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Isle of Wight NHS Primary Care Trust

Volume 506: debated on Wednesday 3 March 2010

I am grateful to have secured this debate on the Isle of Wight NHS primary care trust and its regulatory burden, and I welcome the Minister who is going to respond.

As hon. Members are aware, nationally set targets and inspections are seen by the Government as the best way of ensuring high-quality patient care in a primary care trust. Too often, however, such targets are counter-productive; visits by patients to hospitals and doctors are important, not visits by inspectors. Targets are regarded as a burden to be shouldered rather than a catalyst for best practice, and national priorities get in the way of effectively responding to local needs.

The NHS is a national organisation, but health care is delivered locally whether in the surgery around the corner, the hospital in the larger town or the ambulance anywhere, any time. The population of the Isle of Wight is in excess of 130,000 people, and less than half that number would usually support a district general hospital. Let me be clear: there are no road or rail links to the mainland. Patients transferring off the island are dependent on the weather, so St. Mary’s hospital in Newport is essential. When health care in the south-east was reviewed four years ago, it was recognised that the island’s health service needed to be organised in a different way. Established in October 2006, the Isle of Wight NHS primary care trust is a single organisation that combines the commissioning function and the provider function for all health care on the island. That is unique in the NHS in England.

On the mainland, ambulance, hospital, mental health, community, learning, disability and primary care services are the responsibility of separate trusts. On the island, however, they all fall under the remit of the Isle of Wight NHS PCT. For patients, the merits of such a unitary approach are borne out by the evidence, which suggests that fewer patients are referred to secondary care on the island and that more patients return to their homes following hospital discharge. Care for those with long-term conditions is of a very high standard.

In a recent survey, 82 per cent. of islanders said that they were satisfied with the local NHS; 90 per cent. were satisfied with the local ambulance service; and 92 per cent. were happy with their GP. Indeed, in the Care Quality Commission’s 2009 annual health check, the Isle of Wight was one of only three PCTs in the country to receive an “excellent” quality rating.

I can speak personally about the outstanding quality of care because in 2006 I suffered a stroke. My recovery—and the fact that I am standing here today—is testament to the hard-working doctors and nurses on the island, and I would like to pay tribute to the dedication of all health care professionals on the Isle of Wight. Without them, our unique system of health care would not be possible.

Through working in partnerships, the PCT delivers a comprehensive and cost-efficient service, but its unique nature has not been recognised in the national inspection regime. We have a single Isle of Wight NHS organisation that should be recognised with a unified set of inspections and targets. Instead, however, each part of the whole is held to account as though it were autonomous, and is monitored separately. Although that may be right for other places, such an approach is not valid on the island and leads to an unhealthy level of targets and inspections being imposed on a single health authority. That disproportionate regulatory burden threatens to undermine the benefits of a joined-up approach.

The island’s PCT receives up to 70 external visits from 20 different regulators or monitoring bodies. No other PCT or trust is subject to such intervention. Furthermore, for 2010 and beyond, the Care Quality Commission has proposed 13 special reviews for NHS trusts, and it is likely that all of those will apply to the Isle of Wight’s PCT. It could get to the point where it becomes necessary to employ people full time simply to satisfy the demands of bureaucracy. That represents money that could be better spent on the front line.

In his response, will the Minister tell me why such a level of visits is necessary, and why they cannot be more effectively co-ordinated? Nationally, each individual trust is subject to separate targets. For example, acute trusts currently have 10 existing and 14 new national priority targets to reach. Mental health trusts have 12 national priority targets while learning disability trusts have five. Ambulance trusts have four existing and six new national priority targets, while primary care trusts have 14 existing and 24 new national priority targets to meet.

Although I do not agree with such numbers, for the sake of argument I accept that such a division of targets is necessary on the mainland. However, on the island it means that our single PCT has 28 existing and 61 new targets to achieve—89 in total. Such a high number does not apply to any other trust or PCT, and such excessive national targets simply do not correspond in the case of the Isle of Wight. Will the Minister indicate whether such a level of targets is necessary for an organisation that exists outside the organisational norm?

More generally, I question whether such a level of targets really caters for the best interests of patients. We need only look at the tragedy in Staffordshire, where managers were motivated more by central targets than by patients who needed treatment. The Government must ensure that targets help to provide for patients’ needs rather than taking money away from front-line care.

