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Rural Healthcare

Volume 720: debated on Wednesday 12 October 2022

I will call Anne Marie Morris to move the motion and then I will call the Minister to respond. There will not be an opportunity for the Member in charge to wind up, as is the convention in a 30-minute debate.

I beg to move,

That this House has considered rural healthcare provision.

It is an absolute pleasure to serve under your chairmanship, Ms Elliott. I have already provided the Minister with a copy of the report by the all-party parliamentary group on rural health and care, which followed a three-year inquiry that we undertook with the National Centre for Rural Health and Care. It contains a lot of detail about the issues and suggested solutions. It looked far and wide across the world, not just across the United Kingdom, and I certainly hope that the Minister will give it more time than I suspect he already has in preparing for this debate.

The number of people living in rural settings is not small—9.7 million people live in rural England—and they have very different needs, so the current one-size-fits-all approach simply does not work. We have a different demographic. Generally, our constituents are older, they have complex comorbidities, they live in isolation, and many are in severe deprivation, but much of that is often hidden because the data collected is at such a high level that the issues are simply not identified. If levelling up, which is a commitment of the Government, is to mean anything, that has to change.

Covering everything in the report would take me more than the time available, so I will limit myself to the Government’s alphabet. Let me go through A, B, C and D. On ambulances—A—I absolutely applaud the Government’s position that the current situation is unacceptable and that we need shorter response times, particularly for category 1 and category 2 emergencies, but I am sure the Minister is well aware that the data shows that rural and coastal areas have some of the worst response times across the country, often because it is simply not possible to reach particular parts. In Devon, there are some areas where it really does not matter how many ambulances there are and how fast the roads might be—they are not—as there comes a point where it is not possible to get further.

We have not looked at a different approach. We have not looked at how we triage this differently so that we improve, rather than reduce, health outcomes. A one-size-fits-all approach means that those in rural areas are at much greater risk than those in urban areas. There is not a specialist centre of excellence for strokes that people can get to very quickly by being popped into an ambulance.

Money is clearly an issue, but if we properly integrated our use of fire services, police, ambulances and first responders, we would get a better outcome. Let us triage the calls as they come in differently, and then let us use those individuals and organisations better. Currently, the barriers are different pay for different forces and the fact that those organisations—fire services, police and ambulances—have different lines of accountability to different Departments, which means that they do not work together.

We could find a much better and more efficient way of doing this. Fire services are vital, because they are often physically located in some of these very rural areas. There is not a lot of point trying to get an ambulance in every rural village; that would be completely inappropriate and unaffordable, and it would not work. Let us look at how we can deal with those blockages and do this differently.

B is for backlogs. The Government’s aim to reduce the backlogs is commendable, and the plan to get waits down to one year by 2025 is fabulous. However, those of us who have rural constituencies know that the resources right now are simply not available, and rural areas have a real challenge to recruit. They are seen as unattractive. Youngsters want to be near the nightlife and the fun when they are off duty. The idea of coming to a rural area is not attractive. That is well known to the Government, because there have been various planned pilots and initiatives to pay individuals more to attract them to rural areas. It simply does not work.

The hon. Lady is making an important point. When it comes to waiting times for cancer treatment, 41% of cancer patients in south Cumbria and 59% in north Cumbria are waiting more than two months to get their first treatment after diagnosis. We know that is certainly costing lives. Does she agree that tackling the cancer backlog has to be the absolute priority for this Government?

More than that, we need to look at the different pathways in rural communities for heart, cancer and stroke treatment. I agree with the hon. Gentleman, but there is a lot more than just cancer, and the rural pathway to care has to be reviewed to see what is realistic in a rural area.

All of this has been made worse by a funding formula that is not fit for purpose. Although there is provision to uplift for rurality, it is not enough and it has been done without any real understanding of some of the challenges.

