, other parts of which have run up large deficits over a period of time. The hon. Member for Tewkesbury made several points about why that should not have been allowed to happen, but it has been allowed to happen. As a result, according to the operating framework that the SHA is passing down on tablets of stone, Avon, Gloucestershire and Wiltshire SHA is being asked to reduce its turnover by 5.3 per cent., against a national average of 3.4 per cent. That may not sound much, but there is still a problem. Some trusts in Gloucestershire have been in balance or close to balance, although it is true that Cotswold and Vale PCT, which is my PCT and that of the hon. Member for Cotswold, has been a problem for a long time, but that problem does not extend to other parts of the SHA. We are being asked to provide ballast across an area for considerable problems in the past. We know that, because about £175 million from the NHS bank has gone elsewhere into other parts of the SHA, not a penny of which was ever put into Gloucestershire, even though Cotswold and Vale has had its own problems. I ask the Minister for a commitment that we shall get some real figures—disaggregation of the figures—for the entire SHA, even in breaking it down within primary care trusts so that we know where the money has been spent as well as where the cuts are being levelled. It is vital that we know where the real money has gone and how that money can be accounted for.

I have one request from the overview and scrutiny committee, which I will put to the Minister. It wrote some seven weeks ago to the Secretary of State seeking clarification on budgetary issues. That was mainly in terms of the month-on-month balance. It has yet to receive a response from the Secretary of State. The committee seeks clarity and it wants to see the Secretary of State. I pass on to my hon. Friend the Minister that urgent request. The committee is now mid-way through the first of its consultations. Yet it could be labouring under a great misapprehension, as the hon. Member for Cotswold rightly said. The committee could be being asked to make a decision on something that is a false premise. There should be quick clarification.

I will concentrate rather more on the partnership trust, the mental health and learning disability trust in Gloucestershire, which is mid-way through its existing consultation. What is the trust being asked to save? I have already said that the national average is 3.4 per cent. in turnover. The SHA is asking us to save 5.3 per cent. in turnover. The partnership trust is being asked to save 12.8 per cent., which is £9.6 million, of its planned expenditure. I do not know whether that means one and the same as turnover. However, I take it to be that an even greater amount of savings is required of the partnership trust than anything else that is being required within Gloucestershire, and maybe within the entire SHA.

As the hon. Member for Cotswold said clearly, about 36 per cent. of older people’s services for mental health and learning disabilities are to be cut. That is a huge reduction in expenditure. It is all driven by the mad idea that we have to come into balance. I do not know where the figures come from for the partnership trust. That is given the historic overspend, which I did not know was there until suddenly it appeared, and the deficit that is coming this year. I do know where the £2.2 million comes from, which is the contribution to the NHS recovery programme. That seems so unfair given the other cuts that have to be made.

It would help me and other Gloucestershire Members who are in their places this evening to know exactly where the figures come from and why a small trust—a specialist trust—is being asked to make a disproportionate contribution in trying to come back into balance. This makes a big difference to my constituency because of the potential changes at Weavers Croft. It is not likely that Weavers Croft will close completely but it will lose its beds. We do not know the impact of the beds that were brought across from Bourton ward in Cirencester, in the constituency of the hon. Member for Cotswold. As far as I know, that has never been evaluated given the impact that that had when we had some 120 beds for older people’s services. We now intend to cut the number to 65 if the proposals are adhered to.

I move on to the Tyndale centre in Dursley in my constituency, where we have already lost day centre provision. That has been lost also at Weavers Croft. There must be questions about whether those facilities will ever be picked up and from where they will be run. As was rightly said by the hon. Member for Tewkesbury, we must focus on the impact, which will be dramatic on social services. I heard the social services committee make a presentation to the overview and scrutiny committee. I was not clear whether anyone has undertaken a detailed impact analysis of the changes that are being proposed. If that has not been undertaken, somebody should see that it is. In this place, we would never allow the nature of proposals to be given superficial treatment, which is what they appear to be receiving. That is not a criticism of the overview and scrutiny committee because it is saying that it has unclear and scanty information about the different proposals.

The organisations in the voluntary sector need to be brought into the process. Underneath the radar, as well as the institutions that are much loved and being fought over, many other changes are being proposed. For example, it is proposed that there should be a 50 per cent. further cut in the passenger transport service. In Gloucestershire, if someone does not have a car they have no quality of life. If someone does not have a car and he or she is ill, it is unclear how they can get to the necessary services. The local newspaper—I refer again to the lady who spoke on Saturday—ran a particular campaign to try to get her to Cheltenham. Visiting took two hours and the situation was difficult for her. Is that something that people can and should be asked to do?

I could go on much longer about the impact on maternity provision. There will be future debates in this place and I have no doubt that, if we do not get satisfaction, we shall go on to examine some of the other service provision, such as the community hospital closure programme, including the Berkeley hospital, which will not save any money because the idea is to move Berkeley up to the Cam and Dursley area. In some instances that makes sense because that is where the larger population is. However, I am not in the mood to agree to a cut in provision when we have no money, apparently, to re-provide a better service anywhere. It would be daft for any Member to say, “I can see that that will be a good move.” We are being asked to make dramatic cuts without any possibility of new investment coming into the county. It would be ludicrous to go along with the proposal unless we have some clarity on what needs to be done.

I ask my hon. Friend the Minister to provide clarity so that we can nail tonight what we mean by coming into balance. We must examine the particular problems of the strategic health authority. These are matters that are serious to Gloucestershire. We feel unfairly treated because of the nature of the SHA with which we unfortunately happen be placed. We need clarity also about the series of consultations that are being held so that we understand more about the impact analysis. That is clearly not happening at present. That is all to do with the speed at which the changes are being driven through. The direction may be right, but we need to separate the direction from the financial imposition. We certainly need to separate it from the speed at which people are being asked to make drastic decisions that have an impact on the young and the old and everyone else who is either a carer or someone who really cares for the facilities in question.

I hope that my hon. Friend the Minister has listened to these difficulties. She will hear about them from hon. Members on both sides of the House. I hope that she will realise also that this is not a party political issue. All the parties are united in Gloucestershire. We need some help, otherwise we will see services lost that have been in place for a generation and more, and for no purpose whatsoever.

I congratulate my hon. Friend the Member for Tewkesbury (Mr. Robertson) on securing this important debate. As my parliamentary neighbour, the hon. Member for Stroud (Mr. Drew) has said, there is all-party agreement and all-party concern among the people of Gloucestershire about the effect that this financial crisis is having on us. I must declare an interest, in that my wife works for Cheltenham and Gloucester primary care trust. Her job is at risk along with everyone else’s. I am certainly not pleading on her behalf this evening.

Why are we here? Are we here to complain about less money for healthier, wealthier areas? No, I am not. I accept the principle that health service funds have to be targeted and that that may mean that areas such as Gloucestershire receive less funds per capita under some circumstances than areas of greater overall deprivation. However, one of the problems with the cuts and the savings proposals that are being imposed on Gloucestershire is that even in towns that may be prosperous as a whole, such as Cheltenham, there are areas of deprivation. It is the most vulnerable and poorest people in those towns who are being hit hardest, because they are the people without transport. They are the people who find it difficult to access services in other towns.

