Independent Reconfiguration Panel
(4 years ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
Siobhain McDonagh (Mitcham and Morden) (Lab)
I have lost count of the number of times that I have spoken in this House about the future of St Helier Hospital. Time and again, the hospital has been hurled head first into turbulence, with countless consultations coated in fancy branding repeatedly asking my constituents whether they want their hospital to keep its A&E, critical care and maternity services. The latest plan—almost laughably named “Improving Healthcare Together” proposes to downgrade both Epsom Hospital and St Helier Hospital, moving all acute services south to leafy, wealthy Belmont. The purpose of this debate is to look at whether the Independent Reconfiguration Panel was actually independent when it came to a decision not to look into these proposals.
The panel is a little known but hugely important body that provides checks and balances to the plans of one of the most powerful institutions in our country: the NHS. The NHS employs as many people as the red army, and some would argue that it is built around the same command and control principles—that is, decisions are made and everyone is expected to row in behind them. Communities are hugely affected by proposed NHS changes. As such, their representatives in local government have the power to consider whether they agree with a hospital reorganisation. If they do not, they can refer it to the Secretary of State, who has the power to refer it to an independent panel of experts.
In the case of the “Improving Healthcare Together” programme, my argument is not that the chair of the panel, Professor Sir Norman Williams, is not a man with a hugely important and successful medical career who has brought benefits to thousands, or that he has not made a huge contribution to the NHS. My argument is simply that he could not be regarded as independent, and that through his involvement as a member of the board of St George’s Hospital—which will be profoundly affected by these changes—he should have recused himself. We know that in public life not only do we have to do the right thing; we have to be seen to do the right thing. I will argue that Sir Norman could not be regarded as independent because his connection is far from “tangential”.
Let me turn first to the plans themselves. The programme proposes to turn St Helier Hospital into a glorified walk-in centre, removing its A&E, maternity services, children’s beds and critical care. Some 62% of beds would be lost from the area where health is poorest and life expectancy shortest. The programme’s own analysis unsurprisingly reveals the indisputable link between deprivation and the need for acute services, but ignores the fact that 42 of the 51 deprived areas in the catchment are nearest to St Helier. It is a slap in the face for expectant mums in my community.
Jim Shannon (Strangford) (DUP)
I congratulate the hon. Lady on securing this debate. Does she agree that although moving beds to a nearby hospital may make sense on paper, to ask expectant mothers to add a lump of time to their journey makes no sense, and that community-led care is essential and should be kept in the community?
Siobhain McDonagh
I agree with the hon. Member.
In the plan, it is assumed that mothers in my area want home births. That is a discriminatory assumption that is completely against their right to choose. It takes maternity services away from the mothers who are most likely to deliver a low-weight baby and mothers who are less likely to want a home birth. It also breaks up the continuity of care, with pre and post-natal services being delivered at one hospital and the birth at another.
The programme ignores the intrinsic link between old age and life expectancy in pointing to the higher number of elderly people in Belmont when deciding where need is greatest. The sobering reality is that Mitcham has a far lower life expectancy than Belmont—nine years lower, in fact. There are more elderly residents in Belmont because, quite simply, its residents live longer. To experts, it is yet another example of the Tudor Hart law, or the inverse care law as it is also known: the understanding in health academia that the areas in greatest health receive the most health investment. Or as my mum, herself a nurse, would say, “Much gets more.”
The reality is that the Minister and his Department are being asked to commit £500 million of scarce NHS resources to move acute services to one of the richest and healthiest areas in London, at the expense of one of the most deprived. Surely the Minister can see that that is wrong, if not from a health perspective, then from a financial one. The plans require 22% more capital than the option of rebuilding where health needs are greatest. Improving St Helier would have a higher return on investment, posing far less risk with a significantly lower capital requirement. Our economy is being decimated by the virus. Can the Minister not see that this proposal goes completely against Treasury guidance and value for money?
This was a devastating decision before the pandemic, but have we learned nothing from coronavirus? How can it possibly make sense for south-west London to come out with fewer acute beds and fewer intensive care units than before? Surely the decision to place the only intensive care unit on the same site as a cancer hub now has to be questioned. I do not dispute the extraordinary work of the Royal Marsden or challenge whether it requires an intensive care unit, but these plans were formed long before the pandemic was known about and have to be reassessed in the light of it.
The programme’s own impact assessment in January warned that any unplanned event such as a pandemic could challenge the resilience of the proposed reconfiguration. It described this situation as “unlikely” and yet, astonishingly, just five pages of analysis have been produced on the pandemic’s impact on the plans. It is the wild west, where everything proceeds full steam ahead, no matter the evidence presented—evidence that cannot be dismissed.
