NHS Annual Report and Care Objectives

Chris Skidmore Excerpts

Wednesday 4th July 2012 Commons Chamber

[Mr Lansley]

I am grateful to the hon. Gentleman. I said during the passage of the Health and Social Care Act 2012 that it had been intensively considered in its every aspect. The Act expressly rules out the introduction of any charges across the NHS, other than by further primary legislation, and there is no primary legislation to permit such a thing. So I reiterate the point: there will be no additional charging for treatment in the NHS.

[Chris Skidmore (Kingswood) (Con)]

Many of my constituents are concerned that under the Labour Government £11 billion of PFI contracts were signed, which will cost the NHS over £60 billion to pay back. They are concerned that PFI, Labour’s toxic legacy to the NHS, has the potential to bankrupt many health trusts. Can my right hon. Friend reassure my constituents about possibly renegotiating some of these contracts?

[Mr Lansley]

My hon. Friend makes an important point. When the shadow Secretary of State was attempting to suggest that there were trusts in trouble across the country, he might have had the humility to admit that the hospital trusts in the greatest difficulty are the ones that were saddled with unsustainable debt by the Labour Government’s poorly negotiated PFI projects. He might have instanced Peterborough and Stamford Hospitals NHS Foundation Trust. Monitor wrote to him and his colleagues, telling them that that PFI project should not have proceeded. The Labour Government went ahead with it anyway and it is now unsustainable.

We have been very clear. We have gone through a process of identifying where trusts can manage, not least with us assisting them. In the latter part of last year we identified seven trusts that we will step in and support if we believe that they are otherwise unable to restore their finances to good health. It will entail about £1.5 billion of total support for them to be able to pay for their PFI projects. Where there are opportunities for renegotiation we will exercise them, but unfortunately it is in the nature of coming into government that we inherit what the previous Government left us. We were left with 102 hospital—[Interruption.] The shadow Secretary of State says from a sedentary position that they were our PFI schemes. No NHS PFI scheme was signed before the Labour Government took office in 1997. Two years ago we inherited 102 hospital projects with £73 billion of debt, yet the Opposition thought that in the years before they had used taxpayers’ money to build these new hospitals. No, they did not. They saddled the NHS for 30 years with that debt.

NHS (Foreign Nationals)

Chris Skidmore Excerpts

Tuesday 22nd May 2012 Westminster Hall

[Chris Skidmore (Kingswood) (Con)]

Thank you, Mr Streeter, for calling me to speak. It is an honour to serve under your chairmanship.

I very much appreciate having the opportunity to speak on the issue of foreign nationals’ use of the NHS today. I know that it is of concern to all Members of the House, regardless of political party, because for many of us it is a huge issue for our constituents, who are genuinely concerned about the NHS, which is free at the point of use.

Obviously, the constituents I speak to accept that we should never turn away at the door anybody who is in genuine need, whether they are asylum seekers or not. Obviously, there are big public health issues and I welcome the fact that the Government have extended HIV treatment to those people in need regardless of nationality, because that will benefit the whole of our society. However, we cannot get away from the fact that there is a large issue, and one that is growing, regarding the use of NHS facilities by foreign nationals who are ineligible for free care.

As a member of the Health Committee, I am particularly concerned about this issue and I have put down several parliamentary questions, dating back to last year. The Government responded that roughly £35 million had been written off by hospital trusts, in terms of debts that had been accrued by foreign nationals and that had neither been paid back nor claimed back. The trusts involved did not include foundation trusts, so I made a freedom of information request of all trusts across the country. The data that I received back from the 118 NHS trusts that replied to me showed that just over £40 million of debt accrued by foreign nationals had been written off.

Those data also showed that there is a huge variation in relation to the collection of debt accrued by foreign nationals. The highest figure for such debt was for Guy’s and St Thomas’ NHS Foundation Trust, which had written off almost £6 million of such debt since 2004. My own local trust, North Bristol NHS Trust, had written off £1.7 million of such debt. The data showed that some trusts were acting contrary to the regulations and the current guidance, which

“place a legal obligation on the trust providing treatment to identify those patients who are not ordinarily resident in the United Kingdom; establish if they are exempt from charges by virtue of the Charging Regulations; and, if they are not exempt, make and recover a charge from them to cover the full cost of their treatment.”

That is what trusts should be doing when foreign nationals who are ineligible for free care come through their doors. However, it was clear from the information that I received in response to my FOI request that many trusts were not even collecting those data, which is contrary to the guidance. Of those trusts that were collecting the data, some had gone back to 2000 to collect them and some had gone back to 2004. There was a large variation in the data that cannot simply be explained by the fact that some trusts were more willing than others to claim back the debt that they were owed from foreign nationals.

There is anecdotal evidence, too. I have heard from some Members who wanted to be in Westminster Hall today for this debate but were unable to make it, and they asked me to raise some issues. In particular, one MP had a constituent who had come to them regarding an American visitor who was staying with them. During their holiday, the American visitor became ill and attended NHS facilities for treatment. They then contacted their medical insurer in the US, which suggested that they provide proof of the cost of their treatment; the American visitor would need a receipt from the NHS, so that they could claim back the money from their medical insurer. However, when they contacted the trust in question, they were told that no such receipt was available and the trust itself had not collected the data about the nature and cost of their treatment, even though this visitor was a foreign national and ineligible for free NHS care, and actually wanted to pay the bill because they were very grateful for the fantastic treatment that they had received. Consequently, a receipt could not be provided.

So there are examples of how trusts are clearly not following the guidance and collecting NHS debt from foreign nationals. It is particularly worrying that a 2008 survey of NHS managers suggested that a third of them did not even bother to ask patients whether they were eligible for free treatment when they arrived at hospital.

