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The Parliamentary Under-Secretary of State for Health (Ben Gummer)
It is a great pleasure to serve under your chairmanship, Mr Pritchard. I, too, thank my hon. Friend the Member for Colne Valley (Jason McCartney) for the clear-sighted way in which he set out his case. This clearly is a cross-party effort, for which I respect him all the more. Everyone sitting in this room has come here with earnest intent on behalf of their constituents, and I take their representations very seriously indeed. I appreciate the comments of those who have spoken in this debate, including the hon. Members for Batley and Spen (Jo Cox), for Huddersfield (Mr Sheerman) and for Dewsbury (Paula Sherriff). I also thank the shadow Minister. There was an intervention from the hon. Member for Strangford (Jim Shannon), who has left.
This is one of what I imagine will be a series of debates on reconfigurations, because throughout the NHS’s history—I am sure the hon. Member for Huddersfield will know this better than me—reconfigurations and the configuration of health services has been a feature of how the NHS works. In beginning to respond to the debate, it would be helpful if I set out where the Secretary of State and I stand in relation to reconfigurations. That will explain what I am able to do and, perhaps more helpfully, what I am not able to do, because that has changed in the past few years.
I recognise that the clinical commissioning group has presented a very detailed plan—the plan is very detailed, whatever one’s arguments about its merits, or otherwise—but it has, rather classically, chosen a title, “Right Care, Right Time, Right Place,” that is so generic in its quality and so indirect in its aspiration that the CCG should first look to change the title to say what it actually proposes to do. Such generic consultation titles and bureaucratic-speak are a feature across the NHS, and it does not help anyone to get to the nub of the matter.
Were the reconfiguration to procced, it would be for the CCG to make the decision about how it wished to buy services on behalf of the people it serves. That is a key reform of the Health and Social Care Act 2012 but, even before then, previous Secretaries of State—Labour ones—recognised that it is wrong for Whitehall to make determinations on matters of reconfiguration because it is often influenced by politics when it should be the clinical voice that is heard first and foremost.
The hon. Gentleman mentioned the former Prime Minister Harold Wilson a number of times. Harold Wilson was a well-known exponent of valuing expert opinion, and we should do that in the NHS above all, because we are dealing with people’s lives. That is why I ask people speaking in this debate more broadly to listen carefully to what clinicians are saying on both sides of the argument and to weigh up their opinions before coming to a settled point of view.
Mr Sheerman
I absolutely agree with the Minister. It is the clinicians who are talking to us. The clinicians in hospitals do not want this reconfiguration and do not agree with it; it is general practitioners jumped up into management in the CCG who are putting this before us. The clinicians to whom my colleagues and I have talked are almost uniformly against the reconfiguration. He is absolutely right. If we listen to the clinicians, we will have A&E in both hospitals.
Ben Gummer
I will come on to that process. It is a little unfair to characterise the clinical commissioning group in that way. Primary care is the frontline of all patient care in this country. GPs see and deal with the majority of patients in the health service, and they guide the patient pathway. Therefore they should have responsibility for ensuring that services are fit and proper for patients. It is GPs who make the decision on how that happens. If local people disagree with that decision, as the hon. Members for Dewsbury and for Batley and Spen are experiencing in their own areas, a referral can be made to the Independent Reconfiguration Panel via the local authority’s overview and scrutiny panel. The Secretary of State will then take the recommendations of the independent panel.
So far, out of a number of Secretaries of State, none has chosen to go against the panel’s recommendations, although there is always a first time. However, the panel exists, and I do not think that anyone disputes its independence. That is the process. All that I can do here is set out the broader clinical arguments on which I know the CCG will draw, and with which I expect all Members will agree, to talk about private finance initiatives and answer the specific questions raised by speakers in this debate.
