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NHS (Cornwall and the Isles of Scilly)

Volume 494: debated on Wednesday 17 June 2009

Motion made, and Question proposed, That this House do now adjourn.—(Mr. Blizzard.)

I am delighted to have secured the debate, but I am sorry that the Minister whom I understood to be responding is not yet in his place—doubtless that will be put right shortly. The subject of the debate is important. [Interruption.] I am pleased that the Minister is now in his place and I welcome him to his new post.

The subject has significance beyond the geographical designation in the title of the debate. Many places other than Cornwall and the Isles of Scilly experience similar problems in that they suffer significant health inequalities in comparison with the national average and deprivation in terms of the population’s income profile. The geography of a peninsula also presents problems, and I believe that Cornwall and the Scilly Isles are further from target than anywhere else in the country, in the Government’s view.

We are grateful to the Government for ensuring that the Advisory Committee on Resource Allocation studied, over several years, every aspect of the NHS formula for the allocation and weighted capitation of funding to every primary care trust in the country. Consequently, there is a welcome uplift in the funding for Cornwall and other places. However, although Cornwall will receive a 12.4 per cent. increase as a result of the acknowledgement that it is significantly more underfunded than the Government recognised previously, it will still be 6.2 per cent. below target at the end of the current two-year cycle of NHS funding. That is as far as the Government will allow any PCT to be by that stage—the end of March 2011. Although the increase is welcome, it raises issues about which the Minister must, I am sure, be aware.

It is probably also worth pointing out that the problem has not arisen overnight. I have already congratulated the Government on ensuring that the Advisory Committee on Resource Allocation undertook a thorough review. However, Cornwall and the Isles of Scilly NHS services have long suffered from the underfunding arising from the funding formula that the Conservative Government originally introduced. It has taken such a long time to get around to addressing that underfunding, which has affected the poorest region in the UK.

As the Minister would expect, all the Cornwall Members of Parliament have campaigned for many years to ensure, first, that there would be a review and, secondly that it would be robust and thorough. It acknowledged that the revised formula should be introduced at the beginning of the financial year. However, that leaves Cornwall with funding that is £56.5 million below what the Government have identified should be its allocation.

In preparing for this debate I looked at the funding for other parts of the country. To be fair, there are areas in Norfolk, Nottinghamshire, Derbyshire and Lincolnshire where funding is 6.2 per cent. below the target, but where it is also marginally above Cornwall’s gross level of underfunding, because of the size of the PCTs by which those areas are served.

Will my hon. Friend put the level of underfunding into perspective, perhaps by giving an indication of the debts that the Royal Cornwall Hospitals NHS Trust has accumulated over a number of years and saying to what extent just giving Cornwall the funding that the Government’s formula says it needs would help to address that long-standing problem?

I am grateful to my hon. Friend for raising that point. She has been a champion for the NHS in Cornwall. It is as a result of the teamwork among Cornish MPs, in bringing the case to the Government and ensuring that the message is heard loud and clear, that we have made so much progress, although we obviously still have a great deal of progress to make.

The figure of £56.5 million for underfunding in the financial year 2010-11 stands in contrast with the position in 2006, when the Royal Cornwall Hospitals NHS Trust was placed in special measures, after it was discovered to be more than £15 million in deficit. That figure for debt changed rapidly to £32 million, as a result of the resource account budgeting system, which the Treasury insists that Departments put in place, and, later that year, to £57 million, as a result of an estimate of the commitments that the trust had already made.

We are still awaiting a review this year of where the trust is now. We are reassured by the messages from the trust that it is not only in recurring balance, but doing its best to retrieve the situation financially. However, as my hon. Friend rightly pointed out, there is the question how a trust can get itself into such a position of underfunding when the Government and their advisory committee have acknowledged that for all these years—one might argue for at least the last decade, because that is how long we have been campaigning to get the formula changed—we have been underfunded by the equivalent of the debt that, under its worst interpretation, the trust has faced. That is a significant issue.

In 2006, when the trust’s debt was first identified, it was placed in special measures and given support from the Department of Health. The chief executive resigned and initially—certainly in the first year—the trust went through a period of what I would describe as panic-laden decision taking to try to recover the financial situation as quickly as it could. Since then, the trust, under the Department’s close guidance, has had a turnover of five chief executives and five chairmen.

I am not prepared to comment on individual cases, but since the fact that the trust faced serious financial problems was first identified, issues have arisen that are clearly not the responsibility of the local community. One of the themes that I want to draw out from this evening’s debate is the importance of establishing a system of NHS delivery in local communities that is far more accountable to those communities than has hitherto been the case in Cornwall and the rest of the country.

I know that Ministers use the language of encouraging greater localism and greater local decision making on the priorities relating to the allocation and spending of NHS resources, but in Cornwall we have experienced the serious problem of too much micro-management from Richmond House and, arguably, from the strategic health authority. That has clearly not contributed to a calm situation that would allow the kind of decision making that Cornwall has needed over the period in question.

My hon. Friend has identified an incredibly important subject. In 2006, we in Gloucestershire also found that the level of accountability to the local population for some of the drastic decisions that were taken was not very high. We are still fighting to restore services, such as the overnight children’s services at the Battledown children’s ward in Cheltenham, that were lost in those cuts. Does he agree that, in looking for cost savings and greater accountability, we might consider the future of the strategic health authority for the south-west as a whole as a possible area for economy and improved accountability between the Government and the local people?

I am grateful to my hon. Friend for raising that issue. Government quangos and departmental bodies are making decisions that are vital to the local communities that benefit from these crucial services, yet the people in the communities have very little influence over those decisions. Most people in my area are pretty cynical about the consultation exercises and believe that they are merely a process of public window-dressing before a decision that has already been made is implemented.

