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Derbyshire CCGs’ Finances

Volume 646: debated on Tuesday 4 September 2018

[Sir Christopher Chope in the Chair]

I beg to move,

That this House has considered Derbyshire clinical commissioning groups’ finances.

It does not give me great pleasure to raise this matter of great importance: the finances of our local health services and the clinical commissioning groups in Derbyshire. Two months ago—ironically on the 70th anniversary of the NHS—all the voluntary sector organisations in Derbyshire were shocked to receive letters stating that their funding from the clinical commissioning groups was to be cut. Our voluntary services provide much-needed support to thousands of frail, elderly and disabled people across Derbyshire, including support when they come home from hospital, befriending services, respite care, overnight stays and community transport.

Thousands of volunteers give their time to help vulnerable people, often in very rural areas where no other services are available, to live independently and stay well. They provide a constant check on those people’s physical and mental wellbeing. I thank all the volunteers across Derbyshire and the services that support them in helping people. They help older people to manage on their own, reducing the calls on GPs, visits to accident and emergency, and stays in hospitals or care homes for a fraction of the cost of those services. For example, the night-sitting service in High Peak provides emergency and respite care overnight—for example, when a carer is ill or to prevent a patient who would otherwise have to go into hospital from being admitted.

I congratulate my hon. Friend on securing this important debate. Does she agree that, alongside the financial consequences of their cheaper cost, many voluntary organisations, such as Age Concern, which I saw last week, keep old people well and prevent them from having to use health services by providing services such as the befriending service in Chesterfield?

Absolutely. Age Concern and other voluntary services work fantastically well with thousands of older people.

Last year, the night-sitting service supported 93 people with more than 2,000 hours of care at a cost of just £34,000. That works out at just £369 per person for an average of three nights’ support each. Just one of those nights in a hospital would have cost the CCG more than that.

The CCG says that the county council provides an alternative service, and it may do on paper, but as we have a drastic shortage of social carers, like so many other places, no other help is available. The voluntary sector provides friendly, personalised, local care for far less than any other service could. For example, New Mills and District Volunteer Centre told me that it supports 550 mostly elderly, widowed and disabled clients for an average cost, between the staff and the volunteers, of just £2.26 an hour. If just two of those 550 clients have to go into a care home as a result of losing the volunteer services—in practice, it is likely to be many times that—the cut will cost more than has been saved.

I congratulate the hon. Lady on securing this important debate. I agree with her: the work that volunteers do in my constituency and the support they get from the centre for voluntary services is vital. Does she agree that it is short-sighted in the extreme to try to fix a medium-term funding issue by creating irreversible long-term damage to voluntary services in the area? The way it was done—with the threat of little notice—was equally crazy, as there was no way of replicating the structures in that time. We need a long-term, sustainable solution, not a short-term quick fix that does long-term damage.

The hon. Gentleman has just summarised the next 11 minutes of my speech extremely well. I absolutely agree with him.

Having asked their commissioners to make a decision about all the cuts to voluntary services two weeks ago, after just four weeks of consultation over the summer, and in the face of challenges from Healthwatch Derbyshire and the county council’s health scrutiny committee and a large public outcry, the CCGs are now being forced to look again at some of the cuts, but they are still on the table. They come on top of all the other cuts to health and social care in Derbyshire, where the county council has lost more than half of its funding since 2010.

I share the concerns outlined by the hon. Lady and my hon. Friend the Member for Amber Valley (Nigel Mills), and I absolutely regret what the CCGs are proposing for the voluntary budgets. I hope they think again, as I am sure everybody in this Chamber does. However, does the hon. Lady agree that contextualising this issue with a wider point about cuts, which she is about to start doing, is not as accurate as it could be? The litany of historical poor management decisions by the four CCGs got us to this place and is the problem we are dealing with now. As my hon. Friend said, we need a long-term solution, and we should not default to a narrative of Government cuts when we know that is not quite correct.

Actually, the alternative is correct. The CCGs in Derbyshire were managing absolutely fine until the five-year forward review in 2016-17. They were making surpluses, and there was no problem—particularly with North Derbyshire CCG, which covers my area and the hon. Gentleman’s area. It had surpluses and hit the 1% target underspend—[Interruption.]

Order. It is intolerable that the hon. Member for North East Derbyshire (Lee Rowley) should seek to intervene from a sedentary position.

The figures speak for themselves, as do the cuts to the county council, and as do all the other cuts that the CCG has had to make since the reduction in its funding increase in 2017, which I will set out in detail.

Last year, just after I was elected, our local dementia assessment and support ward in Buxton was axed. It was a gold-standard service that took the most difficult patients with dementia and helped them back into care in their own home in an average of less than six weeks. Our rehabilitation and support ward at Buxton, Fenton ward—the only place where acute patients in High Peak can be sent, as we have no nursing homes at all—is due to lose more than half its beds, despite the fact that a waiting list of patients in our acute hospital need those beds, even during the summer.