For the record, I will explain what the CCG claims are its reasons for the reconfiguration. It is important for people watching this debate to know the CCG’s side of the story also. The CCG believes that the NHS services in Halifax and Huddersfield, as currently organised, do not deliver the safest and most effective and efficient support to meet patients’ needs. It believes that the trust is affected by shortages of middle-grade doctors and a high use of locums in its accident and emergency department; I will turn in a minute to the remarks on that matter by the hon. Member for Huddersfield. Sickness absence levels are high, and clinical rotas are described as “fragile”. There are difficulties providing senior consultant cover overnight and seven days a week, which is a wider issue in which hon. Members will know the Government have an interest.
Both hospital sites operate an emergency department and a critical care unit. The care provided by both those services is, in the CCGs’ view, neither compliant with some of the standards for children and young people in emergency care settings nor fully compliant with guidance on critical care workforce standards. Neither site satisfies the Royal College recommended minimum of 10 consultants per emergency department and 14 hours a day of consultant cover.
Inter-hospital transfers are often necessary due to the lack of co-location of services on both sites. Those factors have a direct bearing on the safety of patient care. The co-location of emergency and acute medical and surgical expertise can result in significant improvements in survival and recovery outcomes, most notably for stroke and cardiac patients. The most seriously ill with life-threatening conditions have a much greater chance of survival if they are treated by an experienced medical team available 24/7. That last comment is not just the opinion of the CCG; it is the recommendation of Professor Bruce Keogh, the medical director of NHS England. I think that we all agree on the principles from which he speaks.
The CCG believes, first and foremost, that the proposals are designed to save lives. It is not an issue of cost. However, there is an issue of cost involved in deciding where the co-located services should go. We must be open about that; the CCG has made a value for money determination suggesting that the better site is in Halifax, at Calderdale Royal hospital, and not at Huddersfield.
Ben Gummer
On a value for money basis, because of the ability to release the Huddersfield site to build the new hospital and the more modern facilities available in Calderdale. That is the CCG’s determination, and it is important in these discussions that everyone examines whether they believe that the CCG has made the right determination.
Turning quickly to an issue of numbers, I want to make a general point about the number of people being supported by A and E services across the country. The current chief executive of NHS Improvement, Jim Mackey, ran a successful large hospital system in Northumberland where a reconfiguration is providing some of the finest patient outcomes not just in the United Kingdom but in western Europe. It was brave and controversial at the time. What he has proved, and what has subsequently been proved in Manchester and in London stroke services, is that where services are reconfigured sensibly, outcomes improve. I know that that is the driving ambition of clinicians in Mid Yorkshire, and indeed in Huddersfield and Halifax. Whether they are arriving at the correct way of delivering those improved outcomes should be the exercise of the consultation, so it is an appropriate way to start the debate, but it is important to inform the discussion with all the current facts.
According to Public Health England, the Calderdale and Huddersfield NHS Foundation Trust serves a population of 402,000 across two hospital sites. That means that each hospital serves what is, in the scale of the NHS, a small population group. To give some local comparisons, Leeds Teaching Hospitals Trust serves a population of 752,000, and Mid Yorkshire Hospitals NHS Trust is also a bit larger at 553,000. Within the scale of local health economies, Calderdale and Huddersfield serves a relatively small population, across two sites. The CCG’s judgment, and I suspect clinical opinion across the NHS, is that something must be done to improve clinical outcomes by concentrating consultant and clinical offer. I am not making any judgment about where that should happen, merely about the principle being established by senior clinicians.
Turning to the issue of deaths, it is the judgment of Professor Bruce Keogh, who is coming to the end of his urgent and emergency care review, that intensive procedures are best done by people who are well practiced and do many a year. The best way to do so is to ensure that they are concentrated in centres of excellence. The understanding of the rest of the world is that we prevent deaths by doing so. The hon. Member for Huddersfield contends that we could cause 157 deaths by joining the services.
Ben Gummer
Yes. I caution the hon. Gentleman about using such figures. Whereas the CCG has been careful not to use a precise figure for how many lives will be saved, merely citing international evidence about improved outcomes, that figure, which has been provided to him, makes the serious error of conflating and confusing emergency admissions with emergency attendances; they are two completely different things. Using those two figures has allowed the person who made that figure to come up with 157. The figure itself is erroneous, and it is important that it is not repeated until there is a proper statistical base that can be shared with local people, because it will clearly frighten people. It is important that that figure, if it is true at all, has a proper statistical base before it is used.
