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Health Provision (Sittingbourne and Sheppey)

Volume 584: debated on Wednesday 9 July 2014

It is good to see you in the Chair, Mr Betts. I am grateful for this opportunity to highlight a number of concerns I have about the provision of health care in my constituency. I want to cover three main issues: the challenges facing my local clinical commissioning group; the provision of renal services to my constituents; and the difficulty in recruiting GPs in Kent in general and my constituency in particular.

Sittingbourne and Sheppey are covered by the Swale clinical commissioning group, which is the smallest CCG in Kent, if not in the country. Because of the way the management component of its budget is allocated on a per capita basis, its size puts Swale at a financial disadvantage compared with larger CCGs. That is a huge challenge. The Swale CCG faces a number of other challenges, and to highlight those I will explain something of the demography of Sittingbourne and Sheppey.

The population pattern of NHS Swale CCG is broadly similar to that for the rest of Kent and Medway, but in contrast to other areas it has a slightly larger proportion aged from birth to four; and a 68.1% increase is predicted in the population aged 65-plus, from 2011 to 2031. That includes, in the 85-plus group, an even greater predicted increase of 142.3%, from 2,600 to 6,300. In 2009 it was estimated that only 5.8% of the population in my constituency came from a black or minority ethnic group. However, that proportion has gone up over the past five years. In addition, the proportion of Gypsies and Travellers living in Swale is higher than in many other areas. Those things are all challenges.

In comparison with the population profile of England the NHS Swale CCG area has proportionately fewer people aged 80-plus, at the moment, but more people aged 60 to 69; and proportionately more young people under the age of 19. However, there is also a pattern of outward migration resulting in proportionately smaller age cohorts between the ages of 20 and 44. With the overall ageing of the population and predicted demographic change there will be an increase in the risk factors relating to increased chronic disease and, importantly, multiple morbidities. Life expectancy from birth in Swale is 79.3 years—the lowest among the eight Kent CCGs. That compares with 80.9 years for Kent and Medway as a whole. Within Swale there is a huge, 10-year gap between the highest and lowest life expectancy. In some more affluent areas the life expectancy is 84 years, while in our more deprived areas it is just 73.8 years. Indeed, Swale is the third most deprived district in Kent and is ranked 99 out of the 326 districts in England.

As to deprivation at the practice level, none of our GP practices is in the 40% least deprived category, but eight are in the 20% most deprived category. A number of areas in Sittingbourne and Sheppey are in the bottom 20% quintile on the national deprivation scale. That level of deprivation has been identified as contributing to lower life expectancy. The bottom 20% of the population also has a greater prevalence of preventable diseases such as heart disease, stroke, diabetes, chronic obstructive pulmonary disease and cancers. In addition, people in long-term deprivation have a higher risk of poor physical and mental health.

Deprivation is also associated with unhealthy behaviour such as higher smoking rates, alcohol misuse and decreased physical exercise. Health and social effects resulting from long-term deprivation including unemployment can last for years, and possibly a lifetime, because of the accumulation, through chronic stress, of factors that trigger the premature onset of chronic diseases. Thus demographic change and relative deprivation are likely to drive an increase in chronic disease, unless primary and secondary preventive measures are systematically put in place.

To add to the long-term challenges, the population of Sittingbourne and Sheppey is growing rapidly. That rise in population, the level of deprivation in my constituency, and the need to address health inequalities, were recognised by NHS England when it set the budgets for 2014-15 and 2015-16. Swale was one of 82 CCGs nationally that received an allocation above the 2.14% basic increase for all CCGs. For 2014-15 we have been allocated a 2.63% increase, compared with the average of 2.59% across Kent and Medway. That increase equates to an extra £3 million, for which we were grateful. However, I do not think that it properly reflects the challenges facing Swale CCG as it tries to square an ever widening circle of health inequality.

Swale CCG is doing its best, and working with other CCGs and health trusts it is implementing a two-year and five-year plan to transform services in the Sittingbourne and Sheppey areas. One of the key areas of work is the implementation of the Better Care Fund, under which money will be transferred from acute care to community care. The vision is to provide better care in the local community, which will reduce the need for hospital treatment. In Swale steps are already under way to transform health care. They include integrated primary care teams, which involve community nurses working with GP practices in a partnership approach to improving health care. Integrated discharge teams in Medway Maritime hospital and Darent Valley hospital, which, by the way, are not in my constituency, enable patients to leave hospital sooner by putting the support in place that they need in the community. Work is also being done with our rapid response services to provide support to patients with an acute crisis, to enable them to be managed safely in the community.

Improved dementia services will be helpful. Swale has been allocated two additional dementia nurses, bringing the total to five. They work with GPs and primary care teams to identify the support required by people with dementia. That multi-agency approach is making it possible to provide a more proactive response for people with dementia, and it links in with the enhanced services remit to which GP practices in Swale have signed up for over-75s. Of course the number of over-75s is predicted to rise dramatically in my area, so we will need more resources to cope.