Are we here to blame local NHS managers? That is what the Under-Secretary of State for Culture, Media and Sport, the hon. Member for Tottenham (Mr. Lammy), said on “Newsnight” last week. He was asked whether local NHS managers were to blame and he said, “Yes.” But surely that cannot be true. As neighbouring Members have said, in Cheltenham and Tewkesbury in particular, we have a partnership trust with three stars that was about to be in the first wave of foundation trusts; Gloucestershire Hospitals NHS Trust, which is a low-cost provider of health care by national standards and is very efficient; and, above all, Cheltenham and Tewkesbury primary care trust, which has never been in deficit and this year posted a £1.2 million surplus. Our NHS managers have done everything right. They have done everything that the Government asked of them. The primary care trust was described in The Daily Telegraph, which I do not often read, but which I am sympathetic to today—as arguably “the perfect PCT” that has done everything that the Government asked.

Are we discussing how patient care is improving everywhere, as the Secretary of State told the House last week? Well, no, that cannot be true either, although I will prevent the Minister from having to recite the usual things about additional investment in the NHS by saying that I am pleased that there has been additional investment in the NHS. I recognise that, and my party welcomed and supported additional investment in the NHS. We acknowledge the real improvements in health services that have taken place, including the reduction in waiting lists. However, that is not the issue today. The way in which the Government have gone about delivering that spending has led to breathtaking inconsistencies and results that I am sure that they did not intend, but which are proving devastating for our local NHS. We have overspending on things such as the GP contract, the consultant contract and the new out-of-hours service, and even on worthy initiatives such as NHS Direct, which I understand has gone massively over budget.

We have the nonsense of consultants being flown in to Cheltenham general hospital from Germany and France to meet Government waiting list targets at enormous expense at a time when we are facing cuts in front-line services. Initiative after initiative and target after target are being imposed on local managers to the point where it is impossible for people to keep track. Let us think about the simultaneous initiatives that are going on at the moment: payment by results, patient choice, agenda for change, practice-based commissioning, the change to the trusts’ funding tariff, the change to funding NHS dentistry, the reorganisation of the strategic health authorities, and the reorganisation of the primary care trusts, which means that the very managers who are supposed to be coping with all this change and coping with the cuts in front-line services are in the process of having to be made redundant and applying for new jobs themselves. It is little surprise that the overall sense is of panic and confusion and that, as the hon. Member for Stroud pointed out, there is a real misunderstanding of exactly which numbers are which and whether savings have to be made month by month, or whether we are talking about clearing all the financial deficits in one year, which is the line that has been fed down to local managers, as they understand it.

Then we have the political decision—in effect, the political decision that the deficits, however they have arisen and whoever’s fault they are, have to be cleared in one year and have to be funded not from other areas of Government spending, but from the successful areas of the NHS such as ours. There is no law that says that the NHS has to live within its means in any particular budget year. Once the deficits have arisen, it is a political decision as to how unsuccessful areas are bailed out. If one wants to be brutal and insist that they live within their means and make up the whole deficit in one year themselves, that is one argument, but that is not what the Government are saying. The Government are saying, “Well, actually, we will bail them out. They don’t have to live within their means this year.” Where one bails them out from is the political decision. The Government are saying, “We won’t bail them out from ID cards or from troop commitments in Iraq or any number of other areas of Government. We will bail them out from the most successful areas of the NHS such as Cheltenham and Tewkesbury.”

What result does that have for the perfect PCT that has done everything right? On 28 March, 27 Gloucestershire health community savings proposals were announced. I am afraid that no clinical justification was given with them. Of those proposals, 22 are about front-line care. For Cheltenham and Tewkesbury, this means that we have faced a triple whammy. First, our primary care trust economised and tried to live within its means—despite less funding for being a healthier, wealthier area. It made economies and did not launch initiatives that it could not afford. So we lost out there. Secondly, there is top-slicing, which the hon. Member for Stroud has talked about. Finally, we are losing services that we simply share with primary care trusts such as Cotswold and Vale, because they are our neighbours and, overall, we have to make savings on the basis of what has now been invented as the Gloucestershire health community. The promise that I was given about a year ago that the savings and the financial recovery plans would apply only in their own geographical areas has gone by the wayside.

The hon. Gentleman makes some powerful points. Does he agree that there is a further problem, albeit a short-term one? Given that the PCTs are going to be changed this year, there could be redundancy payments and extra pension payments. I accept that that will be a one-off cost, but it will make balancing the books even more difficult. Is it not only reasonable that the trusts should be a given a little bit of time to balance the books?

I entirely agree with that. In fact, the atmosphere in which things are being done is so febrile that, at a recent meeting where all the county’s MPs met the chief executives of the trusts, I asked about the impact of having to take more time—quite properly—over consultation. The impact was another £1 million of savings that they were told to find. The manager who replied to the question said that they did not think that even the existing savings proposals would make up the amount that they were being asked to save by the strategic health authority and, above it, the Department of Health. The atmosphere of financial crisis is all-pervasive. The numbers vary. I managed to find a total of £29 million, but the hon. Gentleman has mentioned figures in excess of £30 million.

I am afraid that the result is not, as the Secretary of State believes, patient care improving everywhere. Instead, there are real impacts on front-line care. St. Paul’s maternity wing is a first class maternity ward that is just 10 years old. We celebrate its 10th birthday party this Wednesday. It is in Sandford park at 12 o’clock if the Minister cares to come along. She might find a rather hostile reception. I was born in its predecessor hospital. We have had that service in Cheltenham since the 1940s—long before this Government were elected. My children were both born in the ward. It delivers 2,600 babies a year and serves a town with a population of 110,000 people. It draws in mothers who wish to give birth there from as far afield as Banbury, Malvern and Evesham, and even from beyond Gloucester in the Forest of Dean. One might arguably say that if one maternity ward were to close it might be Gloucester’s rather than Cheltenham’s, since Cheltenham’s seems to be rather more popular. However, I would not want to encourage recent accusations of snobbery in that respect. The most important thing is that Cheltenham women want to give birth in Cheltenham.

A patient safety argument has been made in favour of the proposal—rather after the event since it came up as a savings proposals. It is argued that bigger and better maternity wards are always safer. That might be true, but in the end that is an argument for the entire country going to St. Mary’s in Paddington for their delivery. There is always a balance of risk to be struck. In a meeting today, midwives put to me the risk posed by combining dual centres into one centre. That makes the maternity ward more vulnerable to infections such as clostridium difficile and the much more widely known MRSA. The whole trend of obstetrics and midwifery recently has been away from big hospitalised units towards smaller, friendly units, and away from treating maternity as a sickness and towards regarding it as a healthy, normal process.

The hon. Gentleman is making the case for Stroud, which is a wonderful midwife-led unit. I am sure that he will agree that there is a lot of evidence that, where obstetrics and gynaecology are in an acute setting, there is a tendency for more intervention, whereas obviously in a place such as Stroud and in midwife-led units elsewhere, there is a belief in natural childbirth, which is what a lot of women choose. If we close down Stroud and Cheltenham, we are taking away that choice.