Likewise, figures have been quoted about PFI. I actually have a dogmatic view on PFI, which is that it is a less than elegant way of borrowing money. Classically, the Government will borrow money at around 4%, and the private sector at 6% or 7%. One can get PFI deals that work; there are some. They work when one can incentivise efficiency over a long period, but it is very difficult to measure, and the jury is still out on even the best deals. There are circumstances in which they do work, but they do not work in every circumstance.
None the less, it is important that we present local people with the figures. My hon. Friend the Member for Colne Valley has mentioned in the House the figure of £773 million over the course of the contract; I believe that that figure is just the sum of all the unitary payments made year by year. If we strip out inflation, as we must in order to come to a real figure, we arrive at a sum that is about two thirds of that: £527 million. If we then subtract from that £527 million the costs of providing maintenance, cleaning, porterage and the other functions that form part of the PFI deal, we come to a figure about half that, or about £263 million or £264 million. It is difficult to divide it up precisely, because it is a unitary payment. That is the financing charge.
If we compare that financing charge with what it would have been for public debt if the money had been borrowed, as it would have been at the time in order to build the hospital, we are talking about a difference of about £90 million to £100 million. Again, when presenting these figures to the public, it is very important that we are consistent about it. This figure is not £773 million and in that sense it does not matter who signed it, and I will be the first person to stand here for hours defending Sir John Major. It is much closer to £100 million over and above what would have been paid for had it been public debt.
Again, I think that puts it in context and may explain why this figure is not the defining figure, because when £100 million is divided up by the course of the contract it comes out at a much smaller figure than might be supposed. It is not the determining factor in what the CCG is trying to do, and I am convinced of the CCG’s arguments in that respect.
However, the CCG is very open about the value for money that it says there is in using the Halifax site as opposed to the Calderdale site, and Members should discuss that with the CCG. They might have a very interesting discussion with it about how it will dispose of the capital one way or another.
I will just run through the CCG’s proposals quickly in response to the problems it has identified in the local area, and then I will just turn quickly to some of the additional comments that have been made by Members.
The trust identifies that in the area the summary hospital-level mortality indicator—the SHMI mortality figure—was 108.9 in March 2015 against an expected benchmark of 100, so it is significantly over the expected figure. The trust did not achieve a reduction in its mortality rate during 2014 and 2015; it was not able to narrow the gap in the mortality rate to 100. In large part, it puts that down to the operating problems it has on the two sites.
Therefore, the trust’s answer to that problem is to provide exactly the kind of specialised concentrated care that Members from all parties have identified—albeit they think it is in the wrong place—as part of a joined-up community care plan, which it is developing in co-ordination with the wider local area.
The hon. Members for Dewsbury and for Batley and Spen came to speak to me in great detail, and very interestingly, about the proposals for their area. I take very seriously the remarks that the hon. Member for Batley and Spen made about looking at the wider area of mid-Yorkshire in co-ordination with this work.
I do not know whether I have been to Huddersfield and I told the hon. Member for Huddersfield why. I spent the first year of my life in Wakefield, as I explained to the hon. Members for Dewsbury and for Batley and Spen the other day, and so maybe my mother took me to Huddersfield. I would like to return in the near future and experience it properly as an adult, and I shall. Nevertheless, it is clear that the area we are discussing is a very complicated one to deal with. It is a hilly area, something which—being a boy from East Anglia—I do not understand very well, and it has a lot of towns of considerable population that are divided by difficult terrain, and travelling between those towns can be less simple than travelling in other parts of the country. So I take on board the points that the hon. Gentleman made.