On the Isle of Wight, the burden of regulation not only places demands on the time of professionals that could be better spent treating people, but imposes a heavy financial burden. I am told that all NHS trusts and service providers will have to register services with the CQC by October this year. For the Isle of Wight PCT, that means 18 different service types across 12 different locations. Such a level of bureaucracy for a single organisation is bad enough, but from 1 April 2011, an annual registration fee will be required for each service provider. The Isle of Wight PCT is an amalgamation of many local providers, and such fees could therefore have acute financial consequences. Will the Minister give me an assurance that when the new fees system is put into practice, he will look carefully at the fees that the Isle of Wight PCT will have to pay?

On the whole, the Isle of Wight PCT seems to be being penalised for its unique nature. Over and over again, we see the organisation contorting to fit into the inspection regime when it is the system that should adjust and adapt to the organisation’s circumstances. Will the Minister review the level and type of regulations for such a unique organisation and, in doing so, give scope for a more flexible approach? If we attempt to push inappropriate national criteria on a local organisation, we run the risk of undermining the benefits to local people.

While I have the Minister’s ear, I should like to mention one other matter. On 4 November 2009, the Prime Minister gave me an assurance at Question Time that the excessive cost of guarding prisoners receiving health care outside prisons would be dealt with. I was surprised to hear from my local PCT that it has heard nothing further from the Government on the matter. Will the Minister kindly ensure that that, too, is followed up?

The Isle of Wight health service is full of dedicated professionals who want to be able to get on with what they are paid to do—caring for my constituents and visitors to the Isle of Wight, not filling in endless forms to meet meaningless targets.

I congratulate the hon. Member for Isle of Wight (Mr. Turner) on securing an important debate. Regulation is about ensuring that we maintain the quality and standards of the national health service throughout the country. We know very well that a failure to ensure that quality and standards are maintained can lead to problems such as those at Mid Staffordshire. We do not want a repeat of those problems anywhere in the country or, indeed, a repeat of the issues that we have seen at Basildon and one or two other hospitals, which, although they were not on the scale of the Mid Staffordshire debacle, were certainly worrying for the health service as a whole.

We have a health service that throughout the country provides, by and large, a good quality of care for patients. Individual examples of hospitals that fail always hit the headlines and may contribute to a disproportionate public perception of the NHS. However, as a result not only of the standards of professional competence for health professionals and managers in the health service, but also of regulation, by and large, the standard of the health service is good across the country as a whole. We need to ensure that we keep monitoring the quality of that health care and that we have the proper criteria and mechanisms to do that.

The country differs greatly. There are various local frameworks for the NHS and methods of organisation to which we cannot possibly address a national system of regulation. The Isle of Wight is in many ways almost unique in how it delivers health care. The hon. Gentleman is right that the standard of care provided on the Isle of Wight is in the category of excellent. The way in which it is delivered is a result of the particular circumstances. Like many people, I am familiar with the Isle of Wight from going on holiday there—I cannot remember on how many occasions, but it is a significant number. It needs to be recognised that because of that situation, the Isle of Wight has to deliver health care in a particular way, and it does so very well indeed.

I can well understand that the health professionals and managers and those who have to deal with NHS finance are concerned that the way in which regulation occurs on a national basis does not accommodate the Isle of Wight’s particular circumstances. There is a strong argument that that is the case and the hon. Gentleman has very eloquently put it. Other parts of the country might advance similar arguments that the way in which regulation occurs does not fit their circumstances. I am not sure that they are all quite as unique as the Isle of Wight. None the less, there are many different ways of doing these things. If we had a national system of regulation that was tailored to each area, we would be getting into a very expensive and complex system of regulation, and we cannot do that, but that does not mean that we cannot help the Isle of Wight. I shall come back to that issue in a moment.

The hon. Gentleman raised the key criteria by which regulation occurs—targets, for example—and asked whether there should be quite so many targets. We are conscious that some health professionals have said to us, “Look. Targets are important, but there are too many and you must not only put them in but, when they have done their time, take them out.” We accept that and are examining some of the targets on waiting times. Some of those are, in a sense, bypassed because the waiting times are now so short that we have hit the target and gone well beyond. Therefore, the health service does not need some of those targets, but when we have a national health service, we do need to have national minimum standards across the health service as a whole, particularly on waiting times—four hours in A and E, 18 weeks for an operation and two weeks to see a cancer specialist after referral by a GP. Those are basic standards of health that the health service throughout the country should provide.

