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The Minister of State, Department of Health (Mr Philip Dunne)
It is a pleasure, as always, to serve under your chairmanship, Mr Hollobone. I am conscious that there is the possibility of a vote coming rather earlier than we had anticipated; in which case, I will try to ensure I do not use up all the available time. I congratulate the hon. Member for Dewsbury (Paula Sherriff)—Dewsbury, Mirfield, Denby Dale and Kirkburton, but I will use Dewsbury for shorthand—on securing the debate and securing the support of the hon. Member for York Central (Rachael Maskell), who made a compelling case today. She referred to our recent meetings on this subject and previous debates on it in the Chamber, demonstrating her clear commitment to the cause.
It is no secret that the NHS faces significant challenges. All the Opposition Members who spoke referred to some of the financial pressures currently acknowledged as affecting the NHS. However, I do not think they quite recognised that the NHS’s own five year forward view identified some significant challenges that need to be addressed in relation to the way in which the nation supports the healthcare of the population as a whole. Throwing money at it inexorably is not always the right solution. Some difficult choices have to be made about the way in which the public lead their lives. What we can do, through a combination of public health support, advice and education, to encourage the public to lead healthier lives is an important responsibility of Government. It is important for individuals to help to ensure that they lead long, independent lives in as healthy a condition as possible.
Rachael Maskell
The five year forward view was put in place long after people established lifestyles either of being overweight or of smoking. To penalise them after the event was not the intention of the five year forward view. That strategy is about improving people’s health, whereas this programme is about causing health to deteriorate.
Mr Dunne
I do not accept that. It is important that we use all the tools at our disposal to encourage the public to lead healthy lives where possible. These measures form part of the suite of measures that are necessary to bring that about.
The Government have backed the five year forward view. Opposition Members raised the issue of finances. We have committed to a real-terms increase in funding through the spending review period. Most recently, in the Budget only last month, we committed an additional £2.8 billion on top of the £8 billion real-terms increase by 2020. We are providing significant extra resource, but we recognise that different areas of the country will face different challenges and so will develop different approaches to how they use their resources most effectively in patients’ interests. That will inevitably involve making difficult decisions. It is right that we trust local NHS organisations, clinically led, to make those decisions, rather than second-guessing them centrally.
Having said that, we have set certain expectations of the system, one of which is that blanket bans on treatments are completely unacceptable and incompatible with the NHS constitution. That is why I refute the challenge from Opposition Members to say whether or not we are imposing rationing on the NHS. The local management responsible for the NHS in their areas have to respect the constitution and should not introduce blanket bans, but they do have to look at ways to provide care for their populations in a manner that lives within the budgets they have been provided with.
Paula Sherriff
I have listened to the Minister carefully. Can he explain why he feels it is acceptable that someone in Wakefield could have surgery, while someone nine miles away in Dewsbury could not? They might both be smokers, and the surgery would be carried out by the same surgeon, probably in the same hospital. Are we not in danger of going into a very big postcode lottery once again?
Rachael Maskell
To put this into the context of how it is working in reality, patients who do not meet the thresholds are automatically put through a system, and therefore it is completely in breach of the NHS constitution. There is no individual input about the clinical needs of a patient.
Mr Dunne
I will come on to that. We are talking primarily about what is happening in North Kirklees and Greater Huddersfield CCG areas, which have not yet implemented this policy. I will explain why I do not think that that should be the case.
On the healthcare optimisation plan, I take the gentle chiding from the hon. Member for Ellesmere Port and Neston (Justin Madders) about the way in which the NHS describes proposals. I have some sympathy with what he says about the way in which language is used, but this is a plan to encourage greater public health among the population of North Kirklees and Greater Huddersfield CCG areas, for which they are responsible. I talked to the CCGs in preparation for the debate and was advised that they do not see this as a blanket ban on treatment. I have emphasised to them that they should not do so and that there should not be a blanket ban on treatment.