I will certainly take back the suggestion by the hon. Member for Batley and Spen that this issue we are debating today should be looked at in the wider context, and I undertake to ask Jim Mackey to see whether there is a co-ordination between these two plans and whether he can encourage the CCGs to adopt a more joined-up approach to what they are doing. Maybe they are already joined up—I am not prejudging the conversations that have happened—but it is important that the CCGs answer these questions.
Mr Sheerman
On the figures, we listened intently on the lesson on PFI. But these figures have been in the public domain from many sources since the announcement and the PFI has been looked at. People find these sums difficult to understand. It is our job to ensure that we make the toughest case we can. Yes, we have used those figures, and they are still pretty appalling. Regarding the figure of 157, we got it from an impeccable source; we will go back and check it, but I think it is good.
Ben Gummer
I would submit both figures. There is a difference between £773 million and £100 million, although one is larger than the other. I am not justifying the original deal, but it is important that we put it in context.
My hon. Friend the Member for Colne Valley asked me whether I would arrange a meeting with the Secretary of State; of course, I will be happy to do so. However, can we wait for some of these issues to have been thrashed out with the CCG, so that we have a proper evidence base that we all agree on? That is part of the point of a consultation. Then we will have an even better informed meeting than if we had one tomorrow. So let us have a proper public debate locally and allow the CCG to respond to some of the accusations that have been made here and elsewhere.
My hon. Friend also asked about investigations into the PFI deals. Each PFI deal is different; some are legally very difficult to unpick while some are easier. We have unpicked quite a few during the past few years and I know that the team are looking at all the PFI deals on a revolving basis. Therefore, I can make a commitment that the Department of Health will continue to look at PFI deals—each and every one of them—to see whether we can get more value from them. However, I have to be clear with my hon. Friend that this deal, which was one of the earliest to be made, has been very carefully worded.
Jason McCartney
This gets to the nub of the matter. May I just confirm that the Minister’s team will specifically look at the Calderdale PFI, because it was a bit generic there as well? There are discrepancies over the figures, which are slightly different. Incidentally, my colleagues and I would be absolutely delighted if this process were not being influenced by the PFI; if the issue is down to clinical reasoning and other matters, Huddersfield will keep its A&E unit.
Ben Gummer
I can guarantee that Lord Prior is looking at every single PFI in the country on a revolving basis, because we are trying to ensure that we can squeeze maximum—
Ben Gummer
This one is part of “every single PFI in the country”, so I assure my hon. Friend that it will be looked at.
Ben Gummer
May I just respond to my hon. Friend’s original point?
We must remember that the PFI deal is borne by the entire trust, so it is not as if it fixes precisely on one site or another; it does not influence the decision of where to go. It could be possible to run a cold site on the PFI hospital and fill the hospital that way. It does not have to be filled with the particular function that the CCG wishes to put there. The CCG just believes that the buildings there are better, more suited and more modern—the hon. Member for Huddersfield would agree with that assessment—for the particular purposes it wants to put there.
It is for the CCG to justify that; I cannot speak with any authority about this, because I do not know. However, I really do not think that the PFI has a bearing, because no matter where the services are put, the PFI deal will still exist. All I am saying is that I want to be realistic about our ability to unpick every single PFI in the country, because in many cases they have been very carefully worded and agreed in a lawyerly fashion—
Mark Pritchard (in the Chair)
Order. I remind colleagues and the Minister, first, that the Minister should face inwards, so that we can get a good shot of him on camera. This debate is being televised—just a gentle reminder. Secondly, those Members who want to make comments should stand up to do so, so that the Hansard writers can identify who they are. Thank you very much indeed.
Mr Sheerman
Thank you, Mr Pritchard. I hope this is a useful intervention. We have written to the Public Accounts Committee to ask it to have a look at this particular PFI, on the basis that it would be a very good one to try to unpick. That might be helpful to the Minister and us.
Ben Gummer
I am sure that the Chairman of the PAC will listen carefully to the hon. Gentleman, who is her esteemed colleague. I know that the PAC has looked at the PFI issues many times before, but I would be glad if it were willing to look at them again.