Community hospitals across Derbyshire are facing the loss of 84 beds. Bolsover Hospital and Bakewell have already closed, and staff at Clay Cross and Ilkeston hospitals are living with a threat to their wards. Anyone would think we were seeing a reduction in the number of patients with dementia, or elderly and frail people who need rehabilitation to get them home from hospital. Of course we are not. Instead, there has been an explosion in the need for those services at a time when our NHS is being forced to make short-term cuts that will have long-term implications for the care of our patients and for the skilled staff we need to keep in the NHS.

I had thought that the Government’s aim was to keep our long-term health costs down. Instead, cut after cut is forcing up costs—not just in the long term but immediately. The hours have been cut at our minor injuries units at Buxton and in Erewash. Our local A&E had an immediate increase in patients, which is costing the NHS even more. That A&E department, which usually sees 200 cases a day on average, rising to 250 in winter, has been seeing 300 patients a day over the summer. There has not been a spate of accidents; those patients have long-term illnesses that are not being managed because our local health services cannot keep up with the increased demand as they are not now being funded to do so.

It seems that, whichever service that helps people to stay out of hospital or long-term care one thinks of, it is being reviewed or cut. Our respite care for people with severe learning disabilities is one of the services that patients have been told is being reviewed due to the challenges it faces. My constituent Christine told me that her daughter Julie, who is 38 but has a mental age of eight, receives four or five days of respite care a month, and that is all that enables Christine and her husband to continue to care for her at home, as Christine is 62 and her husband 75. The alternative of permanent residential care would be far more expensive for the state to provide.

Specialist nurses who help people to manage very serious long-term conditions, including heart failure, diabetes and Parkinson’s disease, are also proposed for cuts. After more outcries, especially from the GPs who would be shouldering that huge extra burden, those cuts have been put on hold until next year. The threat, however, is still there, and the specialists and the committed staff who run the service do not feel secure in their jobs.

Even funding for wound dressings has been removed. After suture removal and the first dressing, GPs are supposed to send patients with suppurating wounds to clinics many miles away, although often those patients have no transport. Otherwise, GPs have to pick up the burden themselves to prevent their patients from suffering serious infections, ending up in constant pain and back in hospital. In the case of our average small rural GP practice, that is 1.5 days of practice-nurse time a week. To keep that up is not sustainable.

Given all the rhetoric from the Department of Health and Social Care about sustainability, why is that happening? Why are short-term financial decisions impacting so hard on our frontline health services, on our voluntary services—which are vital as part of a long-term sustainable service—and on the frail and vulnerable people who need them? The short answer is finance. Finance has become the be-all and end-all for decisions on healthcare in Derbyshire. It is not an unusual area and we do not have particularly unusual health needs, apart from being more rural and having a slightly older age profile. The cost of our health needs, as in most areas, increases by about 3.5% a year.

Our CCGs were doing absolutely fine—meeting all their targets, delivering the required underspends and building up reserves—until the funding formula changed in 2016. North Derbyshire, for example, had a reserve of £20 million until, instead of the average CCG increase of 3.75%, North Derbyshire received only 1.6%. With a flat budget for 2017-18 and only a 2% increase for 2019-20, that is disastrous. The CCG was told by NHS England to find £16 million in cuts over six months during 2016-17. When that did not happen, it was placed in special measures and told to find cuts of 7% in 2017-18. However, long-term services with loyal staff cannot be cut that quickly, so again the deficit mounted.

Now Derbyshire’s four CCGs are applying to merge so that they can achieve the required efficiencies of scale and organisation. However, their combined deficit is now £95 million. NHS England has stipulated that if they can make £51 million of cuts, the other £44 million will be written off. That is all well and good, but it is dependent on those £51 million of cuts being made in just seven months. If the CCGs cannot make those cuts, they will have to find not only the £51 million but another £44 million. That is on top of the unmet extra costs of services next year of a further £21 million.

The Government claim that they are increasing spending on the NHS, but that is not what we see locally. Our communities see cut after cut after cut. Even the long-promised uplift of 3.5% a year from 2020 will only meet that one year’s increase in need; it will do nothing to deal with the huge backlog of cuts from a decade of austerity for our NHS.