[Mr Virendra Sharma (Ealing, Southall) (Lab)]

Is the hon. Gentleman now talking about those foreign nationals who arrive here specifically to receive treatment, or those foreign nationals who come here as visitors, become ill and are then unable—for whatever reason—to pay for their treatment? We must not mix the foreign nationals with political asylum seekers, overstayers and others who, for whatever reason, live here for many years but are not eligible to receive NHS treatment. Is the hon. Gentleman mixing those two groups, or separating them?

[Chris Skidmore]

No, I am certainly not mixing them and I will come to the issue of eligibility that is defined around the term “ordinarily resident”. I want to talk about that in terms of the historic issues that determine whether foreign nationals should be charged for treatment. Obviously, there have been various reports in the past decade, including a 2007 report by the Joint Committee on Human Rights that examined services available to asylum seekers, and those reports have raised that very issue. If access to care and treatment was denied to those who are vulnerable and in genuine need of care, that would undeniably make the situation worse and cause them far greater distress and harm. In those circumstances, we have a right and a moral duty to ensure that people are treated.

On the other hand, we have what some red-top newspapers might call “health tourism”. I use that phrase with some trepidation, because the situation is certainly more complicated than that phrase implies; it suggests that people are simply flooding in across our borders to ensure that they can receive NHS treatment, and that is certainly not the case. There are eligibility criteria that apply, but my concern is that they are not being applied strictly enough by various trusts. On the back of the previous Government’s consultation on this issue, between February and June 2010, the current Government have now decided to tighten certain eligibility criteria, particularly regarding asylum seekers and specifically when asylum seekers have their right of asylum refused.

There is obviously an issue with border security as well, and I welcome the fact that the Government have introduced measures, through the Home Office, in relation to those who have left the country with unpaid debts to the NHS of more than £1,000. I put down a written question that suggested that each year there are 3,600 foreign nationals who accrue such a debt for their NHS treatment and that they should not be allowed re-entry to this country unless those debts were paid off. There is a spectrum through which one has to view who is a foreign national and who is “ordinarily resident”.

I do not deny that establishing the difference between those two groups can be very difficult and that there is a very fine balance to strike. Nevertheless, it is clear from the data that I have received in response to my FOI request that the current system is not working. If there is a situation, as there is at the moment, whereby debts are being accrued and not reclaimed, and whereby a third of NHS managers are not even asking patients whether they are eligible for free treatment or whether they are a foreign national, that is a very big issue.

In many ways, one can understand why someone working within an NHS trust would not want to ask someone about their nationality; it might simply be easier to provide treatment. That is because of the simple fact that, once someone has been categorised as a foreign national and therefore they must be charged because they are ineligible for free care, those charges must be recouped. The costs of recouping those charges could far outweigh the charges themselves.

Moreover, I do not deny that some patients will turn up at an accident and emergency department or trust with a particular complication, which becomes severely worse. For whatever reason, they happen to die and there is no way in which the charges for which they would have been liable can be recouped. All those particular situations need to be taken into account.

In the Health Committee, we looked at how different trusts operate and collect their debts, or even monitor which people coming through their doors are eligible for free care and treatment. West Middlesex University hospital has what is called a “stabilised discharge system”. If a foreign national is admitted to hospital, the doctor first establishes whether there is a need for urgent life-saving treatment, which is obviously a priority for the NHS. If that is not the case, the person is told what treatment is required and how much it costs. If they are unwilling to pay, they are asked to leave. That policy in the hospital nearest Heathrow airport has saved the hospital £700,000 in each separate year. Even within the existing guidance and criteria, there are the means and possibilities by which trusts can ensure that the criteria are followed correctly and that savings can be made. I am sure that if every trust acted in the same way as the West Middlesex University hospital, we would see the amount of debts incurred by foreign nationals drop significantly.

The hon. Member for Ealing, Southall (Mr Sharma) mentioned the criteria around a foreign national and who is and is not eligible for care. The context of this debate, as I mentioned, is an historic one. It was not until 1989 that the British Government began to require certain overseas visitors to pay for hospital treatment. That was defined in regulations in 1977, when legislation permitting persons not ordinarily resident in the United Kingdom to be charged for NHS services began to be looked at.

How we define someone who is not ordinarily resident, as opposed to someone who is ordinarily resident, is interesting. In a way, it is a common law concept, but in NHS health care legislation there is no definition of “ordinarily resident”. The only definition comes from a 1982 judgment in the House of Lords, which was actually in the context of the Education Bill that was passing through the other place at the time. The definition of “ordinarily resident” was:

“living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, whether they have an identifiable purpose for their residence here and whether that purpose has a sufficient degree of continuity to be properly described as ‘settled’ ”.

That means that UK citizenship and past or present payments of UK taxes or national insurance contributions, contrary to what many of our constituents might think, are not directly taken into account in the way that “ordinarily resident” has been defined.

In the review that they are currently conducting, I urge the Government to consider how we will define “ordinarily resident” in future. The NHS is a contributory system that people pay into to receive free care at the point of treatment. That is right. The NHS is free for citizens who have paid into the system. It cannot be a free-for-all for everybody to use. Our constituents wish us, as legislators, to address that concern.

It is clear that the current rules and regulations, having been addressed and re-addressed over time, have caused some confusion. In 2007, the Joint Committee on Human Rights produced a report on services to asylum seekers. It suggested that the new rules introduced in 2004 regarding asylum seekers and whether they were eligible for free care—or, once their asylum application had been turned down, whether they were still eligible for free care—caused confusion about entitlement. It suggested that the interpretation of the rules appeared to be inconsistent, and that in some cases people who were entitled to free treatment had been charged in error.

At the time, the Labour Government began a consultation looking at the use of primary care by foreign nationals using the NHS. It is clear that in acute and secondary care, charging regulations apply. The problem is that the implementation of those charging regulations has not been effective, and we need to be more stringent about the implementation of current guidance.