Is not that exemplified by the fact that people are not consulted on two different possible outcomes? Rather, the consultation is simply an exercise in providing information. Does not that devalue the process of consultation altogether?

The Minister is certainly listening, and nodding at some of these points. I do not know whether he is in partial agreement, or whether he at least agrees with the sentiments being expressed. Perhaps there is a potential for finding some common ground on the points that we are raising.

I took part in a debate on these issues on 18 March 2009 with the Minister’s predecessor, the right hon. Member for Exeter (Mr. Bradshaw), who is now the Secretary of State for Culture, Media and Sport. The broad issue of the allocation formula was debated at that time. The Minister said that the formula

“is made up of a count of the population served by the PCT, with adjustments made to reflect factors such as the age of the population, the level of deprivation, unavoidable differences in costs, which are known as the market forces factor, and rurality.”—[Official Report, 18 March 2009; Vol. 489, c. 285WH.]

One of the big issues for Cornwall and the Isles of Scilly is the impact of the market forces factor on the allocation of funding. That element of the funding formula seems to suggest that, because wage levels are low in Cornwall, we deserve less money. The argument seems to be that, because the market circumstances are somewhat lower, we deserve less funding. I was pleased that, as a result of the academic study by the consultant body, that issue was reviewed and put right.

Many in our communities feel that the Government should move much more quickly to allow PCTs that are below target to move more rapidly to meet their target. The response of the right hon. Member for Exeter was that

“moving faster over the next two years would result in painful cuts to services”.—[Official Report, 18 March 2009; Vol. 489, c. 286WH.]

He went on to identify a number of PCTs, mostly in London and the south-east, with allocations over target, whose resources would be cut over a period, resulting in painful decisions having to be made. I sympathise, and if I were the MP representing those areas, I would argue strongly that those changes should not be made—or at least not in a precipitate way that might undermine services. That option might not necessarily need to be taken.

In the chief executive of the local PCT in Cornwall, Ann James, the Minister has a very loyal advocate for the Government and the Department. In preparing for this debate, I asked for her opinion on our distance from target and on the impact of Cornwall’s underfunding on the ability of the local NHS to ensure that services were adequate. She told me that the local PCT, even at this distance from target, had been able to make tremendous advances in health care. She said that it had received more than £400 million of extra funding over the past four years; £2.5 million had been invested in NHS dentistry, resulting in a cut in waiting lists; £1.6 million had been invested in maternity services; and a new GP-led health centre was being built in the constituency of my hon. Friend the Member for Falmouth and Camborne (Julia Goldsworthy). Ann James also mentioned further investment in a number of other services in Cornwall, which I shall come to in a few moments.

The Minister should recognise that this is not just special pleading on behalf of Cornwall, as there is a reasonable case to be heard. Simply saying that funding for areas that are clearly suffering from underfunding cannot be raised because of the potential impact on other areas is not good enough. The Government have been able to sink substantial amounts into an IT project, including the choose and book system, at a cost of £12.4 billion. Another example is the £150 million spent on the roll-out of what some people call the “super-surgeries” as alternative providers of medical services—or “polyclinics”, as some prefer to call them, although I know that the Minister’s Department does not like that term and calls them something different.

Local PCTs have had to deliver in their own areas a number of centrally driven or centrally funded top-down initiatives. Whether such decisions relate to independent treatment centres or the other projects I have mentioned, my argument is that they would be far better taken in communities such as Cornwall, where the services that people are concerned about might be enhanced—and more effectively than by the initiatives from Richmond House. There is scope for argument there, and I suspect that the Minister will disagree, but the matter needs to be considered.

The impact of underfunding on services is very clear. It leads to pressures on staffing levels in acute services. As I witnessed myself, that can be dangerous. Staff levels on some wards really need to be looked at. I was fortunate a couple of years ago to have the opportunity to shadow nurses on four wards at the Royal Cornwall hospital in Truro and the West Cornwall hospital in my own constituency. I was seriously concerned about staffing levels, and particularly about the ratio of staff to the acuteness of the cases that needed to be dealt with. I was also concerned about bureaucracy, form filling and targets, which staff had to chase up at the same time. There were a number of issues of concern.

West Cornwall, a very small hospital in my constituency about which the local community rightly feel extremely passionate, has experienced a rollercoaster of emotions in recent years as a result of panic-laden decision making. Uncertainty and anxiety about the true future of the hospital and the services available to local patients have been a predominant theme. As I said, the trust has undergone a large number of changes of chief executives and chairmen, and is still struggling to recover from decisions that were made only a couple of years ago.

Cornwall has one of the most threadbare NHS dentistry services in the country. I was privileged to be able to invite the chairman of the independent review body, Professor Jimmy Steele, to see what was going on in Cornwall back in February, in the early days of his inquiry. He told me this week that his report would be published next week, and we look forward to reading it.

Most adults in Cornwall simply assume that they will never be able to get on to an NHS dentist’s list—at least, I was going to refer to such a list, but obviously people do not register with NHS dentists nowadays. It is incredibly difficult to arrange to be seen by an NHS dentist. It is not just a question of access, although on a long, thin peninsula there are no alternatives in the form of other PCTs or health services, and as my hon. Friend the Member for Falmouth and Camborne knows, the further west one goes the worse the position is. There is also the perpetual uncertainty. We can be pretty sure that for every new NHS dentist whose arrival in one of the towns in my constituency is trumpeted, another will jettison NHS patients or go private within months, if not weeks, because of the pressure that dentists feel that they are under.