I certainly agree that smaller, friendly units will have a tendency towards fewer interventions. The midwives I met to discuss this issue with, who were concerned—indeed, appalled—by the proposed closure of St. Paul’s, were worried that a bigger, more industrial-scale unit at Gloucester would lead to more interventions, not fewer interventions, thereby achieving exactly the reverse of what Government policy is supposed to be. The notion of patient choice is ludicrous, because Gloucestershire has been left with a single maternity ward. Where is the choice? There is a choice of one, as we will close two maternity wards that would have provided some competition—in new competitive speak.

The increased drive time to the new maternity centre in Gloucestershire poses a risk to Cheltenham. The drive from one of the poorest parts of my constituency, Clyde crescent, to Cheltenham general hospital takes five minutes in the middle of the afternoon. If maternity services move to Gloucestershire royal hospital under the proposal, drive time will increase to 23 minutes, which is a fourfold increase and represents nothing other than an increased risk.

If the hon. Gentleman is concerned about the risk of travelling from Cheltenham to Gloucester, will he consider the position of my constituents in the north Cotswolds? It will take them at least 20 minutes to reach Cheltenham, even by ambulance, and they will have another 20 minute ride from Cheltenham to Gloucester, so they will indeed be at risk.

I am inclined to agree with the hon. Gentleman, as he knows the statistics in his constituency. However, in some cases the percentage increase in drive time is worse in urban areas than in rural areas.

Turning to adult mental health services, which deal with some of the most vulnerable members of my constituency. The loss of non-geriatric mental health services at the Charlton Lane centre in my constituency will be reflected in the loss of adult mental heath places overall in Gloucestershire. The mother of a girl who suffers from paranoid schizophrenia—I shall change her name to protect her identity—recently wrote to me:

“Younger patients, like Emily, will either go to an already existing hospital in Gloucester, whose beds will be heavily over-subscribed, or be…treated in their own homes by rapid response teams. These people cannot give the 24 hour treatment that Charlton Lane Centre gives, patients will be left in their homes to fend for themselves for much of the time. When Emily is poorly, the voices take over the whole of her thoughts and she is unable to cook, clean, shop or take proper care of herself. Those are the physical problems, added to these are the mental problems, the fear, the thought that someone will kill her is always very strong in her mind at these times, that is why she runs, to escape. The voices always tell her she is going to be killed, which in itself is a totally distressing and debilitating state of mind. There are lots of mental health sufferers in the community, but there are times that they can only properly be cared for on a 24 hour basis with properly trained staff in hospitals designed for this purpose. With this closure, there will be a chronic shortage of beds. I feel the Government and the Local Government will be letting down the most vulnerable section of our community with what is so obviously nothing more than a cost cutting exercise. A broken arm can mend at home once the patient has received the correct medical care, a broken mind requires a lot more care and attention if the patient is to survive.”

I could not have put it more eloquently. We need to consider whether the decision to provide more care in the community for mental health is the correct direction of travel. There is an argument for trying to encourage clients to be less reliant on institutional services, but surely that proposal, along with bed closures, should follow the successful implementation of community care. It is particularly brutal to close the service and hope that those vulnerable people will cope while it is withdrawn.

There have been cuts in community nursing, health visitors and community palliative care, too. Surely, the Government should encourage such services in the new direction of travel, but I met nurses today who said that the implementation of the cuts had resulted in qualified district nurses being replaced by nursing auxiliaries. The mix of nurses in Cheltenham and Tewkesbury is 85 per cent. qualified and 15 per cent. unqualified nursing auxiliaries, but under the proposals, that will change to 50 per cent. qualified and 50 per cent. unqualified. Nurses will arrive in someone’s home in the community and find that they have complex health needs. Those nurses may be unable to cope, whereas in hospital they could ask a more senior or qualified nurse for assistance. A palliative care nurse told me that she was certain that there would be a big impact on the care provided to patients. The first community palliative care nurse post has been frozen, although the population is ageing and improved therapies mean that people spend longer in the palliative care phase of treatment. As a result, more care is needed, not less.

Finally, there is a deep sense of injustice in Cheltenham at the loss of overnight children’s care at Battledown. The loss of that service is a stark illustration of the fact that, even though the clinical case was made for its retention, it was subject to a budget cut. A year ago, after a 27,000-signature petition and a £40,000 consultation, in which 98 per cent. of correspondence was in favour of the service, a recommendation was made to accept the clinical case for keeping overnight care at Battledown children’s ward, as 350 children a year would benefit. I pay tribute to Julie Coles, Carol Jones, David Downie and many others who campaigned tirelessly for the service. The recommendation resulted in the acceptance by all three primary care trusts in Gloucestershire that a nurse-led unit should proceed. The decision that overnight care should be saved was minuted—I have provided the Secretary of State with a copy—but it was overturned only weeks before the launch of the unit on the basis of cost. It was listed as a savings proposal, and thus the death knell was sounded for overnight care.

I know something about the issue, which I have debated as a governor of the acute trust. I agreed with the clinical judgment, but the campaigners made a great deal of effort to find an acceptable compromise. That was discussed properly by the acute trust, but none of the proposals, including proposals from the trust itself, were discussed by the governors. Does the hon. Gentleman think that that is the right way to proceed? There is a great deal of unease about the role of foundation governors, and this does not help.

I agree entirely, and I am sure that the hon. Gentleman agrees with 13 of his fellow governors of the NHS trust, who wrote to the Secretary of State on 11 April:

“Over recent times, Governors, Members and local people have worked tirelessly in order to maintain overnight Children’s Services at Cheltenham General Hospital. This and the wider services are now under threat, as are many others, including our Community Hospitals. All this makes the national requirement that significant NHS service changes need to be the subject of full public consultation to an absolute farce.”

I am afraid that the reply that we received from the Secretary of State was not satisfactory. On the subject of consultation, she wrote to me:

“I am therefore advised that the decision not to proceed with a proposal does not require consultation as it does not constitute a service change because the service does not exist.”

I am sorry to say that that is breathtakingly out of touch with reality.

There are many other savings proposals on the list that I would like to discuss, but time is limited. However, the closure of the Delancey hospital has raised fears about the hasty cutting of rehabilitative beds and care. The local branch of the National Council Women wrote to me:

“We know that much of the responsibility for such care will fall on family members, usually women, and doubt that this will be satisfactory. Even care homes, where professional care is available, often have to send their residents to Delancey for specialized care. Relatives, no matter how well-meaning, will not be able to cope.”

Accident and emergency services and patient support services are under threat. The prescription of drugs following new guidance from the National Institute for Health and Clinical Excellence is one of the savings proposals, so it will be deferred. I am sure that the Minister would like to claim credit for Herceptin when it is introduced in the rest of the country, but it may not be available in Gloucestershire. There will be cuts to patient transport and access to acute care—the list goes on and on.