Cornwall has more visitors outside of London than anywhere else in the country, so we have our winter pressures and then there is no respite in the summer months for our staff. We have issues with housing so we cannot recruit staff. Does my hon. Friend agree that there is a case to be made for extra funding for places such as Cornwall, and perhaps the wider south-west, to ensure that we have enough funding to treat all our visitors as well as our residents?

That is an exceptionally fine point. I have no issue with it because we have a similar problem in Devon. The solution is not just about more recruitment and doing things in the same way, because the people to be recruited do not exist. We need to look at doing things differently, by creating new career paths with shorter training periods and trying to train, so we can then recruit, locally. Generally, people will follow a career where they are trained. We need more rural training for doctors and nurses, and that training needs to be not in the local city, but in the rural areas. For example, in Plymouth we have a fine medical school— Peninsula Medical School—but the challenge is that the experience that the individual trainee doctors and nurses gain is not rural, and it needs to be.

My hon. Friend is making a fine point. From my experience, there is an opportunity: young doctors who are becoming GPs tend to be between the ages of 27 and 35. At that time, most people are looking to set up their family, go to school and get married. If we extend some of the career opportunities by extending training in those areas, they are more likely to bed down roots and gain a skill to become a GPSI—a GP with a special interest—in those areas. Does she believe that is a formula that the Government should look at?

I absolutely agree, and it is an excellent suggestion. In a similar vein, when we are asking primary care networks and others to deal with the backlog, it is important that we try to give them much more freedom in how they address the problem. I talk to many of my local commissioners, and they say that they are having to make decisions that they know are right, even though they are not currently in the guidebook as best practice. We need to give them that trust to be able to do the right thing.

C is for care. Members will not be surprised to hear that the adult social care discharge fund, although welcome, is not going to be enough. The reality is that the bed count is often low in rural areas. In the south-west, we have the lowest bed count per head of population; I think it is the lowest in western Europe, although I am happy for the Minister to correct me. It seems to me that we used to be moving towards saying, just in time, “Let’s have care in the community.” However, because of the shortage of care in the community, and the lack of proper validation that it works other than whether people are readmitted, we need to put a halt to closing community hospitals and to look at how they can be used. Some could be repurposed. Perfection can often be the enemy of the good.

Teignmouth Community Hospital in my constituency is on the closure list, but to me that is not a wise decision. There are no nursing care homes in the area. Without that residential care, and without adequate care in the community, removing the only other source of beds is not the way to solve the backlog problem.

I thank my hon. Friend for securing the debate and this important conversation. I also thank the Minister for the community diagnostic centre announced for the Isle of Wight this week. That is great, but we still have a problem similar to that of my hon. Friend the Member for Newton Abbot (Anne Marie Morris): unavoidably small hospitals. There are dozens of those in England and Wales, of which St Mary’s is the most isolated. We were able to work with the Government to improve the funding formula in 2019, so unavoidably small hospitals have got some more money. My concern—the same might be true for hospitals in my hon. Friend’s area—is that that is not enough to cope with the health needs and the demographics in our communities. It would be great if the Minister could meet some of us to discuss the future of unavoidably small hospitals in places such as Devon, Cornwall, Cumbria, Northumberland and the Isle of Wight to see what more we can do to support these important community centres.

A point very well made, which I support.

Care, as we all know, is one of the biggest challenges. If we fix care, we will fix the backlog, so we also need to look at how we train and professionalise not care on its own, but care with health. We need to give care professionals the same respect as we give others—and, frankly, for the same sort of skill, we need to pay the same salary. That is crucial if we are ever to get this to work.

D for doctors is the last letter in the Government’s alphabet. The Government are looking for the GP appointments system to improve, so that anyone who needs to see a GP can do so within two weeks. They want to provide data so that individuals may choose which doctor they go to see, and they want to increase the use of pharmacies.