I am grateful to my hon. Friend for being so generous in giving way. Does he agree that the contract is making the problem of access even worse? I visited an entirely NHS-run dental surgery in Mylor—the only dental surgery in Cornwall that is accepting new NHS patients. Because of the contract and the illness of one of the dentists, the practice had spare capacity which it had to fill by the end of the year. It took on a new dentist and a number of new patients, but the position is no longer sustainable, and it faces having to close its doors to new patients and make an NHS dentist redundant.

As I suspect the Minister will hear when Professor Jimmy Steele reports next week, that is a common theme, and I hope that the Government will reflect on it.

The Select Committee on Health largely precipitated the demand for an inquiry by encouraging the then Secretary of State to call for one, and I congratulate the then Secretary of State on doing so. It was clear that the Government would have to review the impact of the new contract that was introduced in April 2006. Many members of the profession had warned the Government about its potential impact. In places such as Cornwall and, no doubt, Gloucestershire, it resulted in perpetual uncertainty.

I am extremely grateful to my hon. Friend for being so generous with his time. I agree with both him and our hon. Friend the Member for Falmouth and Camborne (Julia Goldsworthy). Does he agree that the problems with the contract date back even further, to the early 1990s and the last Conservative Government? It was they who first mucked about with it in a way that would slowly and quietly send dental practices bankrupt if they maintained NHS services as they had been before. Now the Government have managed the amazing trick of renegotiating the contract and making the position even worse, leaving us with what is becoming almost a privatised dental service.

I certainly think that that is true, but I must also say that there are geographical differences across the country as a whole. The Government measure, and the means by which they pay for these services, is the average units of dental activity. On that measure, NHS provision per head of population in Cornwall is about half the national average. Professor Steele has been looking at this issue, and I am told that provision is significantly better in some parts of the country than in Cornwall. In west Cornwall, the situation is that about one third of the population can get some access to NHS dentistry, and emergency access is even more difficult.

Professor Steele tells me that the unique geography of Cornwall makes it particularly hard to get services in the right place, and when they are not in the right place, travel is, of course, difficult and expensive. Even if the combination of rurality and poverty does not make Cornwall unique, it certainly makes it a very good example of the problems that there can be in delivering services. We in Cornwall hope that, as a result of the review, the review board will come up with proposals that acknowledge the geographically specific problems in some parts of the country, and that it will perhaps even encourage the Government to review again the basis of the funding formula—the allocation and notional level of funding that is available to places such as Cornwall to ensure that they do in fact have adequate provision of dental services.

Midwifery and maternity services in west Cornwall are another subject on which I would welcome the Minister’s encouragement. I shall shortly be seeing a group of community midwives in my constituency. They tell me that their complement of midwives in the towns of Helston, St. Ives, Penzance and Hayle in west Cornwall is significantly below the Government’s recommended level. That puts pressure on services and on what they can provide in terms of the whole-time equivalent assessment of the population they serve and their work load and its throughput.

I secured a debate on the Government’s policy as set out in “Maternity Matters” on 2 May 2007, when I welcomed its principles, but I also asked whether the Government had put the resources in place to ensure that their fine words could be met with action on the ground, so that mothers would have choices in the years ahead. That is clearly not the case in west Cornwall—and I am told that west Cornwall has better midwifery provision than many other communities.

Funding issues underlie all the concerns that I have raised. Services cannot be provided if the funding is not in place, and certainly if there has been a decade or more of considerable underfunding. In contrast with other parts of the country, as a result of its allocation, Cornwall has struggled year on year under the weight of national expectations and as a consequence of patients being aware of national levels of service. I congratulate the Government on their funding in general. Indeed, the Liberal Democrats have always welcomed the funding that the Government have been prepared to put into the NHS across the country, but the allocation has simply left places such as Cornwall behind, year on year, and therefore further behind overall, thus denuding and undermining services and making it increasingly difficult for the professionals who are providing those services to maintain them.

My other theme, which I very much hope the Minister will take on board in his reply, is that we need to provide a structure that not only allows the local community a say through the occasional consultation paper exercise, but genuinely allows locally elected representatives to determine the priorities and champion the interests of their local communities. Many of the decisions taken by the primary care trust are not only technical and medical, but political; they are about the allocation of resources in an area and the implementation of Government policy. We need to decide whether such bodies are simply agents of central Government and the local community is simply something that is occasionally consulted, or whether such bodies are there to reflect the interests and priorities of that local community and to ensure that it is fully engaged in the decision-making process.

I am glad that I managed to catch your eye, Madam Deputy Speaker. I did not intend to contribute to this debate because I did not expect to have the time to do so, but I welcome the opportunity to add a few comments to those made by my hon. Friend the Member for St. Ives (Andrew George).

Although there have been significant challenges for the national health service in Cornwall, the county is greatly blessed in one respect: the quality of staff. The flip side of many of the geographical challenges that we face is that the staff are incredibly hard-working and committed, our staff turnover is a lot lower than that of other places and because the county is such a wonderful place to live we are also lucky to have incredibly and talented specialists who choose to live there. There are great opportunities in Cornwall, but the problem is that successive Governments appear to have been unable to recognise what the challenges are in providing a national health service in very different parts of the country. Our concern is that there has not been significant understanding or recognition of how rural needs manifest themselves and how they need to be addressed.

The Government’s approach has been very much to emphasise that the last thing they want is a postcode lottery, but our point is that the problem with a “postcode lottery” is the lottery bit, not the postcode bit. People want health services that address their needs, which may be specific to their communities. The challenges that we face in Cornwall stem from the fact that it is one of the most deprived parts of the country and from the fact that services can be difficult to access because of the geography. In addition, the county has to deal with huge fluctuations in population—Cornwall’s population doubles over the summer—which brings different pressures, and we have a greater and increasing number of elderly people compared with other parts of the country.