We look forward to the consultation, but the result of the Battledown consultation does not give us great cause for hope. I beg Ministers to reconsider the situation in Gloucestershire, as the proposals will have an impact on one of the most successful parts of the NHS, which should be a model for other services. They must rethink the need to clear those deficits in a single year, if such a ruling has been imposed, and the damage to successful parts of the NHS, whoever is to blame for the original deficits.

Thank you, Mr. Deputy Speaker, for allowing me to catch your eye in this debate. I congratulate my hon. Friend the Member for Tewkesbury (Mr. Robertson) on securing a constructive and—given the circumstances—good tempered debate. Rarely have I heard a debate in the House in which I have not disagreed with anything that other hon. Members have said. As my hon. Friend and the hon. Member for Stroud (Mr. Drew) made clear, this is a cross-party issue. There are no political differences between us. We are interested solely in our constituents in Gloucestershire receiving the best possible health care within the budgets available.

I thank the Minister for being present this evening. As the hon. Member for Stroud said, she has been dragged to four such debates. She is in an unenviable position, but we would be grateful if we could get some answers and some clarity from her this evening. As has been pointed out by everyone who has spoken in the debate, the chief issue on which we need clarification is exactly what remit our primary care trusts are working to. Are they working to a remit of clawing back previous deficits, or are they working to a remit merely of bringing the situation back nearer to balance by the end of the financial year? That is critical.

I hope that the Minister, who is consulting her Parliamentary Private Secretary behind her, will be able to give us the answer tonight. If she cannot, I should be grateful if she placed an answer in the Library as soon as possible. More important, I hope she will be able to give an instruction to the strategic health authority if the remit is different from the one to which it is working. If the SHA is working to the more severe remit, it may well be making decisions and unnecessary cuts to institutions. We had a dire announcement on what I call black Wednesday a few weeks ago, in which 12 of our health institutions in Gloucestershire were shut or severely curtailed, and several hundred jobs and 250 beds were to be lost.

In my area, the Cotswolds, we had already had an announcement of closures in in-patient care in both Tetbury and Fairford. The in-patient care at Bourton is still subject to discussion, and we have had the curtailment of 10 beds in Moreton-in-Marsh community hospital, with the lure of the possibility of a new community hospital to replace those lost facilities in Bourton and Moreton—but only the lure, and with the scale of cuts that we are facing and the financial stringency, I wonder whether we will get any new facility builds. We may find beds being closed on the lure of a possible new facility, but we may well not get that facility. That type of comment pervades the whole debate. The hon. Members for Stroud and for Cheltenham (Martin Horwood) made that point clearly. In Cirencester I am faced with the cut of an entire ward of elderly mentally ill patients.

We were on the march together on Saturday, as the hon. Member for Stroud said. We were marching not only to protect maternity facilities in his constituency, which are attended by people from my constituency, but to protest at the cut of Weavers Croft—further cuts in facilities for mentally ill patients. No new facilities are yet available in Gloucester, where all those elderly mentally ill patients are supposed to go. The existing facilities could be closed before the alternative is arranged. That would be a cruel irony for elderly mentally ill patients. The hon. Member for Stroud noted that a cut, if it is that, of 30 per cent. of the activity of the partnership or mental health trust is a huge cut, and it affects some of the most vulnerable people in society. My constituency used to have—I do not know whether the statistic is still up to date—the third highest number of over-80-year-olds of any constituency in the country. This level of cuts will affect my constituents very severely.

At the meeting on Friday that all Gloucestershire’s MPs attended with health chiefs, it was made clear that the proposals are being driven not only by financial considerations, but by the short time scale in which balances must be restored. The health chiefs have asked for a longer time. If facilities are being cut and people must adjust to the changes that are being made, the Government should allow a little more time and provide a little more certainty about what is happening.

I repeat the plea that I made in an intervention on the hon. Member for Stroud that the partnership trust overview and scrutiny process should have the same symmetrical time scale—that is, 12 weeks. I say to the Minister in all sincerity that if we change the institutions where elderly people have been for many years, the very least we can do—a kindness that we can do for people in such a vulnerable position—is allow them plenty of time to get used to the idea of the changes that may well occur.

As I said, we in the Cotswolds faced the closure of our community hospitals way back in March, long before the big announcement a few Wednesdays ago about the other institutions. With regard to Tetbury and Fairford, the overview and scrutiny committee submitted a case to the Secretary of State on 16 March 2006. It has yet to receive a reply from her. When is a reply likely? If the Minister cannot tell me tonight, perhaps she will let me have a note.

I quote one paragraph from the letter from Andrew Gravells, the chairman of the overview and scrutiny committee, in which he states:

“The local community have concluded that the changes are purely finance driven, which appears at odds with statements in the Government’s own White Paper, Our Health, Our Care, Our Say, which indicates that community hospitals should not be lost in response to short-term budgetary pressures.”

That is what worries me about this debate. We may close facilities in Gloucestershire, and facilities elsewhere that are facing the same budgetary pressures, and regret it later.

With modern technology it is possible to do more treatment locally than was ever possible before. For example, with digital X-ray technology, it is easy to send X-rays to a consultant sitting many miles away at the district general hospital and get advice as to the sort of treatment that should be given. It can then be given locally, instead of all the time wasted by the patient having to be taken, perhaps by ambulance, to the district general hospital on another day with another appointment, with all that costing a great deal of money. I urge the Minister to look into some of the modern technologies available and see what can be done locally.

As a chartered surveyor I am the first to suggest that we should not necessarily keep old Victorian facilities that cost a great deal of money in upkeep. That is not what I am suggesting. If they cost a large sum to maintain, for goodness sake let us sell them and build new facilities that are cheaper to maintain. In Fairford, where the local community has rallied round the League of Friends of Fairford Hospital, we have a very innovative solution. Since March, they have got a private sector provider involved, they have found a new site, they have been talking to the planners, who have given the matter favourable consideration, and it is possible for them to propose a package to provide a new modern day care facility, combined with doctors and elderly treatment services. The NHS would be charged a reasonable rate for those facilities. That seems a possible way forward for a number of our facilities in Gloucestershire.

Will the Minister lay out a blueprint of the pitfalls and the way forward for such a scheme? In particular, the League of Friends is asking how much of the proceeds of the sale of Fairford hospital they are likely to receive to put forward for the new facility. Such questions need to be considered. The Minister should consider this innovative proposal, as it might get her off the hook in similar difficult situations.

The situation of maternity services, about which the hon. Member for Stroud spoke, is one of the strands of the cuts that we are facing. As he said, he and I marched, along with 4,000 people, on a boiling hot day in Stroud on Saturday. We met young mothers and many of the children born at that hospital. About 400 young mothers a year have their children at Stroud maternity hospital. It is one of the few maternity facilities left in Gloucestershire, and if we lose that and the facility in Cheltenham, as the hon. Member for Cheltenham mentioned, all the young women will have to travel to Gloucester to have their babies. I was not making a disparaging intervention on the hon. Gentleman. I was trying to point out to him that if he is worried about the risk of patients travelling for 20 or 25 minutes from Cheltenham to Gloucester, the people from the north Cotswolds have first to travel to Cheltenham and then on from Cheltenham to Gloucester, so whatever the risk for his constituents, they are double for mine. If it takes 40 minutes to get there, I think it entirely possible that some babies, especially second babies, will be born in the ambulance long before they get to Gloucester.