Now, all that is very worthy, but unfortunately, when it hits reality, it becomes the problem. In rural areas, there are too few doctors. If we had data, choice would be great, but there is no choice, because there is not another GP practice. The problem in rural areas is not the level of data, and it is not choice—there is none. It is recruiting the doctors we need. Recruitment in rural areas is in crisis. Yes, we should make more use of pharmacists—that would be fabulous—but in many rural areas pharmacies are closing because they cannot get enough pharmacists. We have a real conundrum, and that is crucial.

If we are to address the issue, we need proper rural medical schools, shorter career courses, and proper training for new routes into medicine and care. Physician associates are a great start, but the reality is that that is only one route, and it is still quite a long training period. More broadly, primary care is mission critical; we know that training in generalist skills across the doctoring profession, if I can put it like that, is done very early but not continued. We need those skills so that we have a much broader range of doctors who, when we have something like the pandemic, are able to cope with the issue. We also need more geriatricians.

D also stands for dentists. The new contract is welcome, but it has been discussed for eight years, I think. It needs to get done. Doctors and dentists need a fair return for the work done and they need to be incentivised to provide the best treatment for the patient. As I understand it, under the existing contract, dentists are in effect encouraged to sub-optimise. They are only paid a relatively small amount, so they will do the minimum rather than what is in the patient’s best interest. We need fairness for the dentist and for the individual patient to be at the forefront of the contract.

We need to step up recruitment, we need to create rural emergency hubs, and I think we need to appoint school dentists. In the same way that a GP is in charge of a particular care home, I see no reason why we should not have a dentist who is responsible for a particular school. I am not suggesting that they should go in and do fillings, but they would at least go in and do regular checks.

My hon. Friend is being very generous with her time, and I appreciate that. I remember—she may too—that, as schoolchildren, we had somebody come into school to check over our teeth, just to see if there was anything going on. It is my understanding that someone does not have to be a dentist to be able to tell whether something is going wrong; dental technicians, hygienists and others can do this work. Does she agree that it would be worth doing pilots around the country, particularly in rural areas, to see whether that could cut down some serious dental issues with our children?

That is an excellent suggestion. There is quite a lot for the Minister to take away and think about.

Having gone through the alphabet, I think there are a number of things that we need the Minister and his team to do, including recognising that rural really is different and that the way we look at it now simply does not work. We need to properly understand and investigate the need in different rural communities, and then we need proper funding. We need to look at how we train locally, which will improve recruitment and retention. We need to create new, shorter courses and new professions—and we need to do that now; otherwise, we are never going to get on top of the backlog. Waiting for degree-qualified nurses and doctors will simply take too long.

We need to equalise the professionalism and pay across health and care, and we need to integrate emergency response across all resources—police, fire, ambulance and first responders. I am happy to volunteer the south-west, which I think would be up for it, as a pilot area. I hope that the Minister will go away and think about that, and that he may be willing to meet those who have raised issues today to see if we cannot find some solutions and to discuss the other issues in my rural report.

It is a pleasure to serve under your chairmanship, Ms Elliott. Before I start, let me pay tribute to the work of those in the NHS and social care services across England, who are delivering excellent care now and have done so throughout the pandemic. The country is rightly proud of each and every one of them.

I congratulate my hon. Friend the Member for Newton Abbot (Anne Marie Morris), who has been a champion not only for her constituency but, more widely, for the importance of improving health services in rural areas. I thank her for securing this important debate, and I pay tribute to her work and that of the APPG, whose report I read with interest.

Although my constituency of Colchester, a relatively new city, does not share the rural characteristics of Newton Abbot, I am committed to excellent healthcare outcomes for all people in rural and urban areas across our country. I probably cannot cover every single aspect of the report, or even all the issues raised by my hon. Friend today, but I will certainly try to cover as many of them as I possibly can. Of course, I am very happy to meet her and any other colleague who would like to meet. I am proud never to have turned down a meeting with a colleague, and that is a record I intend to keep.