Currently, there are no charges for primary care, whether people are eligible or not. People can register with a GP for primary care, regardless of status. The Labour Minister at the time, in 2004, held a consultation on whether there should be charges for foreign nationals and people who were ineligible for free care. He suggested that the consultation was necessary because

“the rules about entitlement to primary care are best described as a muddle.”

I agree. In my own experience as MP for Kingswood, I have found a firm of lawyers in Bristol—Deighton Pierce Glynn—that has been writing to doctors urging them to register patients and saying that if they do not, it will take legal action, regardless of the patients’ nationality and eligibility for free care. I raised the matter in the local media, in the Bristol Evening Post. It is wrong, and I am concerned that our NHS will become a legal paradise for lawyers piggy-backing on doctors who are doing the best that they can with the resources that they have. They know that NHS resources are stretched and need to be rationed and that there is a big problem.

One lawyer responded in the Bristol Evening Post by saying that lawyers were not trying to change the law:

“We are trying to apply the law as it is. Nobody is excluded from GP treatment. It is very clear. Hospital treatment is different. People come to us when they have been refused registration with a GP. There is nothing in the law that permits them to do that. Refusing them isn’t lawful.”

This particular case concerned asylum seekers who had had their asylum applications refused. When the GP in question received the letter from Deighton Pierce Glynn, an unnamed member of staff said:

“Someone at the PCT read the letter and panicked. Do we just register everyone who is illegal?”

There is clearly confusion being stoked by certain members of the legal profession who seem to be taking advantage of the uncertainty of eligibility within primary care so that they can profit when their clients wish to apply to the NHS.

On the situation in primary care, I was interested in a question asked by the right hon. Member for Birkenhead (Mr Field) on 23 April 2012. He asked the Secretary of State for Health

“(1) what documentation a foreign national who seeks to register with a GP is required to provide;

(2) whether a foreign national on a six month visitor's visa is entitled to register with a GP;

(3) on what grounds a GP whose list has not been closed may refuse an application to register from a foreign national.”

The reply was:

“Under the terms of their existing contract, general practitioners (GPs) have discretion in accepting applications to join their lists. However, they cannot turn down an applicant on discriminatory grounds. They can only turn down an application if the primary care trust has agreed that they can close their list to new patients or if they have other reasonable non-discriminatory grounds.

There is no formal requirement to provide documentation when registering with a GP. However, many GPs, when considering applications, request proof of identity and confirmation of address, but in doing so they must not act in a discriminatory way.

A decision on whether to register a foreign national who has a six-month visitor visa is therefore currently for the GP to consider.”—[Official Report, 23 April 2012; Vol. 543, c. 701-02W.]

That raises issues. I do not like to quote Sir Andrew Green, the chairman of Migration Watch UK, but he stated:

“What this means is that someone getting off a plane with a valid visitor’s visa is, in effect, able to access the GP services of the NHS without ever having paid a penny into the system. Over one and a half million such visas were issued last year.”

Once someone is registered with a GP, the regulation and guidance mean that if they need further secondary care, it is the relevant NHS body’s duty and not the GP’s to establish the requirement for free hospital treatment. That raises the issue of the extent to which that takes place. Once someone is on the GP’s books, that is almost a rubber stamp into receiving secondary care.

I am not suggesting that GPs act as pseudo-immigration officials checking people’s eligibility for free care, but there clearly needs to be a more joined-up approach between the people who end up on GPs’ books and who are then referred by GPs to secondary care specialists, and what that then involves in terms of charging. When it comes to the issue of primary care and foreign nationals, I do not believe that foreign nationals should be entitled to free primary care. We should extend the charging regulations further.

[Mr Virendra Sharma]

I apologise; I should have congratulated the hon. Gentleman earlier on securing this debate, which is important not only to his constituents but to people all over the country, who take the issue seriously. It is also important in my constituency, where it is discussed every day.

I am a bit confused; I hope that the hon. Gentleman will clarify. He is mixing foreign nationals and those who have been here for many years. As I see it, in this debate, foreign nationals are those who come especially to register themselves for a few days, who receive treatment and who disappear without paying, due to system failures, although I will not get into that debate. For those already here, if GPs act as immigration officers or work on behalf of the UK Border Agency, that will mean health problems.

[Mr Gary Streeter (in the Chair)]

Order. Interventions should be brief.

[Chris Skidmore]

I certainly do not mean to confuse or mislead. When I say foreign nationals, I mean those who come to this country requiring care who are not defined as ordinarily resident under the current regulations. Personally, I think that we should consider the definition of “ordinarily resident”. I have no problem with people’s nationality, whether they are British or a citizen of whatever country. If they work in this country and are contributing to society, it is right that they should receive the free care towards which they have contributed.

Equally, exemptions apply for matters of public health and vulnerable groups. As the hon. Gentleman mentioned, if denying access to treatment could worsen the health of the community, let alone the individual, it is right that we should act responsibly. However, that should not preclude the creation of a clear definition of who is and is not eligible for care. One reason why we are having this exchange is that there is no clear, black and white definition. There will, obviously, be shades of grey, as there always are in health care. Health care professionals have a moral obligation to treat people in need, the sick and the vulnerable. I do not deny that, but we also have a moral obligation to our taxpayers to ensure that NHS money is spent as well as it can be.

A few people have come to me and said, “Mr Skidmore, it’s only £60 million out of a budget of £110 billion. Surely you’ve got to factor in debt. We should be able to expect that amount of debt to be written off.” I do not accept that argument. My local community hospital, Cossham hospital, is undergoing a £20 million refurbishment at the moment, and my constituents are so excited that it is taking place. That £60 million is a lot of money; it could have paid for the refurbishment of Cossham hospital three times over. We must count millions in order to save billions. During this efficiency drive, when we are trying to reinvest 15% to 20% of NHS resources in front-line care, it is a key aspect of the Nicholson challenge that we look for waste in the system and for instances where regulations are not being applied effectively.