The hon. Member for Dewsbury raised the issue of traffic, as did other hon. Members. Again, it is for the CCG to ensure that it justifies the traffic times that it is putting in the consultation document. I have sympathy with Members who say that these consultation documents are often impenetrable. I cannot speak for this one, because I have not read it in its entirety, but such documents must be written well—especially the parts that will be put to local people—so that they are understandable to people who do not speak NHS-speak. It is not a question of people’s intelligence; it is about ensuring that the document is written in normal English in a way that people can understand. As to whether the document could ask, “Would you like your A&E to move?”, as long as people are informed about the facts of the case and understand that such a move could improve their children’s outcomes, and there is a reasonable case for it, I see no reason why that question should not be put.
The hon. Member for Huddersfield and the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), both raised the issue of wider deficits across the NHS. We addressed that point in the urgent question yesterday; there is financial pressure in the NHS and there are reasons why that should be the case, which I will not go into now. The issue is not cuts, because the amount of money going into the NHS is increasing. The NHS faces a raft of challenges, as it has since its foundation, and our job is to ensure that the money is used as efficiently as possible, which is why we have brought in the controls on consultancy spend, locums and agency workers.
What is true is that under the previous Labour Government and the coalition Government, the number of doctors in training went up. I genuinely do not blame the previous Labour Administration for the current shortages, but we have inherited the numbers from decisions made in the 2000s about the length of doctor training, and before that date about consultant grades. The fact is that, in some parts of the country, it is difficult to recruit—sometimes because the clinical base under which consultants, especially A&E consultants, are asked to operate is not safe. Again, I cannot speak, publicly, about the situation in either of the two hospitals under debate, but that is the case elsewhere, while in some metropolitan centres it is easy to recruit vast numbers of doctors. How do we create hospital bases to which we can recruit clinicians who want to work in a safe place, and carry out good procedures—and numerous ones, to keep the rates up? That is one of the challenges for all healthcare systems across the world, and one that we are determined to meet here in England.
Finally, the shadow Minister spoke about the overall control of finances in the NHS. It is important not to link the overall financial performance of the NHS with this consultation, which, as the CCG makes clear, is centrally about clinical outcomes. I know that the shadow Minister cares very much about ensuring good clinical outcomes, as do all hon. Members; to do that, it is important that local people get a full grasp of the facts. Although we might have a broader argument about NHS finances, it is important to focus on the core facts of the situation. This is about clinical outcomes, the difficulty of providing the outcomes on two sites where they are best provided on a single co-located site, and the value-for-money arguments about what that site should be.
If we can have a strong, well-informed and nuanced debate, and take into consideration the surrounding area—a point well made today—local people can come to a good decision that is supported across the patch, which will mean better health services for those living in Huddersfield and Halifax and the surrounding areas, an improvement in clinical outcomes, and better life chances, especially for those who are born with the least.
Mr Sheerman
I used to have good discussions with the Minister’s father. One thing I know about him is that he, like me, was really interested in good management. The Minister has not come back to us about the quality of management, which is something that CCGs in many places do not seem to have. Good managers in the health service seem to be undervalued. I made what I think was a good point about medical training not containing any management element. I am sorry to remind the Minister of his father’s excellent commitment to good management, but I am sure that he shares that view.
Ben Gummer
I share the view of the hon. Gentleman. Good management is, of course, vital in the NHS, which is why I am never particularly keen to beat up NHS managers—a predilection of politicians on both sides. But it is true that we have not considered carefully enough the quality of management in CCGs; I agree with the hon. Gentleman about that. That is precisely why we are bringing in a CCG scorecard, just as we have done with the Care Quality Commission rankings for hospitals—that is a well-led domain—that describes precisely how well a hospital is managed.
We want to do similar work for CCGs, which will enable the hon. Gentleman to say, “Empirically, my CCG is poorly—or well—managed compared with neighbouring ones”. That will be useful for our holding them to account. I agree with the hon. Gentleman, and I hope that I will be able to deliver, in the next year, precisely what he wants.