In addition, changes are being planned to primary and community care and a consultation is commencing now on devising a new system for people in Swale and neighbouring areas. That consultation will consider how the out-of-hours service can be better integrated with walk-in centres and minor injury units to provide 24/7 care, with better joined-up care for local people, which will support a reduction in the number of people attending accident and emergency. Links are being built with the acute hospitals to facilitate that community-based approach.

To transform health care locally Swale and neighbouring CCGs are implementing whole-system change and have recognised that further support is needed to make it successful. Swale CCG would like support for several initiatives to enable the work it is doing to be completed to the highest quality. One of those is significant training and development for all health and social care staff, to help them adapt to the new health landscape and their roles and responsibilities, and support more clinically demanding care. Another is better engagement of all organisations in the health and social care economy, to ensure that they are signed up to the principles and vision of the transformation, and to break the silo mentality of provider organisations.

Finally, the CCG would like support for a more realistic expectation with regard to quick results, because whole-system change will take years to implement and CCGs should not be penalised, as they are under the current system, but incentivised with new payment mechanisms. Realistic expectations about the pace of change should be supported by transition funding to support the changes that are planned, which will take time to implement and embed. That will make it possible to provide support for the development of new services before the old ones are scaled back. Swale CCG is doing its bit, but it needs help.

The second health issue I want to raise relates to renal services, particularly the delivery of dialysis treatment. I have been campaigning for some time for a dialysis satellite unit to be set up in one of my two local community hospitals. I have some very sick patients who must travel to Canterbury, Maidstone or Medway for dialysis treatment. One very elderly patient who needed daily dialysis was so sick by the time she returned home from her treatment that she was unable to visit the renal unit the following day.

I will continue to campaign for a full-scale satellite dialysis unit in my constituency, but in the interim I am discussing with NHS England the installation in one of our local community hospitals of a bank of home dialysis machines that could be used by kidney patients who are suitable for home dialysis but, because they live alone or have insufficient room in their houses, are unable to make use of the service.

I appreciate that setting up a bank of supervised home dialysis machines in a local hospital will not help all renal patients in my constituency, but if only a handful are saved from having to make long and sometimes uncomfortable journeys to a distant hospital, it will be a worthwhile exercise. Local NHS England managers have so far been extremely helpful and are undertaking a feasibility study that I very much hope will prove that such a scheme is feasible. I wanted to raise this matter today not only to put on the record my thanks to those managers for their help, but to urge Ministers to consider making funds available so that similar units can be set up in all hospitals that do not have dialysis units.

I would like briefly to highlight my concerns about the difficulty of attracting GPs to our area. One of the problems is that because Sittingbourne and Sheppey is relatively close to London, it is difficult to attract young doctors because many of them prefer to work in the capital rather than to move out to the sticks. In Sittingbourne and Sheppey, the problem is becoming acute in some areas where practices are short of GPs and struggling to cope with a rising number of patients.

Swale has one of the highest patient headcounts per doctor in the country, and that will be made worse over the next three years because one in three of our GPs is expected to retire during that period. What steps can Government take to ensure that those GPs are replaced so that my constituents will continue to have access to a doctor and that waiting times to see a GP do not continue to rise?

I congratulate my hon. Friend the Member for Sittingbourne and Sheppey (Gordon Henderson) on securing this debate. He demonstrated his masterly understanding of the health challenges in his area and deep knowledge of and concern for the more deprived parts of his constituency. I thank him for that. His constituents will be grateful to know that he has such a handle on those issues.

Before I respond to some of the particular issues that my hon. Friend highlighted, I want to highlight the excellent work carried out every day by those who work in the NHS, not just in my hon. Friend’s constituency, but in mine and throughout the country. I hope we can always take the opportunity in a health debate to put on the record our thanks to hard-working NHS staff for everything they do in our constituencies.

I turn first to renal policy and particularly my hon. Friend’s local campaign. End-stage renal failure is an irreversible and long-term condition, and he was right to highlight the problems caused by more and more people living with long-term conditions, particularly when combined with other long-term conditions. It results from chronic kidney disease and needs regular dialysis treatment or transplantation.

Since 1 April 2013, NHS England has been responsible for securing high-quality care for dialysis patients as part of its specialised commissioning responsibilities. It has established a clinical reference group specifically for delivery of renal dialysis services, which brings together clinicians, commissioners and public health experts with dialysis patients and carers. It has published service specifications for both home dialysis and hospital and satellite dialysis, which my hon. Friend described. The specifications are important because they define clearly what NHS England expects to be in place for providers to offer safe and effective services. They are there to ensure equity of access in a nationally consistent, high-quality service for patients everywhere.