Healthwatch Derbyshire has challenged the legality of the cuts, because they are being made at such speed that there is little assessment of the impact, let alone proper consultation. Much of the problem is that the benefits of the services that are being cut will not be measured financially—only their immediate cost. As far as NHS England is concerned, as long as £51 million of cuts are made, it does not matter that those cuts will increase costs by £151 million next year and every year thereafter. Furthermore, in the case of our voluntary sector and of our skilled specialist staff, when they are gone, they are gone. Voluntary services such as ours in Derbyshire take years of building up, of working with volunteers and of recruiting staff who are often prepared to be paid for only a few hours a week but who show absolute commitment to looking after their clients and volunteers. No one wants to make those cuts, but as the chair of one of our CCGs said:

“I wish that we had a regulator who would walk the path with us, and would look at the impact of these cuts, instead of simply demanding savings.”

That brings me to my question for the Minister. We should be nurturing our voluntary services and supporting our hard-working NHS staff, whose pay has been declining while their workloads have soared. We should be protecting our ever-growing numbers of frail, elderly and disabled patients, who have seen huge cuts to their social care and become ever more reliant on the health service, and working to integrate our health and social care budgets properly so that we do not see one service making cuts that cost the other even more. We should be building a sustainable health service fit for the 21st century. Please will the Minister tell me that NHS England will enable that to happen in Derbyshire?

It is a pleasure to serve once again under your chairmanship, Sir Christopher. I congratulate the hon. Member for High Peak (Ruth George) on securing this important debate. She has effectively put on record her concerns about the financial challenge faced by the Derbyshire CCGs.

The hon. Lady is right to recognise that the Government are committing more money to the NHS. That is why the Prime Minister has announced a funding increase of, on average, 3.4% each year to 2023-24. The NHS budget will therefore increase by more than £20 billion a year compared with today. Alongside that, it is also right for NHS England, the independent organisation that allocates funding, to question the efficiency of CCGs, in particular by comparison with other CCGs, looking for what efficiencies can be found. Indeed, the four CCGs in Derbyshire have already identified £39 million of savings, against our target which is 3% of their overall budgets. Significant progress has therefore been made to meet the challenge set by NHS England.

Part of that £39 million is £5 million of decommissioning, which includes those voluntary services, so they are now having to be reviewed. That £39 million in cuts is not good news—it is pretty bad news for the NHS, as I have set out.

I was just about to come on to the voluntary sector, because that is where the hon. Lady’s speech started, but in her remarks she talked about the four CCGs coming together as part of the “efficiencies of scale”—her precise phrase—so I shall come back to the voluntary sector later.

I am probably in the position of largely agreeing with the Minister. I remember that, back in 2010, we had the Derbyshire primary care trust, but then the Lansley reforms came in, broke up the PCT and turned it into five different organisations in North Derbyshire. Can he imagine how galling it is for us to hear that those organisations, which went from a very strong financial position back in 2010, are now in utter financial chaos, so the Government are going to undo the Lansley reforms and to get those economies of scale that we were telling them about back in 2010?

There seems to be a slight contradiction in the hon. Gentleman’s argument. He is arguing that, on the one hand, the financial position was strong in 2016—I remind him simply that the Lansley reforms were in 2012—and, on the other hand, that the issue is with the Lansley reforms.

May I make a point of clarification, because the Minister is misquoting me? I said that the financial position was strong in 2010, not in 2016.

In which case, I refer to the remarks of the hon. Member for High Peak, who did say that the CCGs’ position was strong in 2016. The hon. Gentleman is therefore seeking to disagree with his hon. Friend rather than with me.

Every Member present who represents a Derbyshire constituency is concerned about the actions of the CCG, particularly the implication for the voluntary sector. That was outlined by the three Conservatives and two of the Labour Members, either by speaking or by being present. The challenge is that, if we contextualise this debate in a not-quite-accurate framework, we misunderstand why we are here in the first place and therefore how we get out of here. That is why the cuts narrative from the hon. Member for High Peak is unhelpful in the extreme.

My hon. Friend is absolutely right. I was coming on to address the allocations for the four CCGs, which I am told by NHS England are above where NHS England independently sets the target. To be precise, according to NHS England, in the case of the Derbyshire CCGs, North Derbyshire is 6.2% above its target allocation, while Erewash is 2.31%, Hardwick 1.92% and Southern Derbyshire 0.25% above the target.

My hon. Friend is absolutely right that it is about how effectively the money is spent. He is also right that, within that search for efficiencies, alongside the additional £20 billion of funding that the Government have allocated, we need to address the point that the hon. Lady correctly raised about the value for money of many of the voluntary services. He correctly identified that there is a cross-party consensus and indeed concern that the value for money of those services should not be the first line of call when seeking efficiencies.

As part of that discussion, the CCG has confirmed that, having looked into this, three of the voluntary services will be protected. The south Derbyshire, Chesterfield and north Derbyshire Cruse Bereavement Care and the Stroke Association support services will be protected. The hon. Lady made a point about the value for money of night services costing £34,000, which within a £51 million target is a very small sum, and the New Mills where she cited the £2.26 per hour. That is exactly the discussion that the CCG is having. It is unhelpful to scare local people ahead of those consultations, because those decisions have not been taken. One of the benefits of the hon. Lady calling this debate is that it allows Members from across the House to put on record their support for voluntary services as part of looking at the legitimate question of where the efficiencies from economies of scale can be identified across the CCGs.

