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NHS (Buckinghamshire)

Volume 450: debated on Wednesday 18 October 2006

I am extremely grateful to have obtained this debate on the national health service in Buckinghamshire. Right at the start, I want to present the apologies of my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan), who is convalescing after an emergency hip operation and is thus unable to be here today. When I spoke to her on the phone two days ago, she specifically asked me to point out that, to the best of her knowledge, she is the only member of the Conservative parliamentary party to have personally tested the skills of NHS surgeons during this our party’s NHS action week. I shall do my best to voice some of her concerns later. My hon. Friends and, indeed, the whole House will join me in wishing her a speedy recovery.

It is also right to pause for a moment before plunging into the debate to thank on behalf of my constituents and myself—I was once through the doors of accident and emergency at Wycombe hospital—the doctors, nurses, midwives and other medical staff who work in the NHS in Buckinghamshire. They work under great pressure and intense scrutiny, and not all of them have always been led as well as they might have been. They are not always thanked as they should be, so we should thank them today.

I want to begin the debate proper with the recent “Shaping Health Services” exercise in Buckinghamshire. “Shaping Health Services” proposed that children’s and maternity services be moved from Wycombe in my constituency to Stoke Mandeville in the constituency of my hon. Friend the Member for Aylesbury (Mr. Lidington), and that elective operations be moved from Stoke Mandeville to Wycombe. It was also proposed that trauma patients who arrive at Wycombe A and E be transferred to Stoke Mandeville if possible.

The changes were opposed in the southern and middle part of the county by hospital consultants, the local medical committee, local midwives, the Buckinghamshire patients forum, Wycombe Race Equality Council, Wycombe district council, all the main political parties, including the Minister’s, and more than 40,000 local petitioners. In summary, the all-but-unanimous view in my constituency was that the proposals came without a proper transport plan, clinical risk assessment or full financial plan. I shall return later to those three issues: transport, safety, money.

In short, my constituents and others believe that they are paying record amounts of tax and are receiving in return some improved services—that is true—but also the removal of key services from their area. In other words, they believe that the NHS in Buckinghamshire is at risk from the dismal drip, drip, drip of cuts and closures.

An all-party committee, Save Hospital Services, was formed under the chairmanship of Steve Cohen, the editor of Bucks Free Press, to fight the proposals. I acknowledge the work of all those who served on the committee, as I did. It is invidious to name names, but I want to single out Dave Parsons for the exceptional amount of time and trouble that he dedicated to the committee’s work.

Our concerns were graphically illustrated by a letter that arrived in my post last October. It states:

“People think that there is still a fully functioning accident and emergency department here”—

that is, in Wycombe. The letter continues:

“Clearly, this is untrue…Major trauma and sick medical/surgical patients are receiving sub-optimal care and lives are being put at risk. This is a major clinical governance issue. There needs to be a serious revision of the current management of emergency patient care.”

The authors of the letter were the entire anaesthesia department at Wycombe hospital. The Minister is aware that it is extremely unusual for a whole department to sign a letter that uses such stark and graphic language.

On the same day, the minutes of the 12 September meeting of the medical advisory committee of the Buckinghamshire Hospitals NHS Trust also arrived on my desk. Andrew Kirk, the then medical director of the trust, is quoted as saying:

“The system is fragile and there is a need to redress the position…There is also the future service change for women and children, which it is considered can make the situation worse.”

I asked the trust to appoint an independent outsider to examine those claims immediately. It finally consented to do so in February. During the summer, its chairman and chief executive resigned, shortly before the report into the outbreak of clostridium difficile at Stoke Mandeville, which cost more than 41 lives and which I am sure my hon. Friend the Member for Aylesbury will mention later.

Last week, I received a letter from Alan Bedford, the interim chief executive of the trust, which states:

“We still believe that the SHS model is the right model for now. However, it is complex, there are some risks involved”—

I believe that this is the first time the trust has been so candid about risk—

“and as you know the health community is substantially in difficulty financially.”

The letter also confirmed that middle-grade doctors are now providing support 24/7 as a result of the independent review of A and E at Wycombe. I quote:

“We have agreed to do this to ensure that both our A&Es come up to the required standard.”

This confirms that the anaesthetists’ concerns were reasonable, despite the assurances that we received at the time about A and E.

In respect of “Shaping Health Services”, we are, in effect, in no man’s land. We do not know whether children’s and maternity services will be moved to Stoke Mandeville. We do not know the future of what remains of A and E at Wycombe. We do not know who the permanent management team of the trust will be. Indeed, my hon. Friends and I do not know the full future of our local hospitals at Amersham, Stoke Mandeville and Wycombe, or of community hospitals such as Marlow cottage hospital in my constituency.

We do know that the deficit problem that was previously the responsibility of the hospital trust is now the responsibility of the primary care trust. The latest estimate of the PCT’s deficit is £15.2 million, compared with a control deficit of £7.1 million, and the PCT is seeking immediate cuts of £3.5 million. It is worth noting that £15.2 million is only an estimate, as far as I can see, and that a definitive figure will be known only when the figures for the final period of the former smaller PCTs in Buckinghamshire are known.

The £3.5 million cuts are only the start. The new PCT’s total savings target is more than £31 million. Consequently, it has developed a three-stage financial turnaround programme to achieve it. Details are vague at present, but it is clear that the trust is looking for savings in, inter alia, hospital referrals, prescribing, services for older people and mental health provision. I shall return to the matter later, but I pause to note that a falling deficit in one part of the local health economy tends to worsen a rising deficit in another part of it. For example, what would the scale of the effect on the hospital trust’s finances be if fewer patients were referred to Wycombe and Stoke Mandeville by the new PCT?

I shall now probe what I believe are the five main themes woven through this tale of deficits and, alas, closures. First, there is transport. Buckinghamshire is a narrowly drawn county with few major north-south connections and a considerable rural hinterland, particularly in the north. At the time of “Shaping Health Services”, we were told that a blue-light ambulance journey from Wycombe to Stoke Mandeville could be done in roughly half an hour and that the ambulance service could take the strain, but anyone who has travelled on the A4010, which is not a modernised road, and who is familiar with local traffic, particularly during school-run hours, knows that the half-an-hour estimate simply is—let me put it this way—unreliable. Anyone who has noted that, during the last year, the number of emergency calls to local ambulances has risen sharply by more than one fifth, on average—in the Wycombe area, by 21 per cent.—knows that the service may not be able to take the strain, and certainly would not be able to do so in the event of, say, a flu epidemic or major terror incident.

It is not only ambulances that will have to make journeys on unmodernised roads but cars containing families and, of course, patients. To travel to Stoke Mandeville from Marlow in my constituency, for example, a driver would have to negotiate High Wycombe in order to get on to the A4010 at all. Such a driver might, of course, go to Wexham Park, just north of Slough. That raises further questions about the degree of planning that has taken place not only between the two hospital trusts concerned but at strategic health authority level.