I agree with the hon. Gentleman that we must be careful about how we define a foreign national. I do not want this to be seen as a xenophobic campaign, because it certainly is not. It is based on the conviction that the NHS is a national health service that provides free care at the point of use, but should not be abused; it should be free at the point of use, but not at the point of abuse.

The GP situation includes the lawyers at Deighton Pierce Glynn, who have been contacting GPs, and the Minister of State’s answer to the right hon. Member for Birkenhead about the issue of visas and documentation, which raises an issue that I think GPs would welcome.

Part of the consultation involves clarity about what GPs must look for when patients register in their practices, and whether they can say, “I’m afraid I cannot register you, because you don’t have the necessary data documentation.” As far as I understand it, the lawyers have been writing to GPs saying that by not registering patients, they are applying a discriminatory process. However, I was interested to read that paragraph 5.16 of the guidance on charging, in the section on GPs in primary care, says:

“It is important to see that all patients are treated the same way, to avoid allegations of discrimination.”

That is also clear in the Minister’s answer. The guidance goes on to say:

“It is not racist to ask someone if they have lived lawfully in the UK for the last 12 months as long as you can show that all patients—regardless of their address, appearance or accent—are asked the same question when beginning a course of treatment. The answer to that question may result in others needing to be asked, but again you will not be breaking any laws as long as those questions are asked solely in order to apply the Charging Regulations consistently.”

It is in the guidance that GPs have the right to ask, as long as they ask everybody. They will not be applying a discriminatory process.

As I said, in 2004—they reported in 2009—the previous Government began to consider whether we should extend charging to primary care and how eligibility criteria should be tightened. The review suggested that charging would not be extended to primary care. I hope that we as a Government might be able to reconsider. I know that this Government are committed to ensuring that national health care resources are spent in the right way. My constituents appreciate that, as I have said.

The Home Office has introduced measures so that anyone owing the NHS £1,000 or more will not be allowed to enter or stay in the UK unless the debt is paid. When that is implemented, the Home Office hopes to capture 94% of outstanding charges owed to the NHS; hopefully, it will have a significant impact. Encouragingly, the review commissioned on 18 March 2011 suggested:

“The existing system is still too complex, generous and inconsistently applied. While the NHS remains committed to providing immediate or necessary care, it is important that a balance of fairness and affordability is also struck.”

I agree entirely.

The review taking place will now consider

“qualifying residency criteria for free treatment; the full range of other current criteria that exempt particular services or visitors from charges for their treatment; whether visitors should be charged for GP services and other NHS services outside of hospitals”,

as I suggested; and

“establishing more effective and efficient processes across the NHS to screen for eligibility and to make and recover charges”.

I suggest that as part of the consultation, they consider West Middlesex University hospital and the good work being done there. Finally, the review will consider

“whether to introduce a requirement for health insurance tied to visas.”

I was encouraged when the Minister said:

“The NHS has a duty to anyone whose life or long-term health is at immediate risk, but we cannot afford to become an international health service, providing free treatment for all. These changes will begin the process of developing a clearer, robust and fairer system of access to free NHS services which our review of the charging system will complete. I want to see a system which maintains the confidence of the public while preventing inappropriate free access and continuing our commitment to human rights and protecting vulnerable groups.”

I agree with all those words.

I initiated this debate to ensure that Members have an opportunity to put their views as part of the consultation, which, hopefully, will report later this year. To reiterate, the NHS is a national health service, not an international one. Although we all believe that health care treatment must be free at the point of use, it cannot be free at the point of abuse. I urge the Minister to consider carefully what I have said and what other Members will say in this debate. We care passionately about the NHS. We want the NHS to continue as it has for six decades now. This issue is one that I know all our constituents and everyone in the House, regardless of party politics, will wish to ensure is solved.

--- Later in debate ---

[Mr Jamie Reed (Copeland) (Lab)]

It is a pleasure to contribute to a debate under your chairmanship for the first time, Mr Streeter. I congratulate the hon. Member for Kingswood (Chris Skidmore) on securing the debate. The use of the NHS by foreign nationals is a growing problem and it is important to take a moment to reflect on why we are discussing the issue today. It is a concern among hon. Members from all parties and, as my hon. Friend the Member for Ealing, Southall (Mr Sharma) said, among people representing all communities throughout the country. The issue is of paramount importance to a number of people.

As the previous Labour Government delivered the lowest ever waiting times and the highest ever level of patient satisfaction, along with 44,000 more doctors and 89,000 more nurses, the NHS became the envy of many other countries. The recent Commonwealth Fund comparative study of the state of the NHS makes that absolutely clear. However, a consequence of having one of the—if not the—best health services in the world was, and is, that it became increasingly attractive to foreign visitors. That has brought a number of issues that need to be addressed.

The commonly agreed figure that the hon. Member for Kingswood has mentioned is that the debt accrued by foreign nationals to the NHS is around £40 million. He is right to point that out. It is a lot of money—whether it is £40 million or £60 million—that would buy a lot of medicine and fund a lot of projects in a lot of communities. If the figure is £40 million, it is approximately 0.1% of the £3.5 billion that the Government are wasting on NHS reorganisation now. None the less, that figure is an awful lot of money.

The NHS is built on the principle that it should provide a comprehensive service based on clinical need, not ability to pay. However, at the same time, it is a national health service—not, as has been repeated on a number of occasions, an international health service. There must not and cannot ever be any doubt about that. Therefore, it is right that we impose charges for overseas visitors, who are defined in respect of NHS hospital treatment as people who are not ordinarily resident in the UK.

The previous Labour Government were committed to maintaining the existing system of charges, but they proposed a series of further safeguards, including amending the immigration rules so that anyone who accrued substantial medical debts would not be allowed back into the country if they left without settling their bill. I am genuinely pleased that the current Government have adopted so many of those recommendations. However, we need to look again at the ability to make and recover charges, and we would be happy to work with the Government on that issue. For example, the previous Government considered whether foreign nationals should be charged for NHS services outside the hospital. That issue warrants further close discussion.