We now know that people from black and ethnic groups are most likely to be diagnosed with coronavirus, more likely to require admission to an intensive care unit once in hospital, and up to twice as likely to die than those from white British backgrounds. We know that black women are five times more likely to die in childbirth than white women, and more likely to require neonatal or specialist care baby units. We also know that 64 of the 66 areas with the highest proportion of BAME residents are nearest to St Helier, and that half of those are in the bottom two quintiles of deprivation, increasing their likely reliance on acute services.
It is indisputable: these proposals would negatively and disproportionately impact BAME residents, deprived communities and expectant mums in my constituency. It is no wonder that when they were put out to public consultation, tens of thousands of residents voiced their disapproval, with overwhelming opposition to the downgrading of St Helier. It was also clear from the public response that if these plans went ahead, many residents would not travel to inaccessible Belmont, but would head instead to St George’s—a hospital that is already under immense pressure, with an A&E in the bottom quartile for safe standards.
Why does Sir Norman have a conflict of interest? Because this is a reorganisation of a neighbouring trust that will have a profound impact on St George’s. That is a case that the board of St George’s has rightly and successfully fought, very publicly, so much so that in a letter in March this year, the chief executive of St George’s made it clear that support for the plans was contingent on her hospital receiving capital investment for a new emergency floor to take account of the increased number of emergency care patients that it would receive. That is the kind of change that requires the full consideration, scrutiny and involvement of the board and the most senior staff. I can think of a number of words to describe that relationship: conditional, connected and dependent, but certainly not “tangential”.
In July this year, Merton Council saw these plans for what they are and used its power to call them in for review by the Department of Health and Social Care Independent Reconfiguration Panel. By its name and nature, it is an independent panel of health experts who can cast a fresh, impartial eye for the Secretary of State. The chair of the panel is Professor Sir Norman Williams, who until 30 September 2019 was a long-standing board member at St George’s Hospital. Naturally, I presumed that that conflict of interest would be recognised and he would step aside from judging this proposal. Unfortunately, he did not, with his connection to the plans described as “tangential” and
“not relevant to his role in independently formulating a response”.
This evening, I ask the Minister to consider just how tangential that connection is. In April 2016, Sir Norman became a board member at St George’s, and board meeting minutes and papers reveal that the reorganisation was debated time and time again. The papers from one of his first board meetings in June highlighted the requirement for service change and reconfiguration in south-west London. In March 2017, the chair discussed the upcoming board-to-board meeting with Epsom and St Helier, which would provide an opportunity to discuss the development of joint renal services. Fast forward to October, and the board’s attention was on a joint letter signed by the CEO of St George’s about the importance of considering the future of their hospitals with any reconfiguration at St Helier.
The issue came to the board again in December, following Epsom and St Helier’s indication that it needed to change its clinical model. By the following November, the impact of the proposals on St George’s was so clear that the chair of the board, Gillian Norton, wrote to the programme directly on behalf of her board, including Sir Norman:
“Senior staff within St George’s have spent significant amounts of time over the last 3 months engaging with both the programme team and colleagues in other providers to work through the impact on providers of the shortlisted options…The board agreed that I need to write to you now, formally, to set out these concerns…I understand that a key principle of how programme process has been agreed is that there is no formal requirement to take account of the impact on other providers. I find this difficult to understand in any event given we are a health system but particularly so in the context of the SWL Health and Care Partnership and the expectation that we will work collaboratively.”
I found this letter so extraordinary, after fighting this reorganisation for 23 years, that I wrote back to the board and the chair. Naturally, this issue rightly remained high on the board’s agenda. The papers for the board meeting of December 2018 show concerns from St George’s finance and investment committee about the lack of options explored by Epsom and St Helier, and agreement that the trust should feed this back to the programme. By January 2019, the chief executive spelled out to Sir Norman and the board:
“Any changes to the current configuration of services at Epsom and St Helier are likely to impact St George’s, and it is important these are factored into any future proposals.”
She again used her notes at the February board meeting to state:
“While the location of the new facility is yet to be decided, it’s clear that there are significant estate issues at both Trusts that need to be addressed through capital investment.”
Time and again, the programme was brought to Sir Norman and the board’s attention—in April, in May and in June. This would be a landmark decision for St George’s Hospital. It is completely understandable that it had their full attention.