I think that there will be an increasing tendency for young mothers to have their babies at home. I am not a clinician and will not comment on that possibility, but we have been told for years that young mothers should have their babies in hospital because better care can be provided there. I think that more and more young mothers will choose to have their babies at home, particularly when no clinical danger is identified in pre-natal and post-natal classes. I am concerned about the large unit in Gloucester, and the hon. Member for Cheltenham has already mentioned the risk of MRSA. A small unit would be useful, because many mothers will not need to stay in it for very long.

I did not mean to dismiss the hon. Gentleman’s concern about his constituents’ drive times and accept his point. My point is that the percentage increase in drive times is probably greater from within the urban areas. When I asked the chief executive of the NHS trust about second children—my second child was born within minutes of getting through the doors of St. Paul’s—and whether my child would have been born on the A40, he said that nature will take its course. Does the hon. Gentleman think that alarming?

Yes; the situation will be even worse than the one I have described if babies are born in cars, rather than in clinical conditions in ambulances, as a result of the changes.

Young mothers will have to travel further not only to attend the maternity unit, but to access pre-natal and post-natal care, which is a point that also applies to visits to young mothers who stay in hospital. It is difficult for hon. Members who represent urban areas to understand that public transport in areas such as the north Cotswolds is almost non-existent. It is difficult for someone who is about to have a baby and who may have other children with them to catch a bus from the north Cotswolds to Cheltenham and to change buses in Cheltenham to go on to Gloucester. People who are sitting in offices trying to plan larger and, in their view, better units sometimes fail to take into account the extreme difficulties of people who must travel to those hospitals, particularly when they do not have cars and live in rural areas. My PCT has estimated that every year patients in Gloucestershire travel 1 million miles to out-patient appointments. We are all concerned about global warming, and such distances seem distinctly unsustainable.

One other aspect of the matter has not been emphasised sufficiently in debate this evening. At Friday’s meeting with health chiefs, it was made clear that those people who are referred to the larger units in the acute hospitals in Cheltenham and Gloucester will be discharged more quickly, which means that they will require greater care. In the announcement several Wednesday’s ago, however, we were told that community nurses, health visitors, physiotherapists and other at-home services would also be curtailed. We have got a lot of vacancies for community visitors in the north Cotswolds, and I think that when some people are discharged from hospital it will be impossible to deliver their home help care package, which will cause them hardship. I ask the Minister to consider that point carefully.

I do not think that social services have been sufficiently involved in the discussions. As my hon. Friend the Member for Tewkesbury has said, the effect of the changes on other agencies has not been costed. As the hon. Member for Stroud has mentioned, a lot of voluntary transport activity goes on in my constituency. If patients are going to be discharged from hospital more quickly, they may be distressed and more difficult to transport. As we are finding from our constituency postbags, some of the people who have been discharged from hospital are not suitable for home care. That means that they must be readmitted, which is, again, an extra cost.

I worry about patients with dementia who do not need to be in a clinical setting but who may need to travel periodically to the centre of excellence, which is a problem with the proposal to provide one unit at Charlton lane. Many such people will have to travel by voluntary transport, which is a difficult thing to ask a voluntary driver to take on.

I agree. The matter concerns patients going to and from hospital not only for treatment, but for consultations. The distances will be much larger than those currently travelled to the community hospital.

Will the Minister explain how my constituents in the Cotswolds will get better care closer to home? The Government and the PCTs have said that that will be the case, but I find it hard to believe if their community hospital is closed.

Since I have been a Member of Parliament, the health service has been subject to constant reorganisation. When the Conservative party left office in 1997, there were area health authorities, which this Government reorganised into strategic health authorities. As has been said, there was one care trust for Gloucestershire, which was considered to be too big. It was reorganised into three primary care trusts, which are now considered to be too small and will be merged back into one PCT. Indeed, the SHA set up by this Government will be merged into at least two SHAs. All that reorganisation costs a great deal of money—it means that people are made redundant and that offices are closed. We should reorganise the health service now, but then we should leave it alone for 10 years.

Is the Minister sure that the figures that she has been given by her health service chiefs are robust, because we do not want another round of cuts in Gloucestershire? I do not think that the cost of rebuilding all those new facilities has been properly calculated, and I do not think that the current cuts will be the last, although I look forward to receiving an assurance from the Minister that they will be.

Because of the curtailment of business earlier, this debate has been rather longer than the normal half hour, and all hon. Members present have taken advantage of the opportunity.

The hon. Member for Tewkesbury (Mr. Robertson) has mentioned that the consultation document “The Future of Healthcare in Gloucestershire—Proposals for Developing Sustainable NHS Services”—I downloaded my copy earlier today—states that part of the core remit of those involved in developing and supporting health services locally is to promote good health. It is important to have that written down. As Public Health Minister, I would say that for too long, and too often, health improvement and promoting good health have been the poor relations in terms of providing treatment in our NHS services. In my 12 months in this post, I have begun increasingly to realise that we could do more not only to prevent people from having the conditions that mean that they go into hospital in the first place, but—now that technology and drugs are better than ever before for a person who has had, for example, a heart attack or cancer—to make the step change in helping that individual to look after themselves, having had possibly the best treatment in the world, and to keep themselves fitter and healthier for longer.

Given the Minister’s responsibility for public health, is she concerned about the fact that savings proposal 15 is a cut in the public health promotion budget for smoking cessation?

I am glad that the hon. Gentleman makes that point. Historically, part of the problem is that public health has often lost out when pressure has been brought to bear on PCTs from the acute sector. As we move to a different place in which projects, programmes and interventions have an impact—in some areas, public health promotion could be better in terms of outcomes—we must have a discussion about how many of our services should be provided in hospitals, and how many of the services that are provided in hospitals should have a better link to community services, particularly for people with long-term conditions.

This lunchtime, I was at a conference with the Local Government Association. We are continuing to work, more than ever before, on looking at the role of public health in relation to the way in which local government runs its business. Factors such as the development of housing, safer communities and the general environment all have a role to play in public health. As for smoking cessation, next year we will put in place legislation that will make most public places smoke-free. That will be a major contribution to changing the culture around smoking.

To achieve a more mature, wide-ranging and long-term view of public health, we need to tackle the traditional situation in the health service whereby funding has overwhelmingly been directed towards those in the acute sector at the expense of those in the community. Painful choices are being made because of the need to deal with the deficits in a minority of organisations. That is causing problems even for PCTs that are in balance. My own PCTs in Doncaster—an area with huge health challenges—are in balance. In 1997 they were having to bail out other sectors of the NHS, but that was based on previous ways in which funding was organised and so was not done transparently—it was a fix designed to make everything look all right. It was not all right then, it was not all right in 1987, it was not all right in 1977, and it is not all right in 2006—but now we have an opportunity to try to get it right once and for all.