All those issues throw up different challenges for the health service. My hon. Friend focused on the funding challenges, but they are just one aspect of the wider problem. Successive Governments have given insufficient recognition to the cost of providing health services in rural areas, and although the review has, perhaps for the first time, exposed how big the gap is, we still do not clearly understand how quickly it should be closed. Given that some authorities are far from their target, it is very difficult to understand why overfunded authorities are not meeting the cost of the lowest funded. One can understand why no trust would want its funding to be cut, but I do not understand why the ceilings need to pay for the floors—I hope that makes sense; I might have meant it the other way round.

I have already mentioned the geographic challenges. Cornwall is a long, thin peninsula, surrounded by water on three sides, with one main arterial road that gets very blocked in the summer. That poses specific challenges to the provision of services, and people in Cornwall have to look to other alternatives to meet some of those challenges. Cornwall air ambulance, which is funded entirely by charitable donations, is essential in the summer to ensure that people can be transported to accident and emergency. Last summer, we had the ridiculous situation of motor ambulances queuing outside Treliske, the main accident and emergency centre, to ensure that the hospital met its four-hour waiting times, with the air ambulance having to transfer nursing home patients.

The most frustrating thing is that, while the staff are doing all they can to humanise services, the Government’s approach is that one size fits all, which is why dental services fail to reflect the county’s needs. Only one NHS dental surgery is treating new patients. There is an obsession with a choice agenda, but in Cornwall the most important thing for many patients is to know that their nearest service—which might actually be a long distance away—will be able to provide them with a certain standard of care.

Many services are being centralised outside Cornwall, and decisions are being taken without an accountable process. The Government just do not get how these things need to work in rural areas. Recently, we had a heated, so-called consultation on transferring surgery for upper gastrointestinal tract cancers to Derriford. The strategic health authority said that, to ensure high standards, the service needed to be provided by a team of people who had the experience to ensure the best outcomes, but it seems that every service is being transferred—salami sliced—further away. The Government should consider operating a specialist network that allows skills to be spread throughout the area. Cornwall could be responsible for delivering one of those specialist services, and people in the county would have access to at least one centre.

I agree with those professionals who argue that we want to ensure the best possible outcome for patients, and if that requires a concentration of services, so be it. But, as my hon. Friend says, we should perhaps look at networks and at ensuring that the concentration comes westward as well as going east.

One of the problems for our constituents is that accessing specialist services requires lengthy journeys—to London for neurosurgery, for example. The health care travel costs scheme is not sufficient for people on low incomes, but not on benefit. Many of our constituents are clearly disadvantaged by the lack of funding to compensate them for the impact that the concentration of services in just a few places has on them and their families.

My hon. Friend is right. No account is taken of the costs or the time taken to travel such distances. In parts of my constituency, visiting a sick relative being treated in Derriford can take three hours by car every day. Such factors should be taken into account, but currently are not.

That can also be seen in other policy areas, where once again the approach seems to be that central Government take a decision and the strategic health authority and primary care trust see it as their role to implement decisions locally rather than to feed information back up the line to make the case for what they consider to be most appropriate for the needs of their area. We see that happening in a variety of ways. The example that springs most obviously to mind is that of walk-in centres. It has been decreed that every primary care trust must have one, and the primary care trust has to justify where it puts the centre and why it is needed.

It turns out that the PCT has decided that the walk-in centre is needed in my constituency. The justification is that it is the most densely populated part of Cornwall and that some regard has been given to the fact that there are lots of migrant workers who will need the centre, as they are unlikely to be registered with a doctor. If such centres are to be of any use, they should be in areas where a lot of people are travelling to work. One could argue that other places in Cornwall, such as Truro, have huge numbers of people travelling into the area every day. If they want flexibility in being able to drop in and see a doctor, they might want the centre to be there.

GPs with surgeries in more rural areas say that the best way of ensuring that migrant workers have access to the health services they need is for an individual relationship to be built up between the surgery and the farmers who employ agricultural workers, rather than simply plonking a massive centre on an industrial centre somewhere. These people, who have no access to their own transport and who might be able to catch a bus every other Monday, if they are lucky, will have no means of getting to such a centre. It seems that the decision is made centrally and then it is up to the PCT to justify why it is needed locally.

I am grateful to my hon. Friend for giving way a second time. This is a rather classic example of the Government’s imposing a solution that might be satisfactory in an urban setting but that is still an urban solution to a long-standing rural problem. Cornwall, from the Tamar to the Isles of Scilly, is more than 100 miles long. We have to question whether alternative provider medical services will provide for the whole of Cornwall. The PCT has not been able to show that those services will not undermine the settled provision of existing services in a way that damages the local community or that the benefit of the investment will be spread for the benefit of the whole population served by the PCT.

My hon. Friend is absolutely right. The nub of what I am saying is that people in Cornwall are not asking for services that are better funded than those anywhere else in the country. In a debate earlier this week on the impact of the recession on rural areas, my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron) emphasised that point. He said that the Liberal Democrats had made the case for extra investment in the NHS, and that people living and working in rural areas had contributed towards that extra investment like everyone else and that they want to see that they stand to benefit in the same way as everybody else. They should have health services that reflect their needs and that are able to meet them. The concern is that that is not happening and that, with the current lack of accountability in the way decisions are taken and resources are spent, they have no opportunity to have their voice heard.

There are two parts to the problem. We must recognise the need and must ensure that there is accountability in decision taking. Unfortunately, for too many people in Cornwall, not only are their needs not being met but their voices are not being heard.

May I apologise to you, Madam Deputy Speaker, to my hon. Friend the Member for St. Ives (Andrew George) and to the House for not being in the Chamber at the beginning of his speech? I was involved in the debate on the Business Rate Supplements Bill and took the opportunity to leave the Chamber for a short while, anticipating that the next debate might continue for longer than it did. I am pleased that you found time to call me to speak, however, Madam Deputy Speaker, and I thank you for that.