We also need to learn from those hospitals that are more successful at recovering charges. The hon. Member for Kingswood referred to some of those. Hospitals have a legal duty to recover any charges made to overseas patients and, frankly, some hospitals need to be much better at that. Sometimes dealing with that problem can be as simple as improving the recording of contact details, so that the patient can be pursued for payment, but I accept that the rules and procedures could be demonstrably improved. The Government should ensure that that is done and, again, we will support them in their efforts to do so.

A relevant issue that has not been touched on today is the Olympics. It would be helpful if the Minister explained what plans are in place to ensure that the NHS can meet the rise in demand from overseas visitors during the games. Will she tell hon. Members what exemptions are in place for athletes and officials? “Newsnight” recently reported that Olympic VIPs could receive fast-track emergency care. With A and E waits already increasing, is there not a danger that taxpayers who are paying for the NHS and the Olympics will be pushed to the back of the queue?

[Chris Skidmore]

I would have raised the Olympics in my speech had it not been for the fact that I wanted this to be a cross-party debate. The criterion that Olympic officials and athletes should receive free treatment was part of the bid that was successful in 2005 under the previous Government. We would not have been awarded the Olympics if that had not been part of the 2005 bid.

[Mr Reed]

The hon. Gentleman makes a good point. He is obviously aware of the fact that although he, I and other hon. Members are privy to those details, the general public are not. There is a salient concern out there about the perceived emergence of a better standard of care being afforded to people who are involved in the Olympics. I visited Homerton hospital in Hackney, which is one—if not the—Olympic hospital in London. I saw some tremendously innovative professionals there who are developing innovative medical treatments and systems of working. They need to get the message across that local people who use that hospital on a daily basis will not be disadvantaged by the Olympics. We need a clear exposition of why that will not be the case.

Although I have considerable sympathy with the contributions I have heard this morning, all hon. Members must recognise that, under the UN convention on human rights, the UK has an international obligation to provide free NHS treatment to those seeking asylum here. All of the contributions I have heard today indicate that that will not be too hard to achieve, but hon. Members must guard against those Members who advocate that we should not fulfil that obligation, because the temptation will be too much for some. When we produce facts and figures used in support of the arguments, that must be acknowledged.

We must also guard against Members from all parties who advocate that the NHS should turn away pregnant mothers or patients in need of emergency care. Overall, this issue requires a diligent, careful approach. It is not the platform for a weird, xenophobic virility contest. I look forward to hearing what the Minister has to say. There may be little common ground between my party and the Government on the NHS, but we can agree that NHS care must always be based on clinical need, not ability to pay. At the same time, first and foremost, the NHS must serve the people of the United Kingdom—those whose taxes fund the NHS, those who believe in it passionately as the guarantor of a better society and those who expect it to be there for them when they need it. I hope that we can agree on that principle as we continue to debate the issue constructively and develop the fair and appropriate policy responses that the issue deserves.

EU Working Time Directive (NHS)

Chris Skidmore Excerpts

Thursday 26th April 2012 Westminster Hall

[Chris Skidmore (Kingswood) (Con)]

As a member of the Select Committee on Health, I am very interested in this debate. I have learned a lot from the engaging contributions of all hon. Members who have spoken.

I want first to acknowledge the hard work of my hon. Friend the Member for Bristol North West (Charlotte Leslie), and not only for this debate. I want to put on the record the fact that she has campaigned on the matter for nearly two years. She has brought it up in recess Adjournment debates, Health questions, Prime Minister’s questions, and a ten-minute rule Bill—the NHS Acute Medical and Surgical Services (Working Time Directive) Bill. She has not let the issue go, and I think it is important to put that on the record because, without all her work over the past two years, we would not have achieved this Back-Bench debate today, which is extremely important, and the final Backbench Business Committee debate of the Session—and very apt it is too.

Following my hon. Friend’s two-year campaign, the exact financial cost and burden on the NHS caused by the directive is becoming clear. On 18 March, The Sunday Telegraph published a freedom of information request about the cost, and some of the figures have been read out, but I want to read out a few more to place them on the record. Of the hospital trusts that provided figures, 80% admitted spending more than £1,000 per shift on medical cover as a result of the EU working time directive. In total, £2 billion has been spent on that since 2009, which is roughly equivalent to the wages of 48,000 nurses or 33,000 junior doctors.

We have talked about inequalities. It is worrying that some trusts are clearly suffering more than others, and some are in extreme financial difficulties. Yet North Cumbria University Hospitals Trust spent £20,000 on hiring a surgeon for one single week. Mid Staffordshire NHS Foundation Trust—my hon. Friend the Member for Stafford (Jeremy Lefroy) referred to this—spent £5,667 for a doctor for just one 24-hour shift in a casualty unit. The Christie NHS Foundation Trust in Manchester spent £11,000 on six days’ cover for a haematology consultant. Scunthorpe general hospital offered £100 an hour for one month’s work in a temporary post. Princess Alexandra Hospital NHS Trust in Essex paid more than £2,000 for a locum doctor to work a 12.5 hour shift last October.

I could go on, but I want to come back to that £2 billion in two years, and to relate it to the Nicholson challenge, which is a cross-party issue, of saving £20 billion to reinvest back into front-line services. The challenge was set in 2009 by the previous Government to take place over three years. As a result of the comprehensive spending review, that has now been extended to four years. No MP can claim that that is a cut by one Government or another, although some MPs have tried to. It is a cross-party approach, and we in the Chamber are responsible and understand that if the NHS is to remain free at the point of use, regardless of ability to pay, we need to make savings and to reinvest them into front-line care.

The coalition Government have already done a fantastic job in making savings of about £7.5 billion on the way to the £20 billion figure. But the reality is that, if this £1 billion a year cost to the EU working time directive remains, that will be a £4 billion cost over the period of the comprehensive spending review. Therefore an extra £4 billion will need to be found in efficiency savings. We are moving from a 20% efficiency gain, therefore, to almost a 25% one. [Interruption.] It appears that the Minister disagrees, but it is just a back-of-an-envelope calculation.