When we have gone through a period during which the taxpayer has put in vast amounts of extra money—it depends how we look at it, but there has virtually been a tripling of the budgets of the health service—it is important that the taxpayer knows that something tangible and measurable is coming out of that extra investment and that it meets a basic minimum standard and is better than what was provided in parts of the health service in the past. That is why I am a defender of targets. We now wish to move from managerial targets to guarantees for individuals, so that each individual would have the right to enforce a guarantee in their own case. I believe that we could do that in fairly short order if, perchance, we were to win the general election—a matter for the electorate. I am a strong defender of those measurements of what we, as taxpayers, are receiving for the extra investment and higher taxes, and it is higher taxes that we pay to ensure that the NHS is properly funded.

We are talking not just about the NHS: in areas such as the Isle of Wight, there are a number of other services, which are linked up, so a lot of targets end up being built up for the ambulance service, the hospitals and primary care services. I understand that, but we are putting in a lot of extra money. Therefore, there is a justification for those targets and for applying them on a national basis, so I make no apologies for saying to the Isle of Wight, “You, too, as an authority, need to comply with the basic minimum standards of the country as a whole.”

The question then is how we ensure monitoring of compliance and the overall general standard of health care and other services provided, and whether the system of regulation is proportionate to the particular circumstances in a place such as the Isle of Wight. I share the hon. Gentleman’s concern that regulation, particularly in the area that he represents, should be proportionate and should recognise the particular local circumstances, but at the same time it needs to be national and should not become so diversified that it cannot properly compare services throughout the country. Everyone should know basically what is being regulated.

Our new regulator, the CQC, will cover a much broader range of services than previous regulators, so we have brought different aspects of regulation together. The CQC has adopted what is called the gate-keeping role, which requires it not to impose a whole series of regulation inspections and visits in a disjointed and ad hoc way, with different groups arriving at different times and disrupting everyone. Instead, it should take a reasonable and proportionate view of how it regulates the system as a whole. In a sense, it should also gate-keep itself so that it does not carry out inspections and reviews in a way that imposes a disproportionate burden on particular areas.

The CQC has become aware of the problems of the Isle of Wight. That is due in no small measure not only to representations from the various local health bodies, but to the fact that the hon. Gentleman has made sure that the concerns of the Isle of Wight are raised. The CQC will seek to apply the gate-keeping role and to be proportionate and reasonable in carrying out its regulation. I cannot guarantee the hon. Gentleman that there will not be a series of regulatory visits. That is mainly because different regulators regulate different things, so they cannot all turn up at the same time, do the same regulation and disappear at the same time.

There will therefore be a need to manage things in a way that is reasonable for both sides. That will allow regulators to take a view that there are particular circumstances in the Isle of Wight and that they need to gate-keep the regulatory burden to ensure that it is not disproportionate. On the other hand, it will allow people in the Isle of Wight to recognise that regulation in its different forms may impose a burden that is unwelcome, given that the Isle of Wight is in the excellent category, but that that needs to happen to ensure that there is national regulation.

One benefit of being in the excellent category, and one way in which we have changed things recently, is that regulation is much more risk based. Every hospital will have a visit every two years, but some will have visits more regularly—every few months—because they need them and are regarded as high risk. However, given that our approach to regulation is risk based, some hospitals will have fewer visits because they are in the excellent category. High-quality services of the kind that the CQC recognises, at this point at least, in the Isle of Wight should need less regulatory intervention than lower-quality services.

As we all know, services can change, so regulation must change with them. An excellent service can become a not-so-good service, so services must continue to be monitored and regulated. At the same time, where there is a level of excellence in a service, we need to ensure that the regulator can say, “We don’t need to visit them quite so often. When we do visit, we can perhaps do it in a more appropriate way, because there is less of a problem there from what we already know.” If things changed, however, and the service deteriorated, the level of intervention and the unannounced visits and so on, which are needed if there is a problem, would necessarily increase. What I have said is not, therefore, an indefinite guarantee for the Isle of Wight; it simply recognises that if a service is seen as high quality and can demonstrate when visits take place that it remains high quality, the number of visits need not be as high as they would be otherwise.

That is a positive message for the Isle of Wight. It has developed a unique approach to the health service that is appropriate to it. As the hon. Gentleman said, 92 per cent. of patients admitted to St. Mary’s hospital in Newport were happy with their treatment, although the figure that I have is 93 per cent. We can quibble over the 1 per cent., but the public seem very happy by and large with the way in which services are provided. I hope that the standard in the Isle of Wight will remain one that requires a proportionate system of regulation.

The hon. Gentleman asked me to take up the issue of guarding prisoners outside prison, and I will make some inquiries on his behalf about what is happening on that. Having set out some of the issues, however, I hope that I have dealt with most of the points that he raised. In those circumstances, I need not detain you any further, Mr. Cook.

Sitting suspended.