I congratulate my hon. Friend on securing the debate, and it is fortuitous for Cornwall that he did so as we have the opportunity to debate matters in more detail than we might have anticipated. He addressed clearly the underlying funding issues in Cornwall and focused on some of the problems that have occurred, sadly, in the management of the Royal Cornwall hospital in Treliske. Of course, in turn that has caused problems for the acute trust, but it is important to note that the deal that has been worked out to allow the PCT to support the acute trust as it gets its finances back on track has longer term implications for resources across Cornwall.

Many of my constituents in the western part of north Cornwall use the Royal Cornwall hospital at Treliske and are very pleased with the service there, but people in the east of my constituency tend to go to Derriford hospital in Plymouth, the Royal Devon and Exeter hospital or the North Devon district hospital at Barnstaple. The question is whether the necessary support for the provision of acute services in Truro is drawing resources away from the more accessible services over the border in Devon.

If we were starting with a blank sheet of paper to plan for health investment in Cornwall, we would probably not begin by placing a major district general hospital in the middle of the county. We might put one in both the west and the east, but that is not how things are. Many patients in the east of Cornwall cross the border into Devon for their health services; not only does that pose transport problems, as I shall explain, but it causes peak-time car parking difficulties at Derriford. The fact that services are concentrated there—it is one of the largest hospitals in western Europe—may need to be examined in future.

My hon. Friend the Member for St. Ives mentioned the problems encountered by people living some distance away from major health care centres such as the Royal Cornwall hospital. A while ago, I came across a case involving an older lady in Camelford in my constituency. Having been prescribed a course of therapy in Truro, she turned to the hospital transport system to get herself there, but the cost became so prohibitive that she decided to abandon the therapy. Although her illness was not life threatening, it was enough to affect her quality of life. The therapy had been recommended by health professionals: they said that it would benefit her, and it was something to which she was entitled on the NHS. The only thing that prevented her from taking advantage of the therapy was the fact of where she lived.

A truly national health service must reach into every community in the country. Those of us who live in rural areas know that, unlike those who live in urban areas, we cannot have all services right on our doorstep. There are other compensations about living in a rural environment that people come to Cornwall—or stay there—to enjoy. However, there is a baseline of provision in all public services that people ought to be able to expect, and health is no exception to that. For that reason, I would welcome anything that the Minister is able to say about hospital transport.

Hospital transport services come under threat when fuel costs rise. Drivers get some money to provide those services, but in effect they end up subsidising them when mileage allowances do not properly reflect the costs that they incur. That problem eased when fuel prices fell recently, but it could return as they creep back up again.

In the past, Health Ministers have said that the problem relating to car parking provision needs to be addressed, as the NHS cannot be in the business of providing subsidised car parking. They have added that people need to accept that there is a cost to visiting hospitals, but that is all very well where there is a public transport alternative. In many areas, however, there is no such alternative to car use.

The problem is most acute for older people. So many young people have left Cornwall that the county has an ageing population, and that problem is predicted to get worse. Many older people would prefer not to be forced to use their car to travel the large distances involved in accessing health services, but that is what they have to do.

At the meetings that I have had with PCT representatives, they have said that they are keen to work with the acute trust and consider providing more community hospitals. That, of course, is something to be welcomed. There are many clinics, and there has been wider provision in some areas, but a lot more remains to be done on that. If the NHS were able to concentrate, in rural areas, on trying to widen the range of services available in our excellent community hospitals, that would make a great contribution to overcoming the problem of access; transport seems to be proving a barrier.

To follow up on my hon. Friend’s points about primary care trusts saying that the cost of providing car parking needs to be recovered, is not the problem that, in some cases, the amount charged for parking is far in excess of the cost, and that trusts are generating an income, rather than simply covering their costs?

My hon. Friend is absolutely right. It is fair to say that different trusts have taken different views. For example, the Plymouth Hospitals NHS Trust, which covers Derriford hospital, has recently undertaken a review, and has introduced much cheaper shorter-stay parking for visitors, which I welcome. The trust consulted widely before doing that. Unfortunately, probably because of the financial pressures that we have discussed, in Truro the situation is different. I do not want to drag the Minister too far into the specifics, but the barrier system introduced there means that people who are visiting for a long period, such as those who are visiting a sick child in the hospital, may pay for 24 hours of parking; however, if they leave the car park, going past the barrier, during the day and come back in the evening, they have to get a new ticket to get back in, although they have paid for 24 hours. That really adds to people’s costs, and if anything can be done to look into that, it should be done.

We have heard a little bit from my hon. Friends the Members for St. Ives, and for Falmouth and Camborne (Julia Goldsworthy), about the issues relating to the new health care provision that is to be allocated to the Falmouth and Camborne constituency. The model is a walk-in surgery for harder-to-access groups. Of course there are issues to address; we have migrant workers in Cornwall, and anything that can be done to make sure that we have adequate provision for everybody is all to the good. However, that proposal will divert resources into setting up a facility that, as my hon. Friend the Member for St. Ives said, is really aimed at an urban area. There may well be a solution that would have worked better in a rural area.

My constituents in Bude-Stratton and Camelford have been waiting for a long time to get decent medical centres in their area. Bude-Stratton is one of the most remote towns in Cornwall. It has been pretty near the top of the list for a new medical centre for a while. It has outgrown its older premises, and campaigners in the area, such as Mrs. Candy Baker, have long fought to make sure that the primary care trust is aware of that. It is below Camelford on the list, and I have arranged a meeting, to be held in a few weeks’ time, at which representatives from the local improvement finance trust company—Community 1st Cornwall—community groups and, I hope, the PCT will come together to talk about that situation. However, we have done that before, and we are not that much further forward. Of course, in those communities, there may be land and planning issues that delay matters, but the resources that are being put into the sort of centre that my hon. Friend the Member for Falmouth and Camborne spoke about may well have helped to overcome some of the problems, and might have taken us further forward in health care provision.