[Charlotte Leslie]

My hon. Friend is contextualising this debate in an important way, in respect of wider finances and the Nicholson review. Reverting to the question of evidence, does he agree that simple figures, such as these, on the cost of a directive that has been introduced are also evidence? The first-hand reports of clinicians on the ground are perhaps more reliable than the evidence gathered from sources that might not always be willing to tell the truth about the situation, for fear of not meeting compliance targets.

[Chris Skidmore]

Absolutely. On the figures I mentioned, only 34 hospital trusts responded to the requests for information, so the data were incomplete. Only 83 out of 164 responded with any data at all.

[Debbie Abrahams]

Is that not the point? This is about ensuring that we have quality data to inform policy development. It may not be working as it should be—I will accept that—but we cannot use incomplete, poor data to propose solutions. We need to ensure that we have quality data to inform that process. What if I made a statement now and that was regarded as evidence? Surely we are not going to base policy on just one person or on poor data.

[Chris Skidmore]

I agree. I am sure that all hon. Members would echo such a call. We should have complete data. The complete data, if we had them, would show that the situation is far worse and that, instead of the £1 billion a year cost, the hidden cost is, according to the data that I have, perhaps £2 billion. We do not know.

My hon. Friend the Member for Bristol North West, almost like a Cassandra, warned that this would be a problem back in 2010, and started the campaign with no data at all. Two years down the line, we find what she said to be true, in respect of data from individual trusts. We will know more, probably, by the end of this year and there will be more stories in the Sunday papers and it will become an ever bigger issue. That is why it is so important to have this debate now, because when the public and patients who use the NHS ask, “What were you doing about this, as MPs?”, we can say, “We’ve had this debate. Okay, it’s not come up with all the solutions just yet”—we are interested to hear what the Minister says about possible solutions—“but we are on the case.” That is important, because an avalanche of cases will come forward in the near future. It is important to recognise that.

There is a challenge from Nicholson and we need to make those savings. The problem is that this matter is standing in the way of the Nicholson challenge being effectively delivered. Either we have to push harder to gain those efficiency savings—the problem now is that we have inefficiencies of the worst kind and are essentially having to make more efficiencies elsewhere to reinvest in front-line care—or the money will not be reinvested back into front-line care. Working time directive costs are classed as front-line care, when clearly they are not, so money is being removed that could be spent on nurses or on alternative equipment for the NHS that would have benefited patients.

[Mr Simon Burns]

My hon. Friend might find it helpful to know—he is talking about the Nicholson challenge and asking, “What were we doing during this”—and might take some comfort from the fact that, since May 2010, the cost of locums has fallen by 11%.

[Chris Skidmore]

I appreciate that information. I only have pre-coalition data from 2007-08 and 2009-10, although they are not inaccurate. It is interesting to note that, before the coalition came in, the cost of locums was rising enormously, from £384 million to £758 million. The coalition’s inheritance was enormous. It is good to hear that there has been an 11% saving, which is roughly £75 million.

[Mr Burns]

Let me give my hon. Friend the precise figures on the savings. The number of people employed as locums by the NHS has fallen by 11% since May 2010, and the number of doctors in the NHS has increased by about 4,000.

--- Later in debate ---

[Chris Skidmore]

I welcome those figures. The coalition Government clearly recognise that front-line care is in danger of becoming atomised. We want continuity of care and front-line doctors, and we want full-time doctors and nurses rather than locums. Over the past couple of years—I am not blaming any one Government in particular—we have seen a sort of fragmentation and atomisation so that we now have 50 agencies delivering locum services, one of which has a turnover of £100 million a year. We need to look at that issue. The working time directive has been blamed for the rise of locum doctors, and it is good to hear that the coalition Government are making strides to change that, and we must recognise that in this debate.

The issue of training has been raised, as well as the fact that 400,000 hours of surgical time are lost every month—that is 4.8 million hours every year. My hon. Friend the Member for Hastings and Rye (Amber Rudd) was very informative about the impact that that will have on surgery as a craft, and I appreciate that. Professionalism is an issue, and the clock on, clock off attitude is not what any of us wants to see in the NHS. We want professionals to be in charge of their services in the NHS, and such an attitude clearly puts them out of charge.

On the timeline, the Secretary of State for Health claimed that the “Time for Training” report by Sir John Temple reinforced his,

“determination to support efforts to resolve these difficulties and be ready to work constructively with the European Commission and other member states on radical, creative approaches to gain additional flexibilities.”—[Official Report, 9 June 2010; Vol. 511, c. 14WS.]

The Prime Minister responded on the Floor of the House to a question from my hon. Friend the Member for Bristol North West:

“My hon. Friend raises an important issue about the working time directive and its effect on the NHS. Nobody wants to go back to the time when junior doctors were working 80 or 90 hours a week, but I think we all see in our constituencies that the working time directive has sometimes had a bad effect on the NHS…The Health and Business Secretaries are committed to revising the directive at EU level to give the NHS the flexibility it needs to deliver the best and safest service to patients. We will work urgently to bring that about.”—[Official Report, 18 January 2012; Vol. 538, c. 745-6]

My hon. Friend, and others, have spoken about other countries such as Spain, the Netherlands, Ireland and Portugal, which all somehow manage to get around the directive. I was interested to read my hon. Friend’s article in The Times where she wrote about what happens in the Netherlands and stated that Dutch trainee doctors are categorised as autonomous workers because they earn more than three times the national minimum wage. Being classified as working for themselves exempts them from the directive. There is a similar situation in Ireland where training has been exempted from the definition so that work done by trainee doctors falls outside the directive.