In the wake of the parts of “Shaping Health Services” that have already been implemented, will the Minister liaise with his colleagues in the Department for Transport and find out what plans it has, if any, to update the A4010 and other transport links to the north and south of the county and to what timetable? Will he guarantee that before any further structural changes are made a full reassessment of blue-light times and transport times will be made by the hospital trust and published? Will he find out, too, whether the new bus service from Wycombe to Stoke Mandeville, which is essential for patients without cars of their own, is running fully during afternoons and when the service will run at weekends?

If the Department intends Bucks county council to help to fund future transport health requirements, how is the council expected to do that when last year it found itself £15 million short of the funds that it needed to preserve the previous service levels? Finally—at least in this section—what guarantee do we have that the new strategic health authority will help to ensure that the transport plans of NHS trusts in Bucks accord with those of NHS trusts elsewhere?

Second after transport comes safety. The tale of the anaesthetists’ letter confirms that anxieties about safety and the quality of patient care are well founded. I said earlier that the trust is looking for savings in hospital referrals, prescribing, services for older people and mental health provision. I accept that some treatments that are carried out in hospitals can be done elsewhere, and that some treatments have higher priorities than others. None the less, the consequences of the PCT’s plan seem to be that some patients who might have had operations or treatments will not obtain them, that some patients who might have been prescribed drugs will not get them, that some people who might have had follow-up appointments will not have them and that some mental health patients—mental health is, of course, often the poor relation of health care—will be treated in circumstances that are not yet clear. Will the Minister guarantee that a full risk assessment—not, please, the risk description that we had in “Shaping Health Services”—will be made on the proposals that the PCT will put forward for consultation in the spring, and that local doctors and other health professionals will be full partners in the consultation?

Furthermore, can the Minister tell us what impact any cuts will have on improvements that have already been promised, such as the new sexual assault referral centre that will probably, I learned this week, be based in Aylesbury? My hon. Friend the Member for Chesham and Amersham has asked me specifically to mention the Chesham health zone, which was apparently pledged when Chesham hospital was closed. I appreciate that the Minister will say that those are local decisions, and there is some truth in that, but the NHS is a national—I scarcely need to underline that word—health service, for which Ministers have responsibility.

I want now to turn to my third theme, for which there can be no doubt whatsoever that Ministers are responsible. That theme is targets. Conservative Members tend to claim that there are too many targets, that they change too often and that they are too prescriptive, stifling local initiative and accountability. Ministers tend to reply that targets are essential to raise the quality of the service, so I want today to cite a source that is neither Opposition claim or ministerial response, namely Professor Sir Ian Kennedy’s report into the clostridium difficile tragedy at Stoke Mandeville. The report was extremely critical of the precious senior management team at Buckinghamshire Hospitals NHS Trust. Those criticisms naturally tended to grab the headlines when the report was published.

The full report is worth reading closely. On page 89, Sir Ian wrote:

“At Stoke…the increased throughput of patients needed to meet performance targets resulted in patients being moved, difficulties in isolating patients with infection and high occupancy”

rates. There is no suggestion that the trust was unique in that respect. On page 88, Sir Ian wrote:

“There is much in this report to suggest that there may be continuing tensions between the control of infection…and other national priorities”.

That sounds to my ears like a masterpiece of understatement, and suggests that the targets regime was a contributor to the disaster at Stoke. I would be grateful if the Minister told us whether the Department saw a draft of the report before it was published, whether any changes were requested and whether any were made.

Nor can the fourth theme that emerges from circumstances in Bucks over the past few years be shunted away from the Department and from Ministers. We read a lot these days about families with chaotic lifestyles and, indeed, I presume that in the pursuit of health promotion and illness prevention the Department has an interest in reducing such lifestyles. It seems that on closer examination, however, the whole Department is in the grip of a chaotic lifestyle.

When I was first elected in 2001, Wycombe hospital had just been merged with Stoke Mandeville. Since then, the mental health trust has been formed and effectively merged with that in Oxfordshire, primary care groups have become primary care trusts, the three primary care trusts have become one and the strategic health authority has been widened so that its scope includes places as far away from High Wycombe as, say, Ventnor in the Isle of Wight. Not a single combination of chief executive and chairman is the same.

The chief executive at Wycombe hospital when I first arrived, Roy Darby, had been in place for more than 10 years. Wycombe will soon be on its third chief executive in five years—and Stoke, for that matter. Such management chaos and confusion undermines responsibility, weakens accountability, strengthens the temptation to pass the buck and makes sensible medium-term planning in our local NHS all but impossible. There must be—indeed, there is—a link between the unstable and erratic change and the fluctuations in the finances of our local NHS. In 2003-04, Wycombe PCT underspent by £536,000 and the SHA underspent by £4.2 million. In the future, can we please have only change that is built to last?

Finally, and inevitably, comes money. According to the Association of Councils of the Thames Valley Region,

“in 2007-08 PCTs in Thames Valley will in aggregate receive the lowest level of funding per crude head of population of anywhere in England. It will effectively deduct 20 per cent. of the population.”

My colleagues and I were told last week that each Bucks resident receives approximately 18 per cent. less per head of NHS spending than the average resident in England and Wales. I realise that the Minister’s response will be that Bucks is a relatively prosperous area, but that raises some important points.

In even the most prosperous areas there are, of course, pockets of poverty and deprivation. One super output area, as they are now described, in Oakridge and Castlefield in my constituency is ranked among the most deprived 25 per cent. in the country. When it comes to housing, 12 SOAs in my constituency are among the most deprived 20 per cent. in the country and five are in the most deprived 5 per cent. In short, one way of looking at all that is that my poorer constituents are being penalised, in terms of health care funding, for living alongside richer people rather than those who happen to be as poor and deprived as themselves.

There is a wider point. NHS spending is weighted, as we have heard, towards more deprived areas, but it is claimed in some quarters that disease and illness in Britain are relatively evenly distributed. Has the Department considered rebalancing its funding so as to give greater weight to the distribution of illness and disease? What confidence can we have in present financial arrangements when we learn in Monday’s edition of The Times that

“seven times as many community hospitals have closed or are under threat in constituencies held by opposition MPs. There are 62 closed or at-risk hospitals in Conservative constituencies and…11 in Labour areas”

The Times continued:

“The revelation comes a month after The Times disclosed that Ministers and Labour party officials held meetings to work out ways of closing hospitals without jeopardising key marginal seats.”

Many of our constituents will, I am afraid, conclude that they are effectively being punished for not voting Labour.

I accept that NHS budgets are always limited, that not all change is for the worse, and that there have been some improvements. I accept that change is always difficult. However, as our constituents look at their local NHS, they see cuts in their local hospitals, then cuts in the provision of primary care, and then the likelihood, if not the probability, of more cuts in local hospitals—in short, a descending spiral of cuts and closures that leave in their wake transport problems that have yet to be resolved and burning questions about patient safety and the quality of care. Yet all the while existing health bodies are being wiped off the map and senior managers are trooping in and out of revolving doors.

My hon. Friends and my constituents tell me that when the Conservative party was in government life was not perfect, but there seemed at least to be a measure of continuity, stability and predictability. When we were in government, new services were coming to our hospitals, not going out. The blue light now seems to be flashing above at least parts of our local NHS. We hope that the Minister will be able to provide us with some answers.