My hon. Friends the Members for St. Ives and for Falmouth and Camborne have raised crucial issues about accountability, which is not just about people having confidence in the system as a whole, but about their being able to influence where those resources are used and how they are spent locally. My hon. Friend the Member for Falmouth and Camborne and I are on the Local Democracy, Economic Development and Construction Bill Committee, which has had great discussions about the use of petitions. Upper gastrointestinal surgery, to which both hon. Friends have referred, is an example of an issue on which people are petitioning anyone whom they can think of, because they are not quite sure where the accountability lies. Despite having gone through the processes, and having become far greater experts on health funding than many hon. Members in this House—campaigners become experts during the course of their campaign—those campaigners will probably feel that they do not have the influence over decisions that they would like. That is a problem for us all.

My hon. Friend the Member for St. Ives mentioned midwifery services. The situation is exactly the same in North Cornwall. As the father of three children under the age of five, all of whom were born, by Caesarean section, in the Royal Cornwall hospital in Truro, I am well familiar with the services, and the excellent work that the staff there do. However, looking at the period covering those three deliveries, I have to say that I have noticed that the staff are perhaps a little more stretched than they were when my eldest son was born in 2004.

Community midwifery services have played a fantastic role. Arwen Folkes has driven forward the “real baby milk” campaign in Cornwall, and I think that it is being rolled out in other trusts across the country. She very much welcomes the opportunity to work alongside midwives to provide that service. Sure Start benefited in North Cornwall from having a midwifery service, but it has had to be withdrawn because of the overstretch in midwifery. I hope that that issue can be resolved.

Finally, I refer to mental health. We could spend a whole evening discussing that. The Cornwall Partnership Trust has had to deal with problems relating to learning disability, but it is now moving beyond them. I have had the privilege of seeing a number of new facilities that it has opened, which is good, but the community services in particular are extremely overstretched. The fundamental problem is that resources have had to go into the Royal Cornwall hospital at Treliske. Until the financial situation is resolved, the partnership trust will not be able to deliver the sort of community mental health services that we would like to see.

I was wondering how long it would take before I was called to speak. The hon. Member for St. Ives (Andrew George) put his argument fairly. Essentially, he said that the area had received a significant increase in funding, but it was not enough. I have a great deal of sympathy with his case. The Government clearly have a funding target. It will take time—I shall explain why—to reach that target.

The hon. Gentleman argued the case well. It is incumbent on the Government to ensure that we put in place the right formula and the adjustments that that requires. Both increases and, as he rightly said, decreases over time for some areas, or at least smaller increases than they might have expected, need to be phased in. As everyone knows, there is no unlimited pot of money. The Government have tripled the funding going into the NHS, and the hon. Gentleman rightly welcomed that. However, we must ensure that funding is properly managed. Very often that is done at a local level.

The funding formula needs to be reviewed from time to time. As the hon. Gentleman rightly said, the review was overdue, but it has now taken place. Part of the formula was set by the previous Conservative Government and it was enormously unfair to certain areas. We have put that right, which will result in Cornwall getting more money, as he recognised. He put his case fairly, as did the hon. Member for North Cornwall (Dan Rogerson).

The hon. Member for Falmouth and Camborne (Julia Goldsworthy) indulged in a bit of party political knockabout. Somewhere in the knockabout were a few serious points, but when she got to them, they struggled to get out. One thing on which I agree with her is that it is important that we congratulate NHS staff on their dedication and hard work. They are improving the quality of services in Cornwall and across the country, and they are working hard to do so.

As medical science continues to advance, the NHS becomes capable of ever more extraordinary feats of clinical care. For some complex procedures, well-equipped and well-staffed specialist centres are more effective. There, round-the-clock consultant and specialist nurse expertise can be assured and expensive technology can be concentrated. An increasing amount of care is happening in the NHS, and much of it is out in the community in GP practices, health centres and people’s homes, with more complex, specialist or emergency care concentrated in a few more specialist centres. However, Ministers or civil servants in Whitehall do not decide the organisation of local health care. It is decided by local health care professionals on the ground. Organisational changes must be based on medical grounds and what is best for local patient care.

Finance is one of the key issues. The NHS has benefited from an unprecedented growth in finance. When the Government first came to power, health spending was just £426 per head. In 2010-11, it will be £1,612. In 2009-10 and 2010-11, primary care trusts will be allocated £164 billion. That means that, on average, PCTs will receive an increase of more than 11 per cent.—actually, 11.3 per cent.—or an extra £8.6 billion. The people who are best placed to make decisions are those closest to it, and more than 80 per cent. of the entire NHS budget is now in the hands of local PCTs—a higher proportion than ever before, under any Government.

I shall, but I was just going to go on to the hon. Gentleman’s precise point, so I shall happily give way in a moment.

The hon. Gentleman’s point was about the formula, and the independent Advisory Committee on Resource Allocation is made up of GPs, NHS management and academics. It developed the fair funding formula to determine each PCT’s share of resources, and the new funding formula has been used for the 2009-10 and 2010-11 allocations. It takes account of the new information and builds upon and improves the previous formula so that it continues to meet the objectives of equal access for equal need and the reduction of health inequalities. The review leading to ACRA’s recommendations was comprehensive and led to important changes.

When a new funding formula is introduced, the distance between a PCT’s target allocation and its actual allocation will change. Its actual allocation may move from being over-target to under-target or vice versa; it all depends on the relative need of the PCT’s population, as determined by the new formula. A change in target allocation does not mean that a PCT loses out—far from it; the new formula affects a PCT’s funding target and not, initially, the money that it actually receives. We are committed to moving PCTs closer to a fairer share over time.