I will deal as best I can with the points that hon. Members raised about financial balance. However, the important point is what will happen if we continue to stick our heads in the sand and do not deal with the problems that we face.

As health services change, people’s needs change as well. In relation to the consultation launched today on the different services in the Gloucestershire area, I will not deny for one minute that there is clearly a financial imperative. I have read the document and had discussions with hon. Members and health professionals in other regions that I cover, and it is clear that in trying to find a way forward we have to take into account people’s understandable commitment to the health provision that they perceive that they are getting at the moment, as against what they might want in future. Those may be two different things. Someone who is 80 might want something very different from someone who is 60, and very different from what I, as someone in my 40s, might want when I am 70, 80 or even older. Part of this process—I am aware that it is a difficult one—is the honest discussion that people need to have about the services currently provided, and the shortfalls and problems involved, as against what else would be on offer.

The Minister is absolutely right that we need a modern health service; I have said myself that it should not be a sacred cow that we are frightened to touch. But if it is right to cut management costs by 15 per cent., for example, that should be done anyway; we should not have to get to this crisis point. People will not accept that these changes are being made for the right reasons, because they read in the press that the NHS has severe financial problems and is cutting, not planning. The problem is that local health chiefs are not planning. The current situation is a reaction to their being told by the strategic health authorities that this year they have to balance all the books or else. The Minister is right to say that we have to move services on—I have no objection to that.

I thank the hon. Gentleman for that constructive contribution. I have met representatives of the strategic health authority and the primary care trusts. I hope that it is generally agreed that we cannot manage the health service from the centre, because the needs of one area are different from those of another and are affected by factors such as health challenge and geography. The decisions are best made locally.

Perhaps some decisions should have been made previously, but people did not make them. They thought, “We don’t need to face up to that difficult decision. We’ll leave it for a couple more years. We’ve got some more funding coming from the Government. We’ve gone from £30 billion to £60 billion, and to £90 billion for the NHS in the next few years.” The last sentence is the only mantra that I shall recite in the debate but it is true, and worth saying. People may have put off making decisions, but when somebody says, “Hang on, we’ve got sort out these finances, because you can’t carry on like this,” perhaps they will suddenly start to take notice. I am sure that the hon. Gentleman and others will make those points locally. I am sure that they will be raised with existing personnel and in the context of future reorganisation of PCTs. Managing the current position and, as the hon. Member for Cotswold (Mr. Clifton-Brown) said, ways in which to ensure that it does not happen again, will be considered. That is the Government’s ambition. We would be a foolish Government if we wanted to revert to the problems again and again.

That is why we believe that, difficult though it is and unpopular though it may be in some quarters, we must grab the agenda and deal with the problem—because it is clear from examining the information on some of the trusts that have got into deficit that unless the problem is tackled firmly, they do not get out of it, and it gets worse.

I wholeheartedly support what my hon. Friend says. We are examining the detail of the White Paper “Our health, our care, our say”, especially the part of it about which I have asked her previously, about moving “Care closer to home”. She confirmed from the Dispatch Box in a previous debate that maternity services would be judged according to community criteria. May I push her a little further and ask whether that is true of mental health and learning disability services, which are also set in a community context? The partnership trust believes that they should not be judged by the same criteria, which I find strange, given that the people to whom they apply are most in need of being close to their locality and community. Will my hon. Friend say a little about that?

If someone has mental health or learning difficulties, or a long-term condition such as diabetes, or is recovering from heart treatment, it is clear from “Our health, our care, our say” that there is an appetite for services closer to home, for those provided in non-traditional ways and for some creativity in establishing partnerships to provide services—with the voluntary sector, local authorities and other groups. That also applies to prevention services.

In several parts of the country, we are pioneering health trainers—a role that can take a variety of forms. They could be people from the community who will act as ambassadors. They may have suffered from a specific condition, or had, for example, a heart attack, and are therefore well placed to talk to others in that position about what they can do and what support exists to keep them healthy. Similarly, others could act as supporters and buddies. The opportunity exists not only for employed personnel to fill that role, but for others who simply want to give something back to their community. I shall raise the issue that my hon. Friend mentioned with the Minister of State, Department of Health, my hon. Friend the Member for Doncaster, Central (Ms Winterton), because she leads on mental health services.

It is fair to say that for too long, insufficient thought has been given to integrating services for those with mental health problems with those of other providers in the community. The tendency has been to provide stand-alone services in a mental health service context. When I consider my constituency, my leisure centres and community organisations and groups, there is the challenge of whether those services meet the needs of different vulnerable groups in our community. That is important for people’s general well-being.

Treatment, and how we can provide the best treatment for the range of mental health problems, is another matter. Again, that must be decided locally. However, I shall get my hon. Friend the Member for Doncaster, Central to follow up some of the points that my hon. Friend the Member for Stroud (Mr. Drew) made this evening.

I hope that the Minister will answer the core question about the criteria that the PCTs are being set—whether we are considering monthly balance or clawing back the deficit. The deficits have not arisen suddenly; they have existed for a long time. My constituents want to know why the crunch has suddenly come now, because that gives them the impression that the NHS is not budgeting properly. If the Chancellor can budget in his Red Book for a three-year programme, why cannot the NHS do that?

There are all sorts of reasons why some organisations have got into financial problems, as the hon. Gentleman will be aware. The traditional approach to this issue—which has been taken by this Government and previous Governments—was to shift resources around the health economy to bolster different organisations and help them out. My first meeting with the then Doncaster health authority involved discussions on that very issue. We talked about helping out other parts of South Yorkshire using the balances and surpluses in Doncaster.

This has become an issue because of the reforms that the Government have set in place to improve the national health service. Also, with the introduction of payment by results, and of GP-based practice commissioning, it is important that the NHS should be in good financial order.

I want to make a bit of progress, otherwise I will not even get to the questions that hon. Members have asked this evening.

That is true, but I have just looked at you, Madam Deputy Speaker, and I think that you might want to get away before then.

It is important for the national health service to be in financial balance because it is fair to ask how the money going into the NHS is being used. All parts of the NHS in England have faced issues regarding targets, pay for staff, the agenda for change programme, and so on. They have managed all that and remained in balance. There is not just one reason for the problems. However, it is fair to ask those that are not in balance why they are not. Also, we need a system that will get them back into balance.

We have suffered particularly in Gloucestershire because the Avon, Gloucestershire and Wiltshire strategic health authority had the biggest deficit in the country, at some £100 million. We are suffering because of the mismanagement in Bath and Bristol, and because for many years we have not had the capital allocations that other areas have had. Now the Minister is top-slicing us and giving some of our money away to Wiltshire, so we really are being hammered in Gloucestershire. I hope that she will take that into account.

I appreciate the difficulties experienced when areas that are in balance have to help out others. I, too, am in that situation locally to a certain degree. It is important that all Members whose areas are in similar situation should make this point locally, and ask clearly what they can expect back. This is not a process that will keep happening year in, year out. It is going to be put right, to provide a much more sustainable future. That is absolutely fair. From what I understand, trusts in deficit will have to provide to the strategic health authorities a clear plan for dealing with their deficit. This should also be open to the trusts that are in balance, so that those that are helping out in different ways will be clearer about what is being done to improve the situation.