We must either look at the EU angle—many Members have raised the issue of the European Union—or at what the British Government can do within the NHS. GPs are self-employed. Can we not think radically and ask to what extent doctors working in hospitals could also be classed as self-employed so that we can get round the regulations? That is worth thinking about, although I am not sure what the consequences would be.

[Mr Burns]

I really do not want to be a clever clogs. My hon. Friend has accurately described what happens in the Netherlands, but even with the opt-out, weekly hours in that country are limited, in that case to 60 hours.

[Chris Skidmore]

Sixty hours would be a start—65 is what most people seem to be calling for. It is about getting a balance. We do not want to go back to the 80, 90 or 100-hour working week, but nor do we want to face the consequences of the 48 or 56-hour working week. There is a balance to be struck, and I would be very interested to hear what the Minister thinks can be done. This debate is obviously an interesting one because it can go down a European direction, which I know a Health Minister cannot say very much about today. However I would be interested to hear what he has to say about the NHS in his capacity as a Health Minister.

[Ian Paisley]

There is also the issue of bean counting. We must be very careful, because this debate is about delivering something to the patient and ensuring that the team around the patient, including the doctors, co-ordinate their work to meet the needs of the patient. If we get into very strict bean counting—whether we are talking about 48 hours, 60 hours or whatever—and do not recognise that this is about a patient-centred service, we will keep having more and more of these problems that we have discussed. That is the critical issue, and why we need the flexibility.

[Chris Skidmore]

I entirely agree with the hon. Gentleman. Patient-led care is where we must get to. That is why we are all here; that is what the Health and Social Care Act 2012 will deliver. I am sure that we will all be working further to ensure that the patient is placed at the heart of the NHS.

Oral Answers to Questions

Chris Skidmore Excerpts

Tuesday 27th March 2012 Commons Chamber

[Paul Burstow]

Of course, I will be only too pleased to have that meeting.

[Chris Skidmore (Kingswood) (Con)]

Is the Minister aware of the publication today of the industrial action review by the London ambulance service, which details that on 30 November, the day of the public service strikes, in the afternoon and the evening, requests for front-line staff to return to front-line ambulances were made by the London ambulance service. However, of the three unions to strike, only Unison responded to say that it would not ask staff to return to work. Three hours later, after three repeated requests for help, a patient who had been unable to get an ambulance had died. The report has called—

[Mr Speaker]

Order. The hon. Gentleman should resume his seat. I do not wish to be unkind, but topical questions are about short questions, and that was not. I am very sorry. The Minister may give a brief reply if he wishes.

Health and Social Care Bill

Chris Skidmore Excerpts

Tuesday 20th March 2012 Commons Chamber

[Liz Kendall]

I absolutely concur with my right hon. Friend. For the record in this House, I pay tribute to our colleagues in the Lords for their achievements and their efforts in securing some of the protections for the NHS that we are debating today.

There was absolutely no mention of education and training in the original Bill, despite the fact that the Bill abolishes strategic health authorities, which play a vital role in education and training—for example, by hosting deaneries. Labour Members raised this issue in the first Commons Committee stage. We also tabled an amendment on Report to place a duty on the Secretary of State to ensure a comprehensive education and training system for all professions in the NHS, which would have included continuing professional development. Labour Members in the other place then tabled amendments to address the issue. I should note, again for the record, that it was Labour and Cross-Bench Lords, not Liberal Democrat Lords, who argued for those important amendments and who forced the Government to introduce substantive new clauses placing duties in respect of education and training on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups.

However, the critical issue that I want to focus on is how to deal with conflicts of interest in clinical commissioning groups. Clinical commissioning groups will be responsible for spending around £65 billion of taxpayers’ money. They will be made up of a majority of GPs—professionals who run businesses that are largely, and in many cases wholly, dependent on the NHS for their income. Clinical commissioning groups will commission NHS services, some of which will be provided by GPs who are members of the group, or—as is increasingly envisaged by the Government—by companies in which GP members may have a financial interest. The public must have confidence that clinical commissioning groups are making decisions based on patients’ and taxpayers’ best interests, not the financial interests of GPs.

[Chris Skidmore (Kingswood) (Con)]

rose—

[Liz Kendall]

I will finish this point.

However, under the Bill, clinical commissioning groups—the newest bodies in the NHS, and with the least experience—will have the weakest corporate governance of any public body in the country. They are required to have only two lay members. However, there has been no reassurance in this House or another place that those members will be independently appointed. The Government have not even given a reassurance that the chairs of clinical commissioning groups will be lay members. The Government have also failed, at every faltering stage of this Bill, to ensure robust protections against actual or perceived conflicts of interest in clinical commissioning groups.

[Chris Skidmore]

Will the hon. Lady give way?

[Liz Kendall]

No, I am going to proceed.

Let me remind hon. Members that the Bill started out without any requirement for GP consortia—as they were then called—even to have a board to govern their work, let alone any measures to deal with potential conflicts of interest. On 3 March last year, in the first Commons Committee stage, Labour Members called for effective corporate governance and robust measures to deal with conflicts of interests in clinical commissioning groups.

Health and Social Care Bill

Chris Skidmore Excerpts

Tuesday 13th March 2012 Commons Chamber

[Andy Burnham (Leigh) (Lab)]

I beg to move,

That this House notes the e-petition signed by 170,000 people calling on the Government to drop the Health and Social Care Bill; and declines to support the Bill in its current form.

I do so on behalf of the 170,000 people who have signed the e-petition calling on the Government to drop the Health and Social Care Bill.

The petition was initiated by Dr Kailash Chand, a distinguished general practitioner in the north-west of many years’ standing, and I pay tribute to him today. He has united patients who depend on the NHS and professionals who have devoted their lives to it in this simple but sincere call on the Government: “Drop the Bill”. Today, their voice will be heard in this House, as it is entitled to be. We will not let them be silenced, even though attempts were made to stop this debate taking place.