We certainly recognise many of the challenges caused by rurality, including the distinct health and care needs of rural areas and the challenges of access, distance and ensuring a sufficient population to enable safe and sustainable services. I assure my hon. Friend that this Government will remain committed to improving health services in rural areas, as we are committed to doing across all of England.

The Minister alludes to GP surgeries in rural areas, which the hon. Member for Newton Abbot (Anne Marie Morris) also mentioned. Generally speaking, they serve smaller numbers of people over much larger areas. They were supported in their sustainability by something called a minimum practice income guarantee. That disappeared a few years ago, leading to many closures. In Ambleside and Hawkshead in the Lake district in my constituency, some surgeries are facing potential closure because of the removal of that funding. Will the Minister consider introducing a specific rural surgeries subsidy fund to help ensure that surgeries in rural communities in Cumbria and elsewhere are sustainable?

I thank the hon. Member for his question. I am not going to make policy on the hoof, so I will not say yes now, but we are fast approaching the next GP contract, which will run from April 2024, so we have an opportunity to look at all these things in the round. I am passionate about securing access to GPs in rural and remote areas. Perhaps we can double-tag our meeting, make it twice as long and discuss that issue too. I will respond to some of the issues raised about GPs in a moment.

I reassure my hon. Friend the Member for Newton Abbot that we are in full agreement that the NHS needs to be flexible enough to respond to the particular needs of rural areas. That is vital, and that is why we passed the Health and Care Act 2022. The Act embeds the principle of joint working right at the heart of the system, promoting integration and allowing local areas the flexibility to design services that are right for them. Integrated care boards and integrated care partnerships give local areas forums through which to design innovative care models, bring together health and social care, and, importantly, prioritise resources to ensure that they best align with the needs of individual areas.

We are also enabling the NHS to establish place-based structures covering smaller areas than an integrated care system. That could match the local authority footprint, for example, or in some cases it could be even smaller—a sub-division based on local need. That is fully in line with the view expressed in the APPG report that the NHS should foster and empower local place-based flexibility. I think that is at the heart of the report.

As my hon. Friend knows, in establishing those models for the NHS to follow, we have set the framework but have left it to individual areas to tailor them to local needs. I think that is the right approach, because local areas know better than Ministers. We do not always hear Ministers say that, but I think local areas often know better than I do, sitting here in Whitehall, how best to organise themselves, and how to design and, importantly, deliver the best possible care for patients. While we in Westminster can support, guide, hold accountable and occasionally chest prod, it is right that we also protect local flexibility.

When the Minister talks about local flexibility, I interpret that through the guise of funding. Does he accept that there is a funding issue for the 12 unavoidably small hospitals in England and Wales, and will he look at the funding mechanism that was established in 2019? It gives more money to unavoidably small hospitals, but arguably only about 50% to 60% of what is needed.

I have made a note of my hon. Friend’s question and I am going to come to it in a moment. The answer is no, but only because it is not my responsibility. It is the Minister of State, Department of Health and Social Care, my right hon. Friend the Member for Newark (Robert Jenrick), who has responsibility for hospital funding, and in the next seven minutes I intend to commit him to lots of meetings with every single Member present.

Let me turn briefly to the question of resources, about which I know a number of Members are concerned, and which has just been raised by my hon. Friend the Member for Isle of Wight (Bob Seely). It is vital that we allocate resources fairly, as my hon. Friend the Member for Newton Abbot mentioned. That is why NHS England asked the Advisory Committee on Resource Allocation to consider the issue and provide a formula for allocations to integrated care boards. That formula took into account various factors, including population, age and deprivation —but we changed it.

In 2019-20, we produced a new element of the formula, recognising the points that my hon. Friend the Member for Newton Abbot makes, to better reflect the needs of some rural, coastal and remote areas, which on average tend to have a much older population. With an older population very often comes complex health needs. NHS England is using that formula to make allocations accordingly, but we recognise that some systems are significantly above or below target, and NHS England has a programme in place to manage convergence over several years. We also recognise the important challenge in ensuring that rural areas have the workforce—another point rightly raised at length—to provide the integrated patient-centred services that we all want to see.