The Minister repeatedly talks about the problems of tackling the trusts that are in deficit and their need to live within their means. However, the trust covering Cheltenham and Tewkesbury has lived within its means, but it cannot be repaid at some mythical point in the future, because it is merging with one of the trusts that is in deficit now. Local services are being hurt not only because of the top-slicing but because services that are shared with that neighbouring trust are being cut. So we are being penalised twice over.

I cannot be clearer than I already have been. I do understand the hon. Gentleman’s point. However, we also have to work within a wider health economy than just one trust. People in Doncaster, for example, go to Sheffield for cancer treatment and to other parts of South Yorkshire for different services. Other people come to Doncaster from elsewhere for services. That is how the health community in which we live operates. We want access to the very best health care in some of the most challenging and demanding areas of health. That is something that we all sign up to. That is why we have to get this right, and why we have a responsibility to support each other within our local health economies. That is not letting anyone off the hook. That is what happened in the past and it was part of the problem.

It is all about changes for the future. The amount of money going into the areas of hon. Members who have spoken in this evening’s debate is substantial. There is no question that more money has been invested in the NHS. In all the constituencies of hon. Members in their places tonight, people have benefited from greater access to treatment faster than ever before. The minimum standards applied to our targets will continue to apply in the future, but to get to a place where we can think more creatively about provision of the services that we more or less all want, we have to deal with these financial problems and there is no easy route to achieve that.

I want to highlight a few points about how health is changing. In the Gloucestershire area, more people are admitted to hospital than the national average and more people are spending longer there. I acknowledge the point of the hon. Member for Cotswold (Mr. Clifton-Brown) when he said, “Hang on a second—we should not be kicking people out of hospital who need to be there.” Of course not. I have to say that I have heard some worrying stories of older people being kept in beds on hospital wards in unsuitable circumstances when they really would be better looked after elsewhere. I accept that it can be an issue around partnership with social services and it is sometimes the result of a baffling lack of co-ordination with respect to the particular problems.

Let me provide one example relating to another part of the country. Someone was receiving acute care in an acute hospital for his condition and was then transferred to a bed in a smaller community hospital. Why could he not come out of that community hospital? Partly because he had been diagnosed with diabetes and an at-home service for insulin care and management could not be provided. In that context, discussions about support for that individual included the point that choices had to be made about whether to provide the relatively straightforward services that were needed in that gentleman’s home in the community or whether he should spend four months in hospital until something was sorted out. There are legitimate debates about that choice.

About 70 per cent. of people now have surgery as day-care patients, which is a huge change from the past. Nationally, the number of NHS beds has fallen by more than 30 per cent. over the past 20 years, while the number of NHS out-patients has risen by almost 60 per cent. That has changed over the decades, not just in the last few years. Of course, there are new technologies, better drugs, advanced surgical techniques and improved management practices—[Interruption.] The hon. Member for Cheltenham (Martin Horwood) keeps making comments from a sedentary position, but every time he raises questions about new drugs and other choices, it goes to the heart of the issue of trying to provide a health service that can meet people’s needs, but needs to be managed locally.

No, I am not giving way again. I have already given way several times to the hon. Gentleman and responded even to his sedentary comments.

The hon. Member for Tewkesbury raised some specific questions about Winchcombe hospital. I understand that, as part of the consultation, it is planned to enhance services at the Tewkesbury hospital, invest in community services and provide more rehabilitation and support in the home. The consultation will be for 12 weeks and he will be able to explore how that will happen—a pertinent question for the consultation.

I understand that some of the Winchcombe hospital’s problems relate to the building and that maintenance costs are £500,000 a year. The point was raised whether the hospital could be refurbished and used for other services, but it is felt that the fabric of the building is too old, so it would not be cost-effective to do so.

I understand that out-patient and therapy services will be relocated and that, working in partnership, another eight beds will be provided elsewhere for rehab and palliative care. Clearly, those issues will be discussed as part of the consultation exercise. Certainly, in a number of areas, including Gloucestershire, as with other parts of the country, there are options that seek to enhance and improve some of the other community hospitals or services. I understand that one of the options for Dursley is to build a new health and social care facility in partnership with an independent sector provider.

The hon. Member for Cotswold made a point about possible partnerships at Fairford hospital. It is difficult for me to comment to on that, but, clearly, he could have a conversation with PCTs and SHAs about any possible partnership development. Although the number of beds has been reduced at one facility—I think it was Tetbury hospital, which is an independent not-for-profit hospital; I look to the hon. Gentleman for reassurance and see that he is nodding—I understand that there is a discussion about how that service provider could provide more support and care in people’s homes, rather than in hospital, and that it is keen to explore those opportunities.

I will come to the financial balance, but I want to say something about maternity hospital services—an issue that has been raised by several hon. Members this evening. I have glanced at the report in The Citizen local paper. Clearly, there was a well-attended rally on the issue at the weekend. As hon. Members will be aware, the proposal is that, over the next three years, all in-patient births at Stroud maternity hospital will move to Gloucester. I understand that there are just under 6,000 births in the Gloucester area, which services Cheltenham, Gloucester and Stroud, of which about 300 take place at Stroud hospital. Again, I am sure that that issue will be discussed as part of the consultation exercise, but that is quite a small number, and the birth rate is dropping, too.

Clearly, considering what services need to be provided is an issue. This might not meet everyone’s concerns, but I noticed in the article in The Citizen that one lady was talking about the fantastic service that she received in having a midwife-led home birth. That service will continue, including, I understand, both antenatal and postnatal support. The difference is—I am not going to cover it up, because it is in the consultation—that in-hospital births at Stroud will be moved to Gloucester. However, I want to put on the record that antenatal and postnatal services and the opportunity for those women who want to have a midwife-led home birth will still be available to women in Stroud and the surrounding area.

Again, this is a difficult issue. I have looked at the figures: women are having children older, which presents some issues. Women who have IVF treatment are more likely to have multiple births. Other issues need to be considered when providing consultant-led maternity services, particularly working times and the hours worked by consultants, as well as other health professionals. Again, those are factors in the provision of services. There are clearly financial considerations, as in everything, but there are some real issues about providing the best service possible, particularly to those most in need of that specialist service. Several Members have made points about the arrangements for getting to hospital in time, and there is no easy answer. Planning in relation to antenatal services is part of that process, and women and their partners and families need to be aware of what services are available and what arrangements they might need to make in such circumstances. Although I was in hospital for four days when I had my first child, times have changed, and for a straightforward birth, most people are in and out of hospital that day. Everyone wants to be there in the first few hours—I am not trying to mitigate that—but, for most people, days do not have to be extended for visits to their daughter or sister and her new child.

On mental health, my hon. Friend the Member for Stroud (Mr. Drew) referred to the percentage contribution being asked from mental health services, which I will draw to the attention of the Minister of State, my hon. Friend the Member for Doncaster, Central (Ms Winterton), who has been monitoring how mental health services are being affected, the proportions involved and what the safeguards should be.