I congratulate my hon. Friend the Member for Wycombe (Mr. Goodman) on his success in obtaining this afternoon’s debate and on the measured and comprehensive way in which he introduced the subject, which is of massive concern to the constituents of all hon. Members who represent Buckinghamshire constituencies.

I shall touch briefly on three subjects—finance, the implications of housing growth on the health service, and staff morale—but I start by making an acknowledgment on two fronts to the Minister. First, there always has been and always will be change in the national health service. We have to accept that and work with it, but I and my constituents are worried because change in Buckinghamshire seems to be driven by short-term financial crises rather than by a considered assessment of the developing needs of patients and the possibilities of medical science.

Secondly, I happily acknowledge that not everything that has happened under the stewardship of this Government has been wrong. I am sure that the Minister will have in his brief a list of projects that the NHS has completed in Buckinghamshire over the past nine years that he will be able reel off. I remember similar lists being available under the previous Conservative Government.

Yes, very much on the health service. Although the Government have increased considerably the amount of money spent in Bucks and elsewhere, we are entitled to ask why our primary care trust is struggling with a deficit of £18 million—a deficit that it will find difficult to reduce by a mere £3 million during the current financial year. That comes at a time when the county faces a further reconfiguration of hospital services next year and when our constituents are experiencing cuts in the quality and scope of the health care available to them locally day by day.

I turn to the funding formula. I accept that the NHS budget is finite, and that the principle of having some form of distribution formula based on need is correct. However, like my hon. Friend the Member for Wycombe, I rely not on a Conservative party handout for my comments on the impact of the distribution formula but on a more independent source. I shall make considerable reference to board paper 33/06, published by the Thames Valley strategic health authority in May under the signature of Nicholas Relph, the then chief executive.

The paper found that by 2007-08, the average primary care trust in England would get £1,388 per head to spend on health care, while the average PCT in Thames Valley, covering the counties of Buckinghamshire, Berkshire and Oxfordshire, would receive £1,125 per head. As my hon. Friend pointed out, that is the lowest per capita rate anywhere in England. If Thames Valley were funded at the national average, it would receive an extra £575 million per year extra; if it were funded at the level of the highest paid—I do not argue for that today—it would have an extra £1.1 billion for local health spending. Mr. Relph’s conclusion was that the distribution impact of the formula is so significant that it must be asked whether it is too great, and that it leaves some parts of the country with such a low level of funding that the range of care provided will have to be constrained. The board paper went on to say:

“What might be considered core services elsewhere will have to be critically examined to see if they are affordable.”

That is the considered view of a senior professional health service executive who was responsible for NHS resources in our area.

The charge is sometimes levelled that such deficits are down to inefficient management, so let us consider the figures provided by the strategic health authority. The official NHS analysis shows that in the most recent year for which figures were available, 2003-04, Thames Valley had the fourth most efficient services in England, that admissions were well under the English average, that prescription costs were likewise below the average, and that the number of available bed-days in hospital were considerably less than the average. It is not inefficiency that is at the heart of the problem. The truth, in Mr. Relph’s words, is that

“in order to balance the books commissioning PCTs should be purchasing 21 per cent. less acute community, mental health and other services than the English average PCT. It follows that in Thames Valley we should have one fifth lower hospital, mental health and community provision than the English average.”

What does that mean for my constituents? Children who are diagnosed as needing speech and language therapy are being refused treatment and funding. At one school in my constituency, physiotherapy for physically disabled children at a special unit has been halved in frequency. I was told last week that child protection work is done by a community nurse who is so overstretched that she is unable ever to meet other members of her child protection team. The entire overnight community nursing service is now under threat and may be axed.

The Ian Rennie hospice at home has written to Members of Parliament and others to say that it is struggling to meet the demands placed on it and points out that only 14 per cent. of its costs—less than half the national average for PCT funding of hospices—are being met by the Buckinghamshire primary care trust. I ask the Minister seriously to consider—not in his speech, because he will have prepared a brief, but perhaps after the debate—whether the current distribution formula is not putting at risk some basic core health services in constituencies such as mine.

The hon. Gentleman makes a powerful case on behalf of his constituents, but I want to apply the logic of his argument as it applies to other constituencies. Is he saying that NHS money should be taken away from parts of the country where people die younger than in his constituency?

I am looking not only at the straightforward matter of distribution but at the structure of the allocation system, and separating those parts of the NHS budget for which the costs are more or less the same throughout the country from those matters that are variable. I hope that my hon. Friend the Member for Westbury (Dr. Murrison) will be able to take up that issue if he catches your eye later, Mr. Cummings.

The growth of Aylesbury is of huge importance not only to me, but to my hon. Friends the Members for Buckingham (John Bercow) and for North-East Milton Keynes (Mr. Lancaster). As the Minister knows, the Government have decided to impose significant new housing growth on Buckinghamshire, and particularly on the Aylesbury vale area and Milton Keynes. Our area is one of the four zones in the south-east that have been designated by the Minister’s colleagues in the Government for major growth over the next 15 years. That clearly has serious implications for health provision.

Last year, senior health service managers in the Milton Keynes and south midlands area jointly commissioned an independent report from the Hedra consortium—

Sitting suspended for Divisions in the House.

On resuming—

I am advised that it is in order to proceed without the Minister being here. I am sure that he will attend as soon as possible.

I am sure that in the Minister’s absence invisible hands will be making notes on further contributions to this debate to make sure that he is adequately briefed when he returns.

I was referring to the impact on health services of the Government’s plans for significant residential growth in the Aylesbury vale and Milton Keynes areas. I want to make two points—about the capacity of health provision that will be needed and the pace at which funding responds to population growth.

First, last year the chief executives of trusts in the Milton Keynes and south midlands growth area commissioned an independent report from the Hedra consortium about the impact on local health facilities of the Government’s plans for growth. The conclusion of that report was that the Milton Keynes and Aylesbury vale areas alone will, if the Government’s plans come to fruition, need 178 additional hospital beds by 2021 and 430 by 2031. Those are just acute hospital beds. The report added that within the same time frame an extra 958 community beds and 639 community day places will be needed.

Throughout that independent report ran a consistent theme: it would be a strain on the NHS to accommodate the demands of a significant rise in population and that it could be accomplished only on the assumption that the NHS would be able to reduce the average length of stay in acute hospitals and the provision of community and domiciliary services could be improved. Yet, in Aylesbury and elsewhere in Buckinghamshire today we are seeing measures to cut back on community and domiciliary care services. On the assessment of the primary care trust, there is the consequent impact of additional admissions to acute hospitals and longer stays, with additional numbers of delayed discharges.

Secondly, I was talking on Friday to local GPs about the pace at which funding responds to population growth. They said that, although it is true that, in time, additional per capita funding follows a growth in population, what the Department quaintly terms “the normalisation procedure” means a gap of as much as 18 months between new people arriving and health funding being delivered to local trusts and GP practices. That gap is too great, particularly if there is an increase in population of some thousands each year for a decade and more. There needs to be a much smaller gap between the establishment of the need, the increasing demand for health treatment and the delivery of resources to meet that demand.