I will describe the proposals, as I understand them. They have been developed by the CCGs since autumn 2016, and the objective is that patients who are overweight with a body mass index of 30 or above will have 12 months to lose at least 10% of their overall weight or to reduce their BMI to less than 30, while patients who smoke will be encouraged to take up to six months to quit smoking before undergoing routine surgery. Those who quit smoking for four weeks or achieve their target weight loss will be able to be referred for surgery under the policy.
The development of the plan coincided with the UK’s childhood obesity strategy and the proposed introduction of the soft drinks industry levy, reflecting the Government’s commitment to tackling the major public health problems affecting large sections of society. The hon. Member for Dewsbury and the hon. Member for York Central recognised the need to address the obesity crisis in this country. I am grateful for their support and that of the Opposition spokesman, the hon. Member for Ellesmere Port and Neston. I think we are united in recognising that something has to be done about this. I hope they support the proposals that the Government have made for the obesity strategy and the considerable progress we have made in reducing smoking since 2010. Hon. Members have made the point that the policy should not be at the expense of treatment if treatment is urgent or, if there is no treatment, it might lead to degradation of the health condition of the patient subject to the policy.
Paula Sherriff
I thank the Minister for his generosity in giving way. Does he agree that the decision must be made by a surgeon? That is so important, because they are highly trained and are surely the ones who can come to a decision on whether the patient can wait.
Mr Dunne
I will come on to that. The short answer is that I agree that the relevant clinicians should make those decisions.
Going back to where the CCGs are in this process, as I said earlier, they have not yet introduced the proposal. They have been working with the local population and with Healthwatch Kirklees, and have held a number of engagement events with local authorities and interested stakeholders to try to understand the reaction of those parties to the proposal. An engagement event was conducted in March and April of this year, and one with Kirklees Council in August and September of this year.
The CCGs have listened and responded to some of the points made. They have made several changes to their original proposals, including exempting children from the programme. They also recognise the limitations—amusingly identified by hon. Members in their contributions—of using BMI as a measure of body weight. Therefore, for example, people with high muscle mass should be excluded from the BMI calculation for the reasons that were well explained earlier in the debate.
The CCGs are including safeguards in the proposals, and they intend that, in exceptional circumstances, normal individual funding request processes will continue to apply. Hon. Members have criticised that as imposing an undue obligation on the individual to seek that route to secure treatment. That is effectively an appeal mechanism that applies across the NHS and is a well-worn and well-understood path for clinicians to support individual funding requests for patients where needed, which we should continue.
Both the hon. Member for Dewsbury and the hon. Member for York Central used the expression “lives at risk”. I would gently say that there is absolutely no intention that policies such as this should lead to lives being at risk. They are about trying to put individuals in a position where their own circumstances would lead to better outcomes from the proposed surgery. The hon. Ladies have called for evidence supporting the proposition —it was raised by the hon. Member for York Central when we met at the end of last month. I have asked for that evidence. A number of research papers support the propositions made by the CCG, in particular on the question whether obesity at the time of surgery is associated with a wide range of problems. Sustaining weight loss is the key. Rapid weight loss followed by rapid weight gain clearly do not help the patient, but the evidence from the research papers provided to me is that maintained weight loss or cessation of smoking undoubtedly and clearly have clinical benefits for the patient. There is evidence to support that.
I will come back to the point raised earlier on by the hon. Member for Dewsbury and the hon. Member for York Central, but I absolutely recognise that the clinician primarily responsible for the care, whether that is the GP or the secondary clinician, should have discretion to ensure that a referral is made, should a non-referral of a patient or a delayed procedure outweigh any benefits from a period of improving health and reducing risk factors prior to a routine operation. We will encourage the CCGs to ensure that that is in their final proposals, once those are made.
Justin Madders
The Minister says he will encourage CCGs to listen to clinical advice when making referrals. Is there any mechanism by which he will actually ensure that that happens?
Mr Dunne
As the hon. Gentleman knows, CCGs are subject to appraisal and are accountable to NHS England, which is accountable to Ministers. It is not for Ministers to direct individual CCGs as to how they should enact their policies, but there is a route through which we can provide some encouragement to NHS England to ensure that these policies reflect its national position. That is what we will do.