In July 2019, the programme released the impact assessment on St George’s. It is utterly inconceivable that someone as diligent and respected as Sir Norman would not have been aware of this, particularly as senior staff at his trust had helped produce it—a document released just months before he became chair of the Independent Reconfiguration Panel. That Sir Norman was so heavily involved in these proposals is no criticism. He was rightly fulfilling his responsibility as board member of a hospital that would be heavily impacted by these proposals. He declared his role to the other Independent Reconfiguration Panel members, explaining that he had even had recent discussions with senior consultants at Epsom and St Helier through his role as chair of the national clinical improvement programme. All public office holders are subject to the seven principles of public life, one of which is objectivity. But how could Sir Norman be objective? How could he even appear to be so? In public life, it is important not only to be objective, but to be seen to be objective.
My community has fought tirelessly for St Helier, and the least we expect is transparency, honesty and objectivity from the top. Astonishingly, the panel instead considered that there was nothing more than tangential connections, irrelevant to Sir Norman’s role in independently formulating a response for the Secretary of State. Tangential! If there is any doubt over how interconnected the hospitals are, then be aware that the chair of St George’s also became chair of Epsom and St Helier in 2019. Conveniently, it was on the very same day that Sir Norman became chair of the Independent Reconfiguration Panel. Surely the Minister can see that there is nothing tangential in the evidence that I have laid out today. Not only did Sir Norman already know about the proposals before he was asked independently to judge them, he must have known them inside out, having faced them repeatedly at board level and in conjunction with a whole host of the key personnel involved. It was tangential to the tune of millions of pounds of investment on which his former hospital’s support is contingent.
We must not underestimate the importance of a fresh eye. One of the leaders of these plans, Daniel Elkeles, formerly led the infamous “Shaping a Healthier Future” plan, which proposed similar hospital downgrades in north-west London, wasting £76 million over eight years before the Treasury finally put a stop to it.
I draw to a close now. I must say that I respect the Minister. He found time to meet me in the summer when his time must have been so scarce. I explained my reasoning for calling this debate to his office last week so that he could come prepared. I am not trying to catch him off guard. I am asking that he steps away from party politics and recognises that this connection is indisputable rather than tangential. If an independent panel was asked to review the plans, the panel must be independent. I am asking that he consults his Treasury colleagues on why the most expensive option is being chosen at a time of such economic turmoil. I am asking that he reflects on the powerful shoes he is in and the unique opportunity he has to help to close health inequalities in an area where they are so stark. Surely that would make any Health Minister proud of his work, and maybe then we really could improve health together.
The Minister for Health (Edward Argar)
I congratulate the hon. Member for Mitcham and Morden (Siobhain McDonagh) on securing this important debate. I recognise her continued interest in local health matters and her championing of her constituents’ interests. She knows that I have considerable respect for her and her work in this House on behalf of her constituents. However, she will perhaps not be surprised that I cannot fully agree with the picture that she painted to the House today.
Before I get into the meat of the debate, let me pay tribute to all the staff at the trust and across our entire NHS for the amazing work they do day in, day out, particularly at this time. I know that is a sentiment that the hon. Lady would share.
As the hon. Lady said, all proposed service changes should be based on clear evidence that they will deliver better outcomes for patients and should meet the four tests for service change: they should have support from GP commissioners, be based on clinical evidence, demonstrate patient and public engagement, and consider patient choice. It is right that these matters are addressed at a level where the local healthcare needs are best understood, rather than emanating from Whitehall. I should point out that in cases where these proposals are referred to Ministers, they are considered impartially and on their merits, and that is what has happened in this case.
Without recounting all the background that the hon. Lady has set out for the House this evening and on previous occasions, in December 2017, the “Improving Healthcare Together 2020-2030” programme was established to address the significant estate quality and finance challenges that Epsom and St Helier University Hospitals NHS Trust is currently facing. NHS Surrey Heartlands and NHS South-West London clinical commissioning groups are the organisations responsible for making decisions about local healthcare. They led the development of proposals for any potential service changes, and it is right that they did so at that local level, including appropriate consultation. As she set out, following a period of sustained engagement and options development, on 3 July 2020 local NHS leaders approved plans that will see a brand new state-of-the-art hospital built in Sutton to treat the sickest patients and most services staying put in modernised buildings at Epsom and St Helier hospitals.
The hon. Lady raised a number of concerns about this decision—in particular, around transport and travel, bed numbers, acute services, and the impact on more deprived communities and health inequalities. As she said, she also raised these issues at our meeting in July, which it was a pleasure to undertake with her. When the decision was made, measures to address these issues were also set out, including extending the H1 Epsom and St Helier hospital bus route into Merton and further south into Surrey, beyond Epsom, and increasing the frequency of travel between the three hospital sites; reviewing car parking on all three sites; increased bed capacity to care for an extra 1,300 in-patients a year; advances in technology and treatment; closer working with community services so that fewer patients will need an overnight stay and will be able to get home sooner; exploring further opportunities for primary care services at Epsom and St Helier hospitals; and expanding child and adolescent mental health services on the St Helier site. Under the proposals, about 85% of current services would stay put at Epsom and St Helier, with six major services being brought together in the new specialist emergency care hospital, including A&E, critical care, and emergency surgery. The capital investment for those proposals is not only to fund the new hospital but to invest in and improve the current sites at both Epsom and St Helier, including funding for the A&Es.