I also want to deal with the effect of the crisis in the Buckinghamshire national health service on NHS staff. I endorse everything that my hon. Friend the Member for Wycombe said in praise of those staff. They have been subjected to constant reorganisations, myriad targets and other changes. I shall give the Minister a couple of illustrations drawn from a meeting that I had last week with doctors from the Mandeville and Elmhurst surgery in my constituency. That practice serves an area that is as far removed from the caricature of leafy Buckinghamshire as can be imagined; it serves two of the poorest council estates in my constituency.

The doctors first told me about independent treatment centres. I have no problem with the principle of independent treatment centres and involving the independent sector in providing NHS care on contract. However, the doctors told me that the practice has £65,000 deducted from its budget each year as a notional contribution to the cost of independent treatment centres, but that the nearest ITCs are not in Aylesbury. They are in Banbury, Reading and Milton Keynes, which are a minimum of an hour away by car and for which public transport is at best inconvenient and at worst non-existent. When the doctors’ patients ask, “Why on earth do we have to go to those places? Can’t we go to Stoke Mandeville hospital just around the corner?” The doctors usually say, “Yes, you’re right”, because in Southcourt ward, which is served by the practice, 35 per cent. of households have no car. Common sense tells us that those without a car are most likely to be pensioner households, and pensioners are the biggest consumers of health care and most likely to be in need of elective operations. Therefore, the location of those ITCs is doing little good for the patients of that Aylesbury practice. Money is being taken away in return for slots at ITCs that cannot be of service to the patients in the Southcourt, Walton court and Elmhurst estates. The Government need to look at that again. I support bringing independent advisers into the NHS, but they should be brought into the same framework of money following treatment—payment by results—as existing provider institutions.

The second anecdote is about the enhanced services budget, which in this case went to provide a minor injuries service at the Mandeville and Elmhurst practice. The tariff for treating a minor injury was £50. The practice could actually do it for £15, but the crisis of funding at the PCT meant that the service was cut. The result was fairly predictable: patients were instead referred to the local accident and emergency department where the treatment for a minor injury costs £100 a case. No money was saved for the local health economy; the bill has actually gone up and the PCT is now trying to work out how to reinvent the service that it had got rid of in order to try to save money. It is little wonder that staff are frustrated and in many cases very angry.

I am prepared to believe that Health Ministers from any political party discharge their responsibilities with the best of intentions towards the health service and those who work in it, but in the past year senior executives and non-executive directors have telephoned me on their private mobiles from their homes and told me that they are doing so because they dare not tell the truth about the local NHS from their offices as the Department of Health can and will interrogate them on whom they have been telephoning and to whom they have been sending e-mails.

I have had in my constituency surgery health managers and health visitors who are at the sharp end of the service wanting to tell me about their disquiet about what is going on, but begging me not, under any circumstances, to reveal their names because they fear for their jobs. In the past month, I have had nurses saying to me that they are afraid to speak out about the changes proposed for reductions in primary care services in Buckinghamshire and that they have been reminded by management of their duty of confidentiality and that they should attend classes on how to prepare and present their CVs in preparation for when they will need to reapply for posts under the new structure. I am genuinely sorry to say that there is, in my experience, a culture of fear among a great number of national health service staff at the moment. Any Government of any political party ought to hang their head in shame over that.

Between them, my hon. Friends the Members for Wycombe (Mr. Goodman) and for Aylesbury (Mr. Lidington) have offered the House an erudite and clinical exposé of the NHS crisis in Buckinghamshire and of the Government’s culpability for it. In the short time available to me, I should like to focus narrowly on two issues within the NHS of particular concern to me and to the substantial number of constituents who have approached me about them.

First, I should like to focus the attention of the Chamber and the Minister on speech and language therapy. In the vale of Aylesbury, five and a half whole-time equivalent speech and language therapists cater to the needs of the entire area. It is posited that in due course that number will rise with the amalgamation of the local primary care trusts, but there is no guarantee of that happening. We are talking about five and a half such qualified personnel for the whole of the vale of Aylesbury. There is a recruitment freeze now, which seems set to continue for an indefinite period, so an increase in staff is simply not on the agenda. As we speak, the human consequence of that freeze and of the manifestly inadequate resource available is clear for all to see. Two hundred children in the vale are waiting. They have serious problems and need help, but they have not been diagnosed or assessed and, in the vast majority of cases to which I am referring, they have not been seen at all.

From the panoply of cases that have come to my attention, I should like to focus simply on one, that of two-and-a-half-year-old Peter Metcalfe; he will be three on 13 December this year. His mother, Brenda, is understandably upset and furious about the situation in which she and her young son find themselves. They were seen by a health visitor in November 2005. It was clear that there was a problem, although at that stage the extent of it was uncertain. They were told that an appointment could be made for three to six months’ time, at which progress could be reviewed. Specifically at that point—I underline the significance of this—Brenda Metcalfe was told that, in the event that she wanted at that stage to have an assessment, an immediate assessment could be provided at a drop-in centre.

June 2006 is reached, the health visitor comes and the extent of the problem is clearer. The extent to which the young boy is behind where he should be is apparent to the health visitor and to the mother, and she of course then wants an assessment. She goes to the PCT and asks for an assessment, but is told, “No, you can’t have an assessment. There’s no prospect of that at the moment. There is a recruitment freeze. We have a cash crisis. The service isn’t available. Nothing can be done to assist your child.” In the circumstances, it is absolutely understandable that Mrs. Metcalfe is disorientated and disgusted by the lack of help available from the PCT for her young child. There is nothing on offer.

Subsequently, to add insult to injury, two suggestions were made to Mrs. Metcalfe, and I think that my right hon. and hon. Friends will testify that this is symptomatic of a wider picture. First, Mrs. Metcalfe was offered a meeting. She had a meeting, but it was utterly pointless, as it transpired, for it turned out to involve simply an explanation of the financial difficulties besetting the NHS in the vale of Aylesbury and of the steps that the local PCT was taking to seek to address those problems. There was no offer made, no hope held out, and no assistance on the table.

The first offer, of a meeting, raised expectations and was taken up, only for those expectations to be dampened. The second proposition was, “Go private.” First, very large numbers of people cannot for one moment contemplate going private because they simply cannot afford to do so. Ministers need to understand that point and to lodge it firmly in their heads. Secondly, even for people who can contemplate the possibility of going private, why on earth should we in what is supposed to be a national health service freely available to people on the basis of clinical need and not on the strength of capacity to pay?

The reality is that Peter Metcalfe, approaching his third birthday with a very severe problem of speech and language difficulties that requires immediate attention, is not getting that attention. The point that I want to emphasise in this context is the manifest disparity between what Ministers say and what is medically understood to be important on the one hand, and what is happening at the coal face on the other. In the special educational needs codes of practice, as this Minister will be well aware, it is underlined almost in triplicate that it is important to identify special educational needs as early as possible. To that observation is added the significant observation that once those needs have been identified, early action is vital to address them. That is said there, but it is also said elsewhere, in the Department for Education and Skills 2005 advice to parents. In that context, it is on the record what Ministers think on the strength of the professional advice that they have received. The document states:

“Language is the core to all social interaction. Without it, a child is isolated.”