The Government are allocating more funding to the NHS, but they are looking at areas that are above their target allocation to ask, “Where are the inefficiencies and how do we spend that?” As part of asking taxpayers to contribute £20 billion more a year to the NHS, it is right that we ask how effectively that money is spent and that we ensure that we drive efficiencies.

The hon. Lady did not mention this, but it is pertinent that there is funding to Derbyshire in other forms: for example, the £12.5 million that has recently been provided for the four CCGs to spend on increasing theatre capacity at the Royal Derby Hospital. Again, that is part of enabling the CCGs to drive efficiencies. Some £40 million of sustainability and transformation partnership capital bids are yet to be approved. There are additional funding bids in the Department, NHS Improvement and NHS England as part of driving those efficiencies that the CCGs are being asked to deliver.

Alongside that is the vanguard programme—the CCGs agreed a business case in January 2018 to spend £1.1 million to continue to fund significant elements of the Wellbeing Erewash programme. My hon. Friend the Member for Erewash (Maggie Throup) has been an extremely strong champion of the benefits and importance of the programme in Erewash in her interactions with ministerial colleagues. The CCGs have introduced a range of financial measures to improve their financial position, including development of an efficiency strategy and a move to joint leadership arrangements, to which the hon. Member for High Peak referred. Closer functional working across the four CCGs in Derbyshire will help, but so will the additional capital that is being sought and innovation to work more efficiently through programmes such as vanguard.

On the voluntary sector, which was the meat of the hon. Lady’s remarks, it is important to stress that decisions have not been taken and that a consultation process is under way. The CCGs will have those discussions with local stakeholders. It is important to be clear that before taking any final funding decisions on services through the voluntary and communities sector, that further round of engagement and consultation with the local communities, local authorities, patients, GPs and other stakeholders will take place.

What we desperately do not want is a short-term saving made to fix a short-term problem. Bringing those services back in 18 months’ time when the much-welcome increased funding is available will not happen, because the volunteers and the organisations will have gone. Can there be any kind of downpayment on that future funding, or some slight relaxing of the annual deficit calculations, just to get us through the gap so that we do not do something now that we regret in 18 months’ time?

To some extent, that is already happening in the form of the £45 million of the deficit that is being absorbed by NHS England, but part of the NHS England consultation is assessing where the CCGs are against their target allocation—it is part of the consideration of the £40 million of capital bids for Derbyshire and part of the £12.5 million that was secured for the improvements at Derby county. It is also part of other issues in the NHS such as length of stay—43% of patients in acute hospitals do not clinically need to be there and would be better served in the community, which is where those value for money assessments need to play a part.

Why are 84 community beds, and my beds in Buxton at Fenton ward, which are the only place where patients in acute care can be transferred, being cut?

Again, local clinical decisions are taken by the CCGs, which is the correct approach. This goes to the heart of the point raised by my hon. Friend the Member for North East Derbyshire. Driving efficiency as part of spending more on the NHS is not about not having any change. Indeed, the hon. Lady previously expressed concerns about the specialist dementia inpatient beds in her constituency. Again, those are specific commissioning decisions—it is inappropriate for a Minister to comment on specific decisions—but, although I understand her concerns in relation to the number of specialist dementia inpatient beds, I am assured that the model implemented in Derbyshire reflects the changing needs and approaches to providing health and care for dementia patients. Patients benefit from structured care in their homes or in an adult care-led facility—that model is supported by clinicians.

We need to differentiate legitimate questions from NHS England in an area that is receiving more than its target allocation and where there are opportunities for efficiency, while taking on board the concerns raised by my hon. Friend the for Amber Valley about the transition as the additional Government funding comes, and while allowing the NHS in Derbyshire to change. Just as the additional funding to Derby will unlock efficiencies, so will the vanguard programme and other local initiatives on, for example, dementia care to deliver an NHS that is fit for the future. It needs to evolve but is also needs to take the community with it. That is why it is right that we have a discussion about the voluntary sector without scaring people that decisions have been taken, when services such as the three I mentioned have already been protected and I am told that no decisions have been taken on the other voluntary’s services.

We are committed to spending more on the NHS in Derbyshire. That is the clear commitment the Prime Minister made. The CCG has made significant progress on delivering efficiencies against its 3% target, but we are building an NHS fit for the future, which includes ensuring that we give more money to Derbyshire. As part of the 10-year plan being devised by NHS England and NHS Improvement, Derbyshire will receive its fair share of that additional funding.

Question put and agreed to.