I can reassure the hon. Lady that the Treasury is and will remain fully engaged with not only this proposal but all 40 of the Government’s hospital proposals. As she would expect and know from her long career in the House, the Treasury takes a close interest in any proposals that entail the spending of significant amounts of public money. This is a significant investment in improving healthcare across the communities served by these hospitals, which is why my hon. Friends the Members for Carshalton and Wallington (Elliot Colburn) and for Wimbledon (Stephen Hammond) have recently set out their and their communities’ strong support for these proposals.
The Independent Reconfiguration Panel was at the crux of the case made by the hon. Member for Mitcham and Morden. As she set out, the IRP is the non-departmental public body set up in 2003 to provide the Secretary of State with expert independent advice on contested NHS service changes and reconfiguration. There are currently 15 panel members who review referral cases. They have a mix of clinical, lay, patient representative or engagement, specialist and managerial backgrounds. The IRP has provided independent advice more than 80 times since it was established. With reconfigurations referred to the IRP, there is an open and transparent process, which people expect to be carried out to the most rigorous standards of integrity, honesty and impartiality. We must adhere visibly to those standards, and I believe, on the evidence I have seen, that those standards were met in this case.
As the hon. Lady will know, local authorities have a power to refer certain proposals to the Secretary of State where they consider that there has been inadequate consultation, where reasons given for non-consultation are inadequate or where they believe that the proposal is not in the interests of their area and communities. The Secretary of State can then choose whether to commission advice from the IRP, which is normally provided in 20 working days, and Ministers are clear about the need for that advice to be swiftly and efficiently given. Following collection of evidence, the IRP submits its report either with advice not to proceed or containing recommendations to the Secretary of State on specific proposals. I emphasise that the IRP’s role is advisory, and the Secretary of State ultimately makes the decision.
In July—at roughly the same time as my meeting with the hon. Lady, which slightly limited the conversation we were able to have—Merton Council referred the scheme to the Secretary of State, who referred it to the IRP, which provided its advice on 28 October. Following thorough consideration of that advice, the Secretary of State accepted the IRP’s impartial advice, which was that there was no reason to contradict the proposed choice of Sutton—Belmont—as the location for the new specialist emergency care hospital. I know that there have been some noises locally about the possibility of subsequent legal review or legal action, so I will not dwell on that aspect. I do not believe that any judicial review has been tabled at this point, so I feel that I can comment a little further on the issues she raised. I must emphasise that the IRP provides impartial, independent advice.
I turn to the specific points that the hon. Lady made about Sir Norman. It is up front and totally clear in the IRP report that Sir Norman Williams, the chair of the IRP, declared openly to IRP members what was already a matter of public record: that between May 2016 and September 2019, he had been a non-executive director of St George’s University Hospitals NHS Foundation Trust, which neighbours the Epsom and St Helier University Hospitals NHS Trust, and he made it clear to the panel that that was a linkage. However, Sir Norman clearly left some time before the proposals were considered by the panel and, indeed, before the March date of this year that the hon. Lady referred to. As she said, independent panel members considered that matter and the issues that she had raised, and confirmed that in their view the historic connections with the case did not represent a conflict of interest and agreed that they were not relevant to Sir Norman’s role in chairing the formulation of the advice.
I have to say that I think it would be wrong to question in any way the integrity, impartiality or independence of the panel or the chair, who I believe is more than capable, rightly fulfilled his previous role to the best of his ability and fulfils his current role entirely to the best of his ability, recognising and fulfilling the requirement to be independent in the view he takes. I have seen no reason—or no compelling reason—to suggest that his behaviour has in any way contradicted that need for independence and objective guidance.
It is of course right that all reconfiguration decisions are taken in the best interests of patients and the local population, following due process. The people affected by the changes need to be involved in making the key decisions, and the IRP advice concluded:
“Patients and the public will need to be engaged in shaping and understanding the new landscape of services to gain maximum benefit from them.”
I believe that they will be.
I know that the hon. Lady’s constituents are and will continue to be strongly represented by her. I recognise the strength of her views, but I do believe that the process has been carried out fairly, independently and appropriately, in seeking to reach the best decision for the people who use the hospitals.
Question put and agreed to.