I know that the hon. Gentleman feels that his local PCT should have been moved more quickly towards its target, and that is a fair point. However, there must always be a need to balance continuity and stability in NHS funding. If a PCT is under-target, it will benefit from higher growth than others. The amount that local PCTs, such as his, receive will increase at a higher rate than it will for those that are in the opposing position and being paid over-target.

What matters is not the distance from target but the levels of increased actual funding. I know that there is a historical issue as a result of the very issues that the hon. Gentleman raised, but to rectify any alleged underfunding would effectively mean reopening all the previous allocation rounds, and we are not in a position to do that. We must recognise that we are where we are and have to have a fair and reasonable funding formula for the areas to which it applies. Furthermore, we must not in any way undermine the stability of NHS funding and long-term planning, either in areas such as his, which benefit from the new criteria, or in areas that do not receive the increase that, up to now, they had expected.

I am very grateful to the Minister for giving way. I think that I acknowledged in my opening remarks much of what he has said. I have two questions. First, he said that the PCTs were taking the relevant decisions, and he described that as in some way local. However, those people are appointed indirectly by the Government and are not accountable to the local community, so I should welcome his thoughts on whether Cornwall might be one of the pilot areas where more local decision making takes place.

Secondly, on the formula itself, I acknowledge that Cornwall’s allocation is going up not by 11.3 per cent. but by 12.4 per cent., which is clearly welcome and above the national average. However, it is only a small degree above, and the county will take years to get even close to its target. Does the Minister not agree that some of those national programmes, such as the alternative provider medical services roll-out, the independent treatment centres and so on, involve decisions that would be far better taken in the local community by local people, and that it would be far better to apportion that money in order to move PCTs much more quickly towards their target?

On the question of PCT members, the hon. Gentleman is aware that an independent appointments commission deals with such matters. Ministers do not determine who joins those committees, and the aim is that, wherever possible, people should be appointed locally. I take that view and encourage the appointments commission to ensure that people are genuinely local and have lived in the area at least for a period. That does not always happen, but that is because the commission is trying to get a balanced membership.

One party will say, “Cut this and provide increases for that”; that is always part of political debate. The key point is that as a result of the Government’s changes, the hon. Gentleman’s PCT is looking at larger funding increases than those for many other areas of the country. The PCT funding allocation for Cornwall and the Isles of Scilly is £808.4 million for this financial year and £856.2 million for 2010-11; in 2006, it received £1,227 per head and it received £1,488 per head this financial year. Furthermore, it will receive £1,558 per head next year.

There will be a steady improvement in the PCT’s finances. The NHS in Cornwall is relatively healthy. Staff there are working enormously hard and making an enormous contribution. The funding for them is increasing; they can look forward to that increase as a result of the decisions made following the review. The draft end-year accounts of the hon. Gentleman’s PCT and acute trusts show surpluses of approximately £5.6 million and £2 million respectively, so there is still some latitude in the budgets. However, I appreciate that some PCTs want to put aside cash and roll it over to fund particular projects later.

I am not begrudging the increases that the Minister has just mentioned; indeed, I welcomed them in my opening remarks. However, the proportion of funding available to Cornwall and the Isles of Scilly is still significantly distant—6.2 per cent.—from its ultimate target. The acute trust is clearly not just in a recurring balance; it is also paying back some of the historic debt. The Minister may argue that the situation is due to past mismanagement—not that local communities made the decisions—but the fact is that Cornwall has been chronically underfunded in comparison with the rest of the country, and that is clearly the primary cause of the pressure on mental health, dentistry and other services there. It would be helpful if he acknowledged that that is a likely outcome of a long period of historic relative underfunding.

The hon. Gentleman and I could stand here and knock seven bells out of the previous Conservative Administration, saying that their funding formula was awful and that they are to blame for a lot of the problems in the health service. We can both agree on that, but I am not sure that it will take us very far. We have to deal with the current problems. The situation is not just one in which the Government can decide to give a lot of extra money to one area; the funding is allocated. The issue is devolved and pushed down to the PCTs. If we take funding from one area to give to another area such as Cornwall, we will create problems for that first area.

The best way of managing the situation is by making it clear that we recognise when there is a strong and good case, and we have been clear that Cornwall has a good case. We have acknowledged that and increased the funding steadily to bring it up to the target that we want to hit, without damaging other areas. We want to make sure that the issue is addressed over a period of time. We can rehearse this argument time and again, but that is essentially how the Government approach it. Such an approach is a perfectly reasonable way to ensure NHS funding stability.

I am grateful to the Minister; he is being extremely patient, and I appreciate that.

Of course, one’s view of reasonableness depends on from which end of the telescope one is looking at the matter. The Minister says that things will happen “over a period of time”. How long does he anticipate that it will take for Cornwall and the Isles of Scilly ultimately to reach these targets at the current rate of progress?

I cannot give the hon. Gentleman a precise period. Assuming that we stay in office and the other lot do not get in—sadly for him, I am not talking about his lot—we will steadily increase NHS funding. We all know about the issues in relation to the wider political debate and the fact that the main Opposition party does not have a good record on the NHS, so it depends to some extent on what happens in the future. However, we are committed to moving towards the targets. We accept the funding formula that has been agreed, and as a result, over a period of time, Cornwall will steadily benefit from those changes.