All Members who have contributed to the debate this evening referred to the financial balance. As they will be aware, strategic health authorities are responsible for the performance management of their NHS organisation and for ensuring that they achieve financial balance. The aim is for the NHS as a whole to have returned to financial balance by the end of 2006-07. As I mentioned this evening and in a previous debate with my hon. Friend the Member for Gloucester (Mr. Dhanda), who asked similar questions, within an overall NHS balance position, a minority of NHS organisations might be unable to achieve a balance position within the time frame. However, all organisations that overspend will be expected to show an improvement during 2006-07. By the end of the year, every organisation should have monthly income covering monthly expenditure or a date by which that will be achieved in 2007-08. Strategic health authorities take a reserve at the start of the year, mainly from PCTs, and will not redistribute resources to overspending organisations but will allow them to return to financial balance across the patch with any deficits offset by the reserve held by the SHA. Reserves will have to be paid back to organisations in future years when the organisations currently in deficit start producing surpluses.

The key benefit of the new system is that it provides financial certainty as reserves will be lodged from the start of the year. That means that SHAs will not need to spend time and energy later in the year trying to persuade organisations to underspend and produce a surplus. Despite the difficulties, that has tended to be the way that it has worked—people have planned for a year and then been asked to pull back later in relation to the year ahead. Trevor Jones, chief executive of Avon, Gloucestershire and Wiltshire SHA, said in his letter of 7 June that there is

“a clear requirement for NHS bodies to achieve in-year balance and to recover 2005/06 deficits…In exceptional circumstances, organisations formally included in the Department of Health’s ‘turnaround programme’ may be allowed more time to recover the 2005/06 deficit. In Gloucestershire, only Cotswold and Vale PCT is receiving turnaround support and it will receive £6.8m from the PCT pool in 2005/06 which must be repaid in later years.”

That is saying that organisations must show that they are in balance in terms of their monthly income and expenditure, but that the pool provided allows the SHA to show that the whole local health economy is in balance against the deficits. That recognises that recovering some deficits might take more time in certain areas.

That issue will have to be explored locally, but it must also be recognised that the recovery of deficits cannot keep being put off until tomorrow. That is why consultation, not just about finance but about creating a health service that is better for the future, is so important. We need systems that will improve outcomes, but will also put the service on track to achieve a meaningful financial balance that is not just secured through the reserve produced by the strategic health authority.

I think that the Minister is eliding two requirements. One is the return to financial balance by the end of the financial year: it seems that by the end of March next year, provided that primary care trusts are back in balance, the first of the Minister’s criteria will be met. However, the Minister confused the issue by quoting from a letter from Trevor Jones saying that past deficits must be recovered by the end of the financial year. That is a much stricter and more stringent criterion than our PCTs have been led to expect. Are they to expect the first, or the first and the second?

I think it is a combination of the two. Organisations must ensure that their income and expenditure are in balance on a monthly basis by the end of the year, but must also establish plans to show how they will recover their deficits. By pooling reserve money, SHAs are helping to ensure that the whole health economy is better protected against the deficits that some areas are facing. I shall be happy to write to the hon. Gentleman, but I can say no more than that. All organisations that are overspending will be expected to show an improvement during the current financial year, and by the end of the year every organisation should have monthly income covering monthly expenditure or give a date by which that will be achieved in 2007-08.

I will give way to my hon. Friend the Member for Stroud first. Then I will give way to the hon. Member for Tewkesbury, as he initiated the debate.

The Minister will understand why we feel so much in need of clarification. I have seen the correspondence from and to the chief executive of the SHA. I would not like it, but I think that I would understand, if all parts of the SHA worked with the same rigour that is being requested of Gloucestershire, but I ask the Minister—if nothing else—to examine the figures from the different parts of the SHA. I cannot see that other parts of the authority are being asked to face the same pain as Gloucestershire. If they are, can the Minister make that clear in the letter that she is going to send us?

I think the hon. Member for Stroud (Mr. Drew) made the point that I intended to make, but I will say this. I am grateful to the Minister for her sympathetic approach and I think we all accept that the organisations should be in monthly balance by the end of this financial year. That is a sensible requirement, to which we have never objected. We should like to know, however, whether the requirement for everything to balance—including historic deficits—relates to this financial year. Could it be extended to, for example, three years? That would make all the difference. I realise that the subject is hugely complicated, but perhaps the Minister could focus on that when she returns to it.

As I have said, the problems in different trusts must first be identified, along with the amounts of money involved. The trusts will be expected to produce a financial plan to turn their position around, although we want to see a monthly financial balance. As I have said, I will write to hon. Members including my hon. Friend the Member for Stroud. My hon. Friend made a point that I intend to follow up.

I am grateful for the Minister’s patience in giving way to me again.

Part of the problem may be the term “monthly balance”. That may be what we are struggling with. Does that mean monthly balance in terms of the normal revenue income and expenditure that trusts would have if there were top-slicing for deficits, or does it mean monthly balance including the need to meet the top-slicing requirement? Can she clarify that?

I understand that it is in terms of income and expenditure, but there is also the issue around the outstanding deficits that organisations have. Those have to be dealt with too. Part of the top-slicing that is happening in those parts of the health sector or health trust that are in balance is to try to ensure that there is, if you like, shared responsibility for maintaining health across communities, to follow up on the point that my hon. Friend the Member for Stroud made about what is being asked of different parts of the health service in his strategic health authority area to deal with particular problems and issues.

That still requires an openness to debate some issues that involve some hard decisions and hard choices about the services that are necessary for the future. It raises issues around engaging the public. Importantly, as I said earlier, it involves having a discussion about what sort of services people want but also, in order to get those services, what is necessary. It is undoubtedly the case that, with the best will in the world, for some of our most advanced services to get the personnel to provide the best techniques in certain areas of health in our hospitals, some consolidation is necessary.

It is also clear that, particularly in respect of older people, we have to address some legacy issues of community hospitals, which were created with the best intentions, and to consider whether they can meet the needs of the future. I raise another issue in relation to health staff. Talking to a nurse the other week, I found that one of the problems has been that, in some of our community hospitals—as I say, I do not know enough about all the individual community hospitals in hon. Members’ areas—the sort of service that they are offering, which is at its best a holding bed for older people, is not providing training and other opportunities for staff who want to work in this sector, particularly those who want to work closer to where people live in the community, providing a 24/7 district nurse service, for example, for people who most of the time do not need to go into hospital. They could get the services they need at home, with little disturbance to their life and none of the problems about relatives having to try to visit them and all those other things.

We have had an interesting debate. I hope that we have explored, possibly in a wider way, some of the challenges that face the health service. It is about value for money but importantly it is also about dealing with a problem which has been happening for many years in respect of the way in which health has been funded. It is also about dealing with perhaps some decisions that should have been made earlier about the sort of health service we want, which as I said is about prevention and support as well as treatment. However, to get to the place where we can have that discussion and start thinking about a 21st-century health service, undoubtedly, these problems have to be resolved financially but also in terms of the organisation of services.

Question put and agreed to.

Adjourned accordingly at three minutes past Nine o’clock.