As the father of a child who has significant speech and language difficulties, I can readily testify to the reality of that state of affairs.

In “Every Child Matters”, the Government have once again pinpointed the significance of early intervention. It is not only that early intervention is valuable; there are significant downsides in its absence. If there is not early intervention to tackle speech and language problems—the problem being suffered by so many children in the vale of Aylesbury—real problems result. There are likely to be emotional and psychological difficulties. Educational attainment will be lower. There will be a persistent communication handicap and there will be damaged employment prospects to boot. In very practical terms, grave and possibly irreparable damage can result.

I hope that the Minister will understand when I say to him that it is reasonable for hon. Members to expect consistency between the words that Ministers utter and the deeds that they do—between the promise and the performance—and that is lacking at the moment. I am grievously concerned about large numbers of children in my constituency who are suffering and will continue to suffer unless they get the help that they need. They will not be able to access the national curriculum. They will have damaged prospects in school and their chances of acquiring the training, education and qualifications that they need will be significantly undermined.

A second problem, to which I want briefly to allude, is the threat to the district nursing service. A cut of 50 in the number of district nurses is on the table for Buckinghamshire; that is the proposal. I have met countless constituents who have said what an enormously valuable service it is. I think of Arthur Christian, who wrote to me recently. He is a cancer patient who has been a direct beneficiary of the district nursing service. We are talking about qualified specialist high-achieving nurses, capable of performing a wide and disparate range of specialist tasks for the benefit of patients. If the district nursing service is slashed, people such as Arthur Christian will lose out in consequence. Again, I point to the disparity between promises made and performance achieved to date. It is not merely that my hon. Friends and I are wont to invoke the merits of the district nursing service; the Government themselves have consistently been doing precisely that.

The Secretary of State for Work and Pensions, when he was Minister of State in the Department of Health, acknowledged and highlighted in a written answer on 8 September 2003 the importance of the work of the district nursing service. He said that he wanted that work to be extended and that a greater prominence should be given to the role of the district nurse. In pursuit of that worthy and noble ambition, he announced that he had issued a document entitled, “Liberating the Talents: Helping Primary Care Trusts and nurses to deliver The NHS Plan”, so he thought that it mattered. The Government reckon that it is important but now propose a scenario of substantial reductions in the numbers of district nurses, and their replacement by less well qualified and, inevitably, less dextrous health care assistants. That is not to knock them, but they are not as well qualified.

My hon. Friends have touched on a plethora of serious concerns that affect our constituents. I underline in particular my anxiety about the prospects for an expanded Aylesbury vale if the Government do not get their act together and focus in an intellectually muscular fashion on the task before them. I am expected to absorb another 1,000 houses a year in Aylesbury vale, and my hon. Friend the Member for North-East Milton Keynes (Mr. Lancaster) has to contemplate the prospect of a substantial increase in the population of his community. We are already underfunded and there are major service problems. Significant parts of the national health service in our communities will become inoperable unless the Government recognise that an increased population will inevitably bring an increase in the number of children, in the demand on services and in the requirement for appropriate funding, which is not there.

I like the Minister very much and have a high regard for him. I have liaised with him about the Nuffield speech and language unit and he has been courtesy and responsiveness itself. I appeal to him—whose career, as long as this Government are in office, I wish well—to go better than the average. He should not content himself simply with reading out the prepared brief. He is a bright man and I look to him to respond to the serious points that my hon. Friends and I have sought to put on the table, not in the spirit of political partisanship, but in the interests of our long-suffering constituents. Too many of them have suffered too much for too long with too little being done about it, and that must change.

I remind hon. Members that the debate will conclude at 4.30 pm. I have one more speaker on my list, and of course there are three winding-up speeches.

It is a pleasure to speak with you in the Chair, Mr. Cummings. I congratulate my hon. Friend the Member for Wycombe (Mr. Goodman) on securing this valuable and timely debate. I shall be brief so that other Members can contribute.

I start by thanking the staff at Milton Keynes primary care trust and the hospital for their sterling work in difficult circumstances. If there is one question that I want the Minister to answer, it is this: why at a time when the Government are forcing Milton Keynes to expand are they forcing our health service to shrink? That is simply unacceptable. My hon. Friend the Member for Aylesbury (Mr. Lidington) touched on the normalisation procedure—the time delay between the increase in population and the funding that follows, which can be up to 18 months. Currently, 13 people a day are moving to Milton Keynes. That is 7,000 people in an 18-month period, which means a potential lag in funding of 7,000 people. That is why a local general practitioners’ practice in Milton Keynes village has had to close its books; it is full. Due to financial constraints, the PCT is delaying issuing a new contract. Those are the sorts of problems that we have.

Our funding allocation in Milton Keynes is not quite as bad as it is for other hon. Members elsewhere in Buckinghamshire. We receive 95 per cent. of the national average, but that is still 5 per cent. below the national average. Earlier this year, I outlined the impact that the £5.5 million levy that the strategic health authority forced the PCT to cut from its funding has had on our services. In a moment, I shall touch on the effect that it has had on adult mental health services in Milton Keynes.

Last week was a bad week for health care in Milton Keynes, because, following another 6.2 per cent. cut, Milton Keynes hospital had to withdraw its application for foundation status. That is a major blow for the people of Milton Keynes.

The Government cuts are having an impact on adult mental health services in Milton Keynes. There have been many reports, both nationally and in Milton Keynes, offering visions of how the needs of people who experience mental health difficulties should be met. Two recent Government reports are particularly relevant. The first, “Our health, our care, our say: Making it happen”, has visions of creating health and social care services that generally focus on prevention and promoting health. Another report, “Improving Services, Improving Lives”—these are great titles—proposes to give local people a more direct influence over the services that they receive.

At a local level, a July 2005 report by the Sainsbury Centre for Mental Health proposed a restructuring of the mental health service to give a single point of contact for new referrals; a 24/7 service, including an out-of-hours phone number; a greater focus on recovery in its broadest sense; and a move away from the domination of a medical model of mental illness to a more holistic service. Those are great aims, and were broadly supported by service users in Milton Keynes, but, at a time when it has been agreed that our mental health services need additional funding, the cuts mean that the proposals that were recently consulted on will not be fully delivered. The cuts will affect community-based day services, a memory screening clinic and a community drug and alcohol service. That is a major blow for people in Milton Keynes.

Back in July, I presented a petition with the names of local service users to which the Government response was, unfortunately, “No comment.” They simply do not seem to care about what is happening in Milton Keynes and Buckinghamshire, or about the impact of the cuts. Exactly the same thing happened with the closure of the Fraser day hospital in Newport Pagnell. My hon. Friend the Member for Aylesbury outlined a report that shows how many more places we need, yet we are closing day hospitals. I simply do not understand.

I am conscious of the time, so I shall finish where I started—with staff. What does the Minister suggest that I should say to my constituent, Paula Gawronska, who came to my surgery on Friday to explain that, having just finished her nursing degree in Liverpool, she is pulling pints in Milton Keynes to pay off her £12,000 student loan debt because there are simply no jobs for nurses in Milton Keynes or, it would appear, anywhere else in the national health service?