The hon. Gentleman raised several other issues apart from finance, including dentistry and midwifery. On midwifery, Cornwall and Isles of Scilly PCT has invested an extra £1.6 million in maternity services in the three years from 2008-09. Women in Cornwall ought to have the choice as to where they have their baby, whether at a midwifery-led unit or at home, and in the years ahead we want to ensure that they do have that choice. He says that it is not always available, but in my experience that is sometimes because people have not been informed or simply do not know that they have a degree of choice about where they can give birth. There is a real need for better information and better engagement with local communities. We need to ensure that PCTs are out there telling people about the choices that they can have. Sometimes those choices are not exercised for the convenience of the system—because it is easier, safer and so on to have children in hospitals, or so some think. Choice should be given to women, and it is important that it is available and publicised.

As for dentistry, people in Cornwall are still unable to access an NHS dentist as quickly as they would like. The latest figures show that Cornwall and Isles of Scilly PCT saw fewer patients in the past two years than the national average. I can see that there is an issue in that regard, because that represents 51 per cent. of the population as against 53 per cent for England as a whole. The PCT knows that access to NHS dentistry is an important issue for it. In 2007, it produced an oral health strategy, and it is working further to grow its services and to promote oral health. We can already see the difference being made. In March 2008, the PCT had 1,800 patients waiting for an NHS dentist; now, there are only 160 patients. That is 160 too many, but progress is being made.

The PCT is committed to making sure that everyone who wants NHS treatment is able to get it, and its current and future plans will provide services for around 33,800 additional patients. The PCT has received an additional £2.5 million—an 11 per cent. increase—in its dental allocation. That is a pretty good increase. The hon. Gentleman is right to say that we are looking forward to the report of Professor Jimmy Steele in the not-too-distant future. I hope that as a result of that we will see even further improvements in how dentistry is dealt with.

Recent new dentistry investments include the appointment of three new dentists in Truro and one in Falmouth in July and August 2008, and the opening of a new practice in Launceston with capacity for 5,000 patients in February 2009. March saw another tranche of new practices opened, providing services for 7,000 new patients in Newquay, 2,000 in Bodmin and 4,500 in Torpoint. In April, a new practice opened in St. Austell with capacity for 7,000 patients. I understand that it will be officially opened by the chief dental officer, Barry Cockcroft, later this month. The PCT is continuing that programme of expansion, and over the next 12 months it will provide dental services for an additional 8,160 patients across Liskeard, Tregony, St. Ives, Bodmin, Threemilestone and Truro. That represents a fair amount of work and investment being put into the area.

The hon. Member for North Cornwall made a couple of points that I wish to engage him on. The first was about hospital transport, and he was absolutely right about rural areas. I represent an area that has a large rural hinterland, and it is enormously important that people can get access to transport to a hospital. We need to work harder to ensure that PCTs recognise the importance of ensuring that transport arrangements are in place, particularly when services are located in tertiary and high-skill hospitals, as is often safer. The distance involved needs to be taken into account to ensure that we do not increase risk. It is all very well to say that a patient is safer when they get to such a hospital, but getting them there is also a problem, particularly if access to transport is not easy. It is important that PCTs recognise that they need to take serious account of transport in rural areas.

The hon. Gentleman also mentioned car parking, and he made the fair point that patients and primarily visitors complain that they have to pay for parking when they go to a hospital. They ask, “Isn’t this supposed to be a free NHS?” I, too, have had constituents come and complain to me, asking, “Why are we paying for car park charges in the local hospital?” As he said, they get very annoyed, particularly if they are making long visits, perhaps to a child who has to stay in for a long time.

The hon. Gentleman’s point was fair, and there is a reasonable debate to be had about the matter, but I would respond that there is still a choice to be made on budgets. He and others have talked about budget limitations, and there will always be such limitations. We all know that NHS inflation is a particular problem in relation to the costs of medicine. There will therefore always be pressures on NHS budgets, despite the fact that we have tripled the amount of money going in.

There will always be decisions to be made, and it is important that they are made locally. PCTs must recognise that there is a choice, and that they are better off spending money on patient care than on car parks. There is a high cost to car parks through building, maintenance, servicing, safeguarding, insurance and so on. In principle, it is better that the funding goes to patient care. However, there is always a balance to be struck, and the costs that visitors and patients pay should be reasonable, with account taken of the pressures on people who have to go to hospitals regularly. The charging of very large sums to people who have to visit on a daily basis for a prolonged period because of their circumstances is often unfair. PCTs have to examine that in the context of the pressures on a local hospital.

I would not expect the Minister to have answers about hospital transport straight away. Primary care trusts operate in a framework of Government policy, and that is fine because we have a national health service, but it means that they tend to concentrate on aspects that they have been asked to deliver as priorities. Transport to health services may not currently be at the top of the Government’s agenda, and all I ask is that the Government take it into account in ongoing reviews and, if they find good models, to ensure that best practice is shared. It is important to get it right because, although those who need in-depth treatment or surgery will get themselves to hospital somehow, those with something that is not life-threatening may, like the lady in Camelford, choose not to go. That is part of the problem that prevents good outcomes.

The hon. Gentleman makes a fair point. When we examine access to health care in future, we need to bear in mind transport and transport costs for patients. I agree that, when we review NHS funding and priorities, access and transport should be included. Not only transport in rural areas but car parking and the problems with it should be part of the equation.

I hope that the debate has gone at least some way towards reassuring the hon. Member for St. Ives that funding for Cornwall and Isles of Scilly PCT has not been eroded by the Government with deliberate intent. On the contrary, we want more funding to go to Cornwall. We must ensure that we balance the priorities in the NHS budget, but the hon. Gentleman made his point fairly and I hope that I responded fairly. Investment will continue in Cornwall. The underfunding—which I do not dispute—will be tackled and services in Cornwall will continue to develop in new and innovative ways, in line with people’s expectations of the NHS in the 21st century. The future for Cornwall NHS looks better for the changes in the funding formula.

Question put and agreed to.

House adjourned.