NHS England has recently consulted on amendments to a range of service specifications, including for renal services and dialysis. Those updated specifications are expected to be published later this year following consultation this autumn. My hon. Friend will take a great interest in that because it is obviously directly relevant to the campaigns in which he is engaged. I know that he has had meetings, and the feedback from NHS England is constructive about the excellent way in which he is engaging with it, and I am glad to hear that.

My hon. Friend mentioned the possibility of a satellite dialysis unit at Sheppey or Sittingbourne community hospital, but I gather that to date it has not been possible to provide such a unit because there is concern that not enough people in the area need that service. However, he is rightly pressing local NHS officials on that. One issue that comes into the calculation about setting up such a unit is the safe level of staffing to meet patient need, as well as viability and efficiency. Those are important calculations to ensure that any service meets needs.

The point about what I am trying to achieve is that renal services are trying desperately to get more people into home dialysis, because that is an inexpensive way of providing dialysis. All I am suggesting is that when patients cannot have it at home because they live alone, it should be available at the local hospital. I do not believe the cost should be too much of a factor.

That is a fair point and one that my hon. Friend has raised in the discussion. NHS England is exploring the possibility of a self-care unit in the area. Such units have been developed in a few places around the country and, as he outlined, those units are particularly useful for people who can get themselves on and off machines or bring carers with them to help because they tend not to be staffed units. It is similar to home dialysis but, as he rightly said, can be used by people whose homes are not suitable for that.

I encourage my hon. Friend to continue the discussions. I met local NHS officials yesterday and encouraged them to continue to keep in regular touch on the matter. I understand that the area director for Kent and Medway will write to my hon. Friend shortly following his recent meeting. I would be happy if he kept me informed of how the discussion goes because I am interested in it.

My hon. Friend rightly highlighted in great detail a particular challenge with local funding. Obviously, the Government have protected the overall health budget for the NHS in England and NHS England in turn has ensured that every clinical commissioning group in England will continue to benefit from stable real-terms funding in the next two years. Reflecting changes in population around the country and better targeting is key. Something that often comes across my desk as public health Minister is the challenge of getting that right where there are pockets of deprivation, particularly deep deprivation, in areas that might not flash up on the radar when looking at how resources are meted out. We want the NHS to be in a good position to offer the best services to patients where they can do the most good and meet need. Responsibility for CCG allocation rests with NHS England, but the Government’s mandate to NHS England makes it clear that equal access for equal need is at the heart of the approach to allocation.

NHS England’s decisions in December last year mean that over the next two years every CCG should receive real-terms funding growth. The purpose of doing that for the next two years instead of just one was to try to provide stability and certainty so that local commissioners can plan services. The sort of issues that my hon. Friend highlighted and the long-tem problems associated with deprivation, such as co-morbidity, over-indexing on smoking and so on, need stability of commissioning because they need long-tem consistent intervention in many cases to ensure that we are meeting patients’ needs. That means that every CCG will receive cash growth in funding of at least 3.9% over the next two years, and those with the fastest-growing populations will get more. Swale CCG’s funding allocation increase of 2.63% in 2014-15 is just above the national average and its increase of 2.05% in 2015-16 is just below the national average. That real-terms growth was given to all as a minimum of 2.14% in 2014-15 and 1.7% in 2015-16.

In order that the issue is looked at objectively, free from political considerations, the Health and Social Care Act 2012 made how health funding is allocated between different areas a responsibility of NHS England. NHS England has taken an evidence-based approach that balances the demands of growing populations and looks at historical underfunding, which is probably one of my hon. Friend’s great concerns, and at maintaining stability.

NHS England has also decided to leave the weight given to the inequalities indicator unchanged at 10%. The new indicator has less variation in it than the old indicator when looking at variation across CCGs, and it is now able to pick up pockets of deprivation within CCGs. That adjustment should favour my hon. Friend’s area for the very reasons that he outlined, and NHS England has accepted the advice it has been given by an independent committee that that is a better measure of inequality for this purpose.

NHS England’s consultation on the impact of the new formula earlier in the year did not have an inequalities weighting at all, which led some people to jump to the wrong conclusion, but it does not reflect the final decision, which is to include an indicator of inequality with a weighting of 10%. They are finely balanced judgments, particularly around the progress of the pace of change towards the right amount for a particular area.

While the Minister is talking about the funding and the formulas, I point out that there is an anomaly, which goes back to the dialysis treatment. The CCG is not responsible for the commissioning of dialysis, so it cannot control where the patients go, but it is responsible for funding the transport of those patients to the hospitals. It seems a bit of an anomaly that the CCG has no control over where the patients go, but is expected to fund the transport. I wonder whether that could be looked at.