I do not want to repeat the comments of my hon. Friends. My constituency is the southernmost constituency in Buckinghamshire, so there is an issue about people using services outside the county, which is an essential part of living in a border area.

I could not fail to notice that, when my hon. Friend the Member for Aylesbury (Mr. Lidington) suggested that there was once better predictability in the NHS, a wry smile seemed to pass across the Minister’s face. Given the amount of money that the Government have sunk into the NHS in the past nine years—I am the first to acknowledge that—which constitutes a substantial increase in real terms, the problem that I face as an MP in Buckinghamshire is in understanding how that money has been spent locally and why we face a constant cutting of services, which is currently on an accelerating pattern from an already low base. I hope that the Minister will enlighten us on that. The point has been well made about our overall underfunding in national terms, but if the Government strategy were working, I would expect that somewhere along the line, some little crumbs from the cornucopia of money being spent would be falling off the table towards us. However, that is far removed from the reality of local health services. That is the key issue that the Minister must address in his reply.

It is easy for us to cite examples. In a sense, that is all we can do as MPs, because we have to marry up what the Government tell us in theory with what the evidence and anecdote tell us in practice. First, criticisms are sometimes made of those who run our hospital health trusts and PCTs. In nine years, I have, on the whole, been impressed with the people who run our NHS trusts and PCTs. We have had differences, but I do not think that the place has been run by incompetents. Therefore, the overall impression I derive is that people are labouring under impossible conditions. The report by Professor Sir Ian Kennedy on clostridium difficile at Stoke Mandeville hospital amply illustrates that point: targets are incapable of being met without disrupting clinical practice.

Another example comes from Wexham Park hospital, just across the border, on which a great many of my constituents depend—this is the border issue that I raise with the Minister. Evidence has been presented to me by nurses about management interference in clinical judgments on who should be seen in the accident and emergency department. Decisions might depend on the amount of time that people have spent there. At Wexham Park, as the four-hour point approaches, managers come down from their offices to redirect the nursing and medical staff towards their own priorities and not those of the nursing and medical staff. I am sure that that is occurring.

Secondly, anecdotally, I am told that the Haleacre unit for mental health at Amersham is unfit for purpose. That is clear, and anyone who goes to have a look at it can see that for themselves. When my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan) and I visited it, we were appalled at the demoralisation of the staff and the general conditions. To learn that it needs replacement and then to find, to our amazement, that somebody has decided that it can manage on refurbishment is another illustration of the extent of the crisis that we are facing.

The points have been made about specialist services, speech therapy, which is raised with me frequently, and the understaffing of the child and adolescent psychiatric unit at Amersham, which means that children are waiting far too long to be seen. There is a constant sense of disruption. We are also facing a 50 per cent. cut in district nurses. No sooner has something become a centre of excellence, for example, a physiotherapy service offered by a particular practice, than it is chopped, because a decision is taken that it is absorbing too much money in one location and the money must be redistributed more generally. All those things are pictures of a service in crisis.

I shall give the Minister one final example. It concerns a constituent, who, following a failed operation for a hernia at Wexham Park hospital, developed a fistula. She was sent to St. Mark’s hospital in west London, at Northwick Park. At that stage, it was thought that she would die very quickly, but the Northwick Park and St. Mark’s hospitals thought that they could do something for her. She received excellent specialist care, but it became clear that they had done as much for her as was possible, and that her condition could be managed but not cured. Her returning to Buckinghamshire totally fazed the ability of the PCT and the health trust to manage it, until we finally got to strategic health authority level. It was managed; she died eventually, but she got the services and support she needed.

That did not illustrate to me that these people were uncaring. It illustrated that the moment we put something slightly unusual into the system, it had no flexibility to respond to it. The district nurses pointed out that her case was so difficult to manage that management at home was being proposed, partly for financial reasons although I am sure, it was impossible. The local hospital did not have the resources to do it, and the thing had to be put together as a special package. That does not surprise me, but it troubles me that it needed so much external interference from Members of Parliament and others to sort out a straightforward management problem of a seriously ill patient that ought to be capable of being resolved routinely. That is the extent to which our services are overstretched and cannot cope.

A new raft of cuts are coming up, which we have heard about. I should be interested to hear the Minister’s comments about how he thinks the savings in the PCTs will be achieved without closing community hospitals. I think it almost inevitable that such closures will happen, yet we are told that community hospitals are now rather an important priority for Government. How does the Minister reconcile those two concepts?

The truth is that Buckinghamshire remains seriously underfunded. The hon. Member for Northavon (Steve Webb) raised a point: where there is underfunding, is there a proposal that we should take money from elsewhere, where the need appears to be greater? I am not in a position to answer that question. I am able to say that the redistribution of wealth from wealthy to poorer areas is the precondition of the running of a unitary state, so I accept it. However, I worry not that what is being done is an equalisation to provide a uniformity of service, but that the end result is that those who are disadvantaged in my constituency—despite its being wealthy, there are many disadvantaged people; one ward is listed in the indices of disadvantage—are getting some of the poorest services in the land. They would be far better off moving to north Liverpool. Although there might be other drawbacks of doing so, their health care per head of population and the expenditure would be much greater.

I do not want the Minister to give us a list of what is being done through spending money or capital projects. Some of those may be worthy, but if the revenue expenditure does not accompany it, they will never function properly. I am eager to hear him explain how a Government that are apparently spending so much taxpayers’ money and raising so much more for the national health service than in 1997 should have an area such as Buckinghamshire where the history of service provision is one of continuous cutback.

I am sure that all hon. Members wish to give the Minister plenty of time to respond, so I shall curtail my planned remarks. I am sure that my Conservative counterpart will do the same. I congratulate the hon. Member for Wycombe (Mr. Goodman) on securing this debate. I believe that it is not the first debate that he has secured in the House on health services in Buckinghamshire. I share the good wishes he gave to the hon. Member for Chesham and Amersham (Mrs. Gillan), who I think took part in the last such debate.

The contributors to this debate have all spoken powerfully on behalf of their constituents in Buckinghamshire, and rightly so. One of the interesting features of participating in these debates as a Front-Bench spokesman is that I get to see certain trends occurring across the counties. Some of the examples from Buckinghamshire that we have heard are all too often mirrored in other areas, and I should like to give one example of that.

Clearly, there is always a legitimate argument to say that hospital services should not be set in stone, that they can be looked at and that reconfiguration can be considered. The two preconditions for any consideration of reconfiguration are that it should be clinically driven and locally accountable. The example given by the hon. Member for Wycombe, where the clinicians, local politicians of all parties and local people appear to be pretty much uniformly against the proposals, is a classic case of where the system is failing.

Nobody is arguing that there should not be change in the NHS as we learn new ways of doing things. Perhaps we can do things better. We know that population shifts and that transport networks change, so there is no argument that there should not be review and reform. However, as the hon. Member for Aylesbury (Mr. Lidington) said, it should be driven not by short-term financial crisis management, but by long-term strategic planning. It should also be democratically accountable, with not merely the consent but the active support of the clinicians, to whom one would hope the Government were listening. I agree that when that does not happen it is simply unacceptable.