On where the process is, in October the two CCGs presented details of the proposed plans to Kirklees Council’s health and social care scrutiny committee. The committee requested that the CCGs undertake a further six weeks of engagements, especially with hard-to-reach communities in the area of the hon. Member for Dewsbury. The CCGs have assured me that they are committed to that further engagement with the local community to ensure that the plan is fit for purpose, so there is a continuing opportunity to reflect on the revised iteration of the proposals. I am also advised that the CCGs have not yet made firm decisions on the plans. Instead, as a result of the engagement with local stakeholders, they are considering four options, and variations on the four options, for implementing the proposed plan, including not proceeding with the programme, which remains on the table.
Those options include: first, a phased approach, beginning with applying the programme initially only to patients who smoke and subsequently rolling it out further to obese patients if appropriate; secondly, only implementing the plan for smokers; thirdly, introducing health optimisation periods across clinical thresholds and pathways, in line with NICE guidance; or fourthly, moving away from implementation of the plan as previously defined and focusing on a strengthened education campaign to reinforce the benefits to patients of stopping smoking and losing weight. Those options remain on the table and there will be a further period of engagement. A decision on which option will be taken forward is due to be made by the CCGs in January, and further engagement on the implementation of the recommended approach will then take place later in the new year.
I said earlier that the plan is not a blanket ban on treatment. Instead, the intention is to encourage patients who are obese or who smoke to lose weight and/or quit smoking. There is evidence that that will have benefits, in terms of both surgical outcomes, as I have said, as well as reduced risk for general medical conditions, and there are clearly also benefits to patients’ general health in the long term. Hon. Members can be assured that the CCGs are providing support to the patients on weight loss and smoking cessation, and have agreed to invest £133,000 a year in such services to account for any health optimisation-related increase in uptake.
The hon. Member for Dewsbury asked how we will assure that the plan is in accordance with national guidelines. As she would expect, NHS England has been closely reviewing this and similar proposals where they have been made to ensure that there is robust supporting clinical evidence and appropriate safeguards. The Government expect NHS England to ensure that the responsible CCG is not breaching its statutory responsibility to provide services that meet the needs of the local population. I can confirm to hon. Members that NHS England has had ongoing discussions with both CCGs about the health optimisation plan and will continue to do so to ensure that it works in the best interest of patients. That is the right approach, in terms of both protecting patients and both encouraging the population to put themselves in a condition to maximise the benefits from surgical procedures, without allowing CCGs to introduce an inappropriate blanket ban.
NHS England carries out regular assurance of CCGs and holds them to account through the CCG improvement and assessment framework to ensure that they are fulfilling their statutory requirements, and NHS England can and will intervene if a CCG is failing to discharge its key responsibilities. NHS England’s regional teams also have regular discussions with CCGs about their commissioning activities and plans.
It is important in a debate like this, in which there are allegations of there being a postcode lottery, that we recognise that it is down to clinicians at a local level, through their CCG bodies, to make decisions that affect their local population, rather than, as has happened in the past, central diktat from Whitehall. Those may lead to perverse consequences and a less relevant healthcare capacity and treatments for patients on the ground.
Rachael Maskell
The Minister is being very generous with his time. Is it not important in a national health service that we use the very best clinical evidence on how to produce the best outcomes for all patients? Falsely drawn boundaries should not have any relevance to the kind of treatment people receive.
Mr Dunne
The hon. Lady will recognise that there are different health challenges in different areas, reflecting patients’ differing needs. Encouraging the public to stop smoking and to reduce their weight is, as she acknowledged, an ambition that is shared by Members across the House and across clinical leads.
Mr Dunne
I will not let the hon. Lady intervene again because, amazingly, I am about to run out of time, despite what I said at the beginning. I have taken a lot of interventions.
I conclude by assuring hon. Members that we are paying close attention to what is happening in Kirklees and Greater Huddersfield, and York Central. Other areas of the country may be considering similar proposals, and we need to ensure that it is done in a responsible manner, whereby clinicians stay at the heart of making referrals where appropriate and retain that discretion. We will not get to the situation that the hon. Member for Dewsbury described in her opening remarks, in which she said that people’s lives will be put at risk by policies such as this. That is not the case.