It is a fair point, and I will ask the NHS team in my hon. Friend’s area to consider that as part of his ongoing discussions with it. As I said, getting the funding formulas right is not a perfect science, but the new formula is more responsive to pockets of deprivation. However, he has highlighted some challenges around smaller CCGs in a fair way.

My hon. Friend also highlighted issues and concerns about GP recruitment, and I know he has raised them before. A number of GPs in Swale are due to retire in the next few years. That is a challenge we see elsewhere in the country, and it has also been reported that Swale has a higher ratio of patients per GP than some other areas, so we recognise that that is a potential challenge. GPs work hard and do a vital job, so we are all concerned about making sure that we have the right number of GPs in our area. At a national level, despite a decrease in headcount, there has been a small increase of 1.2% in full-time equivalent GPs since 2012, and the number of practice nurses and other practice staff has also grown. My hon. Friend talked about the great public health challenges, such as co-morbidities, and there are many things that practice nurses increasingly deliver and their interventions can be extremely effective.

However, we recognise that the work force need to grow to meet rising demand. In our mandate to Health Education England, we have required it to ensure that 50% of trainee doctors enter GP training programmes by 2016. The Government will also be working with NHS England, Health Education England and the professions to consider how we improve recruitment, retention and return to practice in primary and community care. That is something that my ministerial colleague, the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), is very closely considering and is engaged in active discussions on.

I understand that the Kent and Medway area team from NHS England are working closely with the local CCGs, GP practices and HEE to improve the overall recruitment and retention levels of qualified doctors entering general practice as a specialty. I also understand that Swale clinical commissioning group has set up the north Kent education, research and innovation hub, which met in June and is meeting bi-monthly. The hub will be looking, at a local level in particular, at what needs to be done to address expected shortages. That is right because, with the best will in the world, these things cannot be solved with a grand plan in the centre. We also need to address some of the local issues and some are very granular with regard to what can help to attract GPs to particular areas. It is right that that is being done at a local level.

In the few minutes remaining, I want to touch on proposals for out-patient care, because, again, my hon. Friend the Member for Sittingbourne and Sheppey highlighted the value of early intervention and community health services, and of keeping people well in their own homes. In particular, as well as being good for individuals, that takes pressure off A and Es. We do not want to see routine conditions presenting in A and E at an acute stage, so it is really important that we get out-patient care right.

Proposals in my hon. Friend’s area include consolidating services into six co-ordinated out-patient clinics from the current 15 sites. The benefits of that include value for money from modern facilities and equipment, a wider choice of appointment times, and a greater ability to perform enhanced diagnosis—the Government have made early diagnosis a real priority; far too many conditions are still being diagnosed at an acute stage in A and E, so early diagnosis is critical. A greater proportion of his local population will also be within 20 minutes of an out-patient appointment, which is important. The East Kent Hospitals University NHS Foundation Trust is working with the NHS Canterbury and Coastal clinical commissioning group in consultation. A public consultation on out-patient services was completed in spring this year. I know that my hon. Friend will have been very engaged with that and that those proposals have now been brought forward.

A number of other workstreams are in place to address the issues that my hon. Friend outlined. I encourage him to talk with the public health directors in local authorities. The public health lead now sits in local authorities, and I am seeing some great innovation around the country from local authorities and directors of public health to address some of the really deep-seated challenges that he outlined. Many of the figures that we are seeing for public health are going in the right direction at a population level, but they often mask what is happening with smaller sub-groups of the population, for whom the figures are not moving in such promising directions. That is exactly what my hon. Friend was describing, so along with all the other people he is engaging with, I encourage him to make sure he engages with directors of public health and, in particular, the local Public Health England teams.

My hon. Friend should ask them what they are seeing in areas around the country that is really working. Some of the places I have visited, with similar demographic challenges and similar public health challenges, are piloting interventions that are really effective. One of the great opportunities of more devolved public health is that it gives rise to local innovation, and we see that imaginative approach being brought to bear by people who really know their populations. However, one slight challenge is how we identify good and emerging best practice and ensure that we get it promoted more widely. I encourage my hon. Friend to ask questions of his local public health specialists, and in terms of the population challenges he faces, he should ask about things that are being piloted elsewhere that might effectively be brought into his area.

I end by congratulating my hon. Friend again on being a really effective champion with regard to the local health challenges his community face. It is great to see a constituency Member with such a grasp on the range of challenges. I often respond to debates on the reconfiguration of bricks and mortar, but understanding the deep health challenges that a particular population face, and doing so at a granular level, is also really important in how we shape services for the future, so I congratulate him on that. His constituents have a great champion in Parliament for their health needs. I am very happy to continue to engage with him, and I encourage NHS England in his area and his CCGs to continue the constructive dialogue that they have had—and continue to have—to provide the best services to his constituents.

Sitting suspended.