We lack democratic accountability in the NHS, because where local people are not happy with the reform, as has happened in Buckinghamshire, the best that they can ultimately do is appeal to the mercies of the Secretary of State, who may or may not refer it to an independent reconfiguration panel, in itself a quango. If the Secretary of State declines to refer it, that is it. Clearly, one can campaign in all sorts of other ways, but the only democratic back-stop to reform in Buckinghamshire, as elsewhere, is the Secretary of State, who may simply decide not to refer or reconsider, and then the deal goes through.

We have also heard from the hon. Member for Wycombe about the knock-on effects when money is tight in primary care trusts. Some eloquent contributions have been made about what gets cut. We have heard about cuts in mental health services. All too often, it is the apparently peripheral services—the unfashionable services, where perhaps the client groups are least able to shout the loudest—who suffer. The hon. Member for Buckingham (John Bercow) spoke effectively and made a powerful contribution about the impact of the cuts in speech and language therapy. No doubt the Minister will read out lists of millions and billions of pounds. Nothing can be done without millions and billions of pounds, but the financial straits in which the hon. Member’s constituents find themselves have a human impact. I hope that the Minister will respond to the hon. Gentleman’s plea and explain whether the Government have any views on how the problems with speech and language therapy in Buckinghamshire will be addressed. I hope that he will not simply say that that is a local problem for the hon. Gentleman, which is what I presume he will say.

The hon. Member for North-East Milton Keynes (Mr. Lancaster) highlighted a problem that is peculiar to Milton Keynes and applies more broadly in Buckinghamshire—population growth. My friend and colleague, Jane Carr—I am sure that the hon. Gentleman knows her—gave me a briefing about the situation in Milton Keynes which tallies with what he said. She said that the population growth in Milton Keynes is such that the area requires a class of children a week. Clearly, the figures must reflect that, but they must reflect it more quickly because capital costs are involved in adjusting to a rapidly rising population. Marginal increments are not sufficient. New facilities are required and there is clearly a time lag before they can be put in place. If the money does not come through for 18 months or more, that makes things difficult for people on the ground.

First, I accept that the calculation of the entitlement of a particular area should be based on accurate figures. In the case of Milton Keynes, it is widely accepted that it was not based on accurate figures. Secondly, it should adjust promptly to the situation on the ground. Thirdly, if there is a formula, leaving aside what it is, and 100 per cent. of the funding under that formula is available, areas should receive 100 per cent., not 95 or 97 per cent. I agree with the contributions that we have heard on that point.

I raised an important point during an intervention. If I were a Member of Parliament for Buckinghamshire, I would have done precisely what the hon. Members who have spoken have done—plead for more money for their constituents. There is no reason why they should not do that because the financial pressures in Buckinghamshire are clearly leading to some practical problems. However, Conservative Front Benchers cannot say that they want more money in Buckinghamshire, Bedfordshire and Hertfordshire—I have taken part in all those debates—without simultaneously saying that they want less money in north Liverpool, Manchester and so on, which was implied. It is reasonable for a political party to say at an election that it will give more money to the south of England if people vote for it and less money to the north of England. If that is the prospectus for the next election, the electorate can make a fair choice.

I shall let the hon. Gentleman speak in a moment.

It is legitimate to raise a debate about the formula and whether the weightings are correct, but I hope that the debate will be consistent because I do not want hon. Members to say one thing in one part of the country and something else in another part.

On the substance of the debate, clearly, there are pressures in Buckinghamshire because of data being out of date, information not being updated, and not being paid at 100 per cent. as should be the case, whatever the formula. Those points have rightly been raised and I hope that the Minister will make a constructive response.

The hon. Member for Northavon (Steve Webb) did not give way to me, as is his right, but had he done so I would have pointed out that he is defending a system that results in his constituents in south Gloucestershire receiving £227 per capita in 2006-07, less than the English average, and £245 in the coming financial year. The correspondent for the Western Daily Press was sitting in the Gallery earlier but has now departed and I am sure that he will be interested to hear the hon. Gentleman’s justification for defending a system that so clearly sees off his constituents, as it sees off mine and those of my hon. Friends who have spoken so eloquently today.

I congratulate my hon. Friend the Member for Wycombe (Mr. Goodman) on securing this debate and on introducing it in his usual robust way. I am pleased to hear that my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan), even from her sick bed, has contributed to this debate by proxy.

Where Buckinghamshire fits into the Secretary of State’s heat map is uncertain. Our freedom of information request on this subject comes to light in a few days—we hope that the response will be free and frank, otherwise we shall apply to the Information Commissioner. My suspicion is that it will show Buckinghamshire as being pretty cold. The reason for that is deficits, which lie at the heart of the difficulties that my hon. Friends have expressed and that I have experienced in my constituency. It beggars belief that the Secretary of State can claim that it is all down to bad managers, which is her thesis. Bad managers choose their appointments for many reasons, but I fear that they do not choose them based on whether there is a Conservative Member of Parliament representing their area. Perhaps it would be a good thing if they did so, but they most certainly do not. We must nail that first and foremost.

We are talking about a matter to do with the funding formula. The hon. Member for Northavon raised it and I shall talk about it in some depth because it relates directly to what my hon. Friends said. Indeed, it lies at the heart of that.

I hope that the Minister has read the work produced by Professor Asthana and Dr. Alex Gibson. He should have done because it was recently submitted in evidence to the Select Committee on Health. They work from the university of Plymouth and have done extensive work on the funding formula. If the Minister has not read it, I seriously recommend that he does so without delay. It points out clearly that deficits are strongly associated with per capita allocation of funding and levels of deprivation. However, it is old age that drives cost in the national health service and the Minister should know that. Old age overwhelmingly causes costs to be generated within the national health service and as diseases of old age—chronic diseases and long-term conditions—become more and more prevalent, it will need more and more focus in a funding formula that since 2003 has given equal weight to measures of social deprivation as it does to old age.

The gradient in the prevalence of chronic disease is much steeper across age bands than across social class bands. I appreciate that the Secretary of State has a particular political axe to grind, and my hon. Friend the Member for Beaconsfield (Mr. Grieve) touched on redistribution. We all accept that redistribution is what Parliament does. It is part of the deal. However, I suggest that redistribution through the funding formula for the national health service is inappropriate and takes us away from what we should be doing: funding disease burden and health care need. What drives those above all else is age. We must all appreciate that because we are all getting older and will increasingly become prey to such conditions, which I fear will be insufficiently funded because of the funding formula that has operated since 2003, when parity was achieved between indices of social deprivation and old age in terms of how funding is apportioned.

The market forces factor also weighs on Buckinghamshire. It is meant to equalise costs in metropolitan and non-metropolitan areas with particular reference to incomes, but the national health service has national pay scales, so market forces do not apply to the NHS to the extent that they do elsewhere. However, they are still a factor. Many of us believe that that should operate in reverse in many of our rural constituencies, such as Buckinghamshire, because we all know that more senior and elderly people tend to work in non-metropolitan areas. We have seen that in primary schools, where there is a particular problem in village schools, which face staff costs far in excess of those in more urban centres. It certainly applies in the NHS.