We know that doctors are more likely to stay in the places where they trained, as my hon. Friend said. That is why, as part of a 25% expansion of medical school places between 2018 and 2020, we opened five new medical schools in rural and coastal locations that historically have been hard to recruit in: Sunderland, Lancashire, Chelmsford, Lincoln and Canterbury. I am conscious that my hon. Friend would want far more; that is perhaps a conversation to have at a later date. We hope—in fact, we expect—that graduates from those schools will stay in the area and will have a far greater understanding of the lives, needs and challenges of the people they serve in the locality.

My hon. Friend mentioned ambulances. As part of our plan for patients, which we launched in July, there is an extra £150 million for 2022-23 to address issues relating to ambulances. I hear what she says about differential pay rates, particularly in rural areas, between different blue light services, and I will take that away. Ambulances fall under the remit of my right hon. Friend the Member for Newark, and I know that he would be delighted to meet my hon. Friend the Member for Newton Abbot to discuss that issue.

On backlogs, I completely understand the points that my hon. Friend makes about recruitment challenges. I will take away her point about incentives not working, and I will look at other measures to attract people to rural and coastal areas, because we know that is a particular challenge.

The hon. Member for Westmorland and Lonsdale (Tim Farron) raised cancer wait time variance. As the Minister with responsibility for cancer, that absolutely concerns me. We are opening new diagnostic centres, but we have to look at more.

I am conscious of time, so I will have to come back to the hon. Gentleman. We are going to meet, and we can discuss that at length. I know it is a concern of his.

Yes—absolutely right.

My hon. Friend the Member for Truro and Falmouth (Cherilyn Mackrory) raised seasonal visitors. I know that is an issue across Cornwall and Devon, and I would be very happy to look at that. My hon. Friend the Member for Bosworth (Dr Evans) raised the issue of GPs, and extending training and career opportunities in rural areas. I totally agree, and we will soon have a date in the diary to meet and discuss that.

My hon. Friend the Member for Newton Abbot was right to raise community hospitals. Again, my right hon. Friend the Member for Newark will be delighted to meet to discuss that at great length, as he would be to discuss unavoidably small hospitals, which I know my hon. Friend the Member for Isle of Wight has raised with the Secretary of State.

My hon. Friend the Member for Newton Abbot and others mentioned doctors. I entirely hear what she says about data. Data is important for choice, but I completely understand that in some rural, remote and coastal areas, there is no choice; there is just one GP, pharmacist and dentist, so we have to look at it differently. But data is important, because it allows the local integrated care board to identify where there are challenges and which practices are struggling. From November, for the first time, we will be publishing practice-level data on appointments and missed appointments. That is important because the patient deserves to see how their tax money is being spent. It also enables us to hold the integrated care board to account for how it is holding to account the practice and ensuring it modernises, is more efficient, and addresses the issues that its patients face. As part of our plan for patients, we are looking at that at great length.

Dentists are a real passion of mine. Dentistry is not looked at in the depth that it should be as part of wider NHS services. My hon. Friend rightly pointed out a number of reforms that were put in place in July. They are starting to take effect, and she will see more as they come to fruition. It is a top priority for me, and I am looking for areas for potential further reform. I encourage my hon. Friend to talk to her integrated care board about what more can be done on centres for dental development.

We absolutely recognise the importance of giving rural areas special consideration. They face a different range of challenges to the NHS in urban and suburban areas, and it is right that we give local systems the flexibility to respond to that. I hope I have reassured my hon. Friend and others that the current system does that. I am sure she will want to continue her work and the important work of the all-party parliamentary group. I certainly look forward to working with her.

Question put and agreed to.