We see no reflection of rurality—

By my reckoning, Mr. Cummings, I have seven minutes and I have spoken for five, unless you wish to correct me.

Thank you, Mr. Cummings.

There has been no reflection of rurality in the funding formula, except in the ambulance service, and we need that. The solution is to have some flexibility on brokerage, which the Secretary of State has removed. That lies at the heart of what Buckinghamshire is experiencing. The brokerage that levelled up the unequal funding formula that I have described has been removed. In the long term, deficits should not recur, and we must consider service items in the national health service using a formula that is based more on the age demographic of the population, and less on social factors.

In response to the hon. Member for Northavon, it is equally important that we fund public health properly. We must separate it from service funding in the national health service, because health inequalities have got worse under this Government. We will not address those problems unless we isolate public health funding and deal directly and transparently with such difficulties as obesity, hypertension and hypercholesterolemia, which are arguably more prevalent in some of the communities to which the hon. Gentleman referred.

It has been a good debate, and I pay tribute to the hon. Member for Wycombe (Mr. Goodman) for securing it. I also pass on my good wishes to the hon. Member for Chesham and Amersham (Mrs. Gillan). I inherited her office when I took over at the Department for Education and Skills, and the curtains were very interesting, indeed. I pay tribute also to the hon. Members for Aylesbury (Mr. Lidington), for Buckingham (John Bercow), for North-East Milton Keynes (Mr. Lancaster) and for Beaconsfield (Mr. Grieve) for their contributions.

I begin by praising all national health service staff who make a difference in those hon. Members’ constituencies and throughout the country. We are united in the belief that staff on the front line make a tremendous difference to the quality of people’s lives. On many occasions, national health service staff go further than that by saving people’s lives.

I shall try to address sensibly and reasonably the comments of most hon. Members. First, however, I shall deal with the contribution from the hon. Member for Westbury (Dr. Murrison). It goes beyond the pale when a Front-Bench spokesman on behalf of Her Majesty’s loyal Opposition seemingly suffers memory loss. When the hon. Gentleman’s party left office in 1997, the national health service was by any standards and measure a complete shambles and in a complete mess. Subsequently, the Conservatives have repeatedly voted in the House of Commons against our proposals, particularly against our most significant proposal to increase national insurance to enable us to put far more money into the NHS.

At the last general election, the Leader of the Opposition wrote a manifesto that suggested the best way of reorganising the NHS was to incentivise people to leave the health service and spend money in the private health care sector. When the hon. Member for Westbury starts lecturing me on public health, I say to him that the Conservatives were the party that banned the use of “poverty” when it came to the development of any element of public policy. Let us please have a balanced debate about what is happening in hon. Members’ constituencies. He should not be impudent when he describes the health service and the improvements that have been made.

Hon. Members cannot argue for independence and the devolution of power to the front line in the health service, and then attend debates such as this day after day, demanding ministerial intervention in individual cases, reconfiguration and the prioritisation of resources in their local health economies. The two positions are intellectually incoherent.

On the question of the fair distribution of resources, we agree that public resources are always finite. The Government will always be required to make decisions about the distribution of resources, and we make no apologies for saying that those areas with higher levels of social exclusion, deprivation and health inequalities needed a larger share of the cake than they had received historically. That is why we reordered the formula. Some constituencies that have benefited are represented by Opposition Members, and I wonder how they would feel if we started to redirect resources. The issue is about fairness, and I do not apologise for focusing resources where health inequality is at its most acute.

I say also to the hon. Member for Westbury that we are right to say to the health service, “You have a budget, and finally, you have a duty and a responsibility to balance that budget just like any other organisation in the public or private sectors.” We cannot move forward organisationally until we control our finances. It is a basic fact for any organisation responding to perpetual change. If its finances are not under control, it is difficult to make the necessary changes.

I shall respond to the specific points that hon. Members have made about their constituencies, but if I do not reach their questions, I shall write to them in detail wherever I can. Buckinghamshire primary care trusts received £524.8 million for the financial year 2006-07, and they will receive £573.5 million in 2007-08. That represents a 19 per cent increase over two years, and by any standards, a significant year-on-year increase.

The hon. Member for Beaconsfield asked what the funding has bought. I shall tell him. It has been instrumental in the fact that no patient in Buckinghamshire waits longer than 26 weeks for in-patient treatment and no patient waits longer than 13 weeks for out-patient treatment. No cancer patient waits more than two weeks from referral to being seen by a specialist, and more than 96 per cent. of people on being diagnosed with cancer wait fewer than two months after referral to be seen by a specialist. Without targets, many objectives would not be achieved. We should debate the right and smart targets, and the unintended consequences of targets, but it is nonsense to suggest, as the Opposition do, that we ought not to have targets for public service outcomes and delivery.

The increased funding has paid for 5,612 more nurses, 794 more consultants, 481 more GPs and 635 more dentists in the NHS south central area since 1997. It has allowed the provision of single specialist medical units for cardiology, respiratory and haematology, and a new stroke unit at Wycombe hospital. First-year data analysis from the strategic health authority shows reductions in length of stay, and improvements in outcomes such as mortality rates.

Hon. Members may be interested to know that the percentage of patients seen as soon as they felt it necessary by a GP in hon. Members’ constituencies rose from 56 per cent. last year to 81 per cent. this year. That is an important representation of how patients in hon. Members’ constituencies feel about improvements in primary care.

In 2003-04, the most under-target primary care trust was 22 per cent. under its fair share of available resources. By the end of 2007-08, Buckinghamshire primary care trusts will be only 0.3 per cent. under target. That represents significant momentum and improvement.

“Shaping Health Services” is the name for the reconfiguration of services. Surely hon. Members accept that it is impossible for a Minister in an office in Westminster or Whitehall to make a judgment about the most appropriate configuration in hon. Members’ localities. They must engage with managers, clinicians and the local community to achieve a sensible way forward. It is not right for Ministers to intervene in decisions about service reconfiguration.

Difficulties in accident and emergency departments and the shortage of anaesthetists have been recognised, and that is why health management has intervened and problems are being put right. The problems should not have occurred, but importantly, management are doing something about that.

It is not for me to write to Transport Ministers about issues in individual Members’ constituencies. However, if they can demonstrate a direct correlation, and they want me to pass on to Transport Ministers communications that relate directly to an impact on health, I am willing to consider it.

The hon. Member for Wycombe referred to the difficulties at Stoke Mandeville hospital. The Secretary of State commissioned an inquiry into Stoke Mandeville hospital, and we all agree that it spotted dreadful and unacceptable failures that led to tragedy.

The hon. Member for Buckingham spoke about speech and language therapy. He cares passionately about it and he is objective about it. He was right to raise concerns about the practical impact on young children such as Peter Metcalfe. I have said that it is inconsistent to ask for ministerial interference while demanding independence, but because the hon. Gentleman is genuine about that issue, I am willing to ask for information from the local health authority about the speech and language therapy situation, and specifically, about the action that it proposes to improve it.

If I have been unable to cover any other issues, I shall write to hon. Members.