That takes us—

[Chris Skidmore (Kingswood) (Con)]

Will the right hon. Gentleman give way?

[Andy Burnham]

No. I have been listening to the strictures from the Chair, and I want to get into my speech so that Back-Bench colleagues have a chance to contribute.

That takes us straight to the heart of the predicament in which we find ourselves. There is huge concern in the country about the Bill, but the Government and Parliament—

--- Later in debate ---

[Chris Skidmore (Kingswood) (Con)]

It is an honour to speak in this debate.

I thought that I should set out the context of our discussion. Members on both sides of the House have talked about demand, in particular, and it is important to look at that question. Most importantly, we must admit that the NHS needs to adapt under new pressures. In 2001 the NHS treated 12 million patients. Today that figure is 17 million, so in other words the number of people accessing the NHS has risen over the past decade from 101 per minute to 124 per minute, resulting in the cost of drugs and prescriptions rising by more than 65%.

[Mr Anderson]

Will the hon. Gentleman give way?

[Chris Skidmore]

No, I will not. The right hon. Member for Leigh (Andy Burnham) did not give way to me, I am afraid, so I am not feeling too charitable.

Despite the coalition Government’s added investment of £12.5 billion over the course of this Parliament, demand will only rise further, with 1.6 million people turning 65 in the course of this Parliament and many living into their 80s and beyond. The number of 85-year-olds will double by 2030. The NHS is facing a perfect storm—an ageing population combined with a rise in chronic conditions, including an increase in diabetes, which will take up as much as 25% of the health budget. That is why we are reforming the NHS. Just as this Government are committed to dealing with the deficit so that future generations will not be burdened with debt racked up yesterday, we must be committed to reforming the NHS so that future generations can enjoy an NHS that is free at the point of delivery regardless of the ability to pay. I am sure that that is what everyone in this House is committed to.

By placing GPs rather than management in control of patient treatment, we will not only drive up standards of care, allowing patients access to more treatments under any the qualified provider scheme, but ensure that recurrent cost savings are made to be reinvested in the NHS to cope with the rising demand. Above all, this is an evolutionary measure. My right hon. Friend the Member for Charnwood (Mr Dorrell) touched on the Blairite doctrine. It was a pleasure that we had Professor Julian Le Grand come to the Health Committee, where he said that if Tony Blair were still Prime Minister and he were advising him, he would have urged him to undertake this measure. It is great to see the right hon. Member for South Shields (David Miliband) in his seat. It would have been fascinating to see what would have happened if he had become leader of the Labour party. I am sure that we would not have seen the rank tribalism that we have seen from those on his Benches today.

[Andy Burnham]

We are supporting the amendment.

[Chris Skidmore]

I am talking about the right hon. Member for South Shields, not the hon. Member for St Ives (Andrew George).

Professor Julian Le Grand stated on 28 February:

“With respect to the NHS bill, it is important that even those who generally prefer to rely upon their intuitions should avoid muddying the waters by accusing the bill of doing things that it does not, like privatising the NHS; and that all those involved should acknowledge the peer-reviewed evidence demonstrating that its provisions with respect to public competition…are likely to improve patient care.”

More hours have been given to debating this Bill than any other during this Session. Despite Labour’s message, which seems to be opposition for opposition’s sake, we are gradually learning what its policy will be for the next general election. It is interesting that at a rally in Manchester last week, the right hon. Member for Leigh stated, in front of his union faithful,

“And I will make you a promise today—if I am the health secretary after the next general election I will repeal this bill.”

According to the Opposition, this is the greatest reorganisation in history. Yet the Bill will save £4.5 billion straight away and then £1.5 billion recurrently, year on year, thereafter.

[Mr Burrowes]

All our constituents will be listening intently to the debate and will hear that following the health inequalities that have grown under the previous Government, the Opposition will oppose and repeal legislation that imposes a duty to tackle those inequalities. What will they think of that?

[Chris Skidmore]

We have already heard one Labour Member say that she welcomes the new measures on health inequalities, so it is a shame that the legislation could be repealed in its entirety.

Last week, Labour Members committed themselves to re-establishing primary care trusts and strategic health authorities—to reconstituting the NHS as if time had stood still, with middle-level management holding the reins. It is remarkable that Labour is not the party of the NHS patient but has become the party of the PCT, the SHA and, above all, the NHS manager.

[Grahame M. Morris]

On the hon. Gentleman’s point about efficiency, costs and so on, I draw his attention to an article in The Guardian today which says that the cost of replacing with a locum GPs who are away on clinical commissioning duties is £123,000 a year, while one clinical commissioning group has reported that 15 local doctors are each spending two days a week away from their surgeries. How is that an efficient use of resources?

[Chris Skidmore]

We are reinvesting the billions of pounds saved on managers into front-line care, and that is why we have already seen over 5,000 new doctors working on front-line services this year. I understand where the hon. Gentleman is coming from in terms of the political spectrum, but I believe that he is referring to a TUC press release that The Guardian published in full.

In a previous debate, the right hon. Member for Leigh said that he would put a cap on private practice in “single figures”. That would take the NHS backwards from its current position, and it is an arbitrary cap based on ideology, not on what is in the best interests of NHS patients. Nor is it in the interests of some of our best-loved hospitals. Dr Jane Collins, the chief executive of Great Ormond Street hospital, has said:

“The lifting of the private patient cap would allow us as a Foundation Trust to treat more patients, but also, through re-investment, to help more NHS patients.”

So Labour has set its face against Great Ormond Street hospital: well done!

We need a constructive debate about what needs to be done for patients in the 21st century. The right hon. Member for Leigh should stop using the shroud-waving language that he used today in stating:

“Time is running out for the NHS.”

In December last year, he said that there were 72 hours to save the NHS. What happened? He should beware, above all, of becoming the boy who cried wolf. I believe that this Bill will improve the NHS. I sincerely urge him to base his argument not on intuition but on facts, and, for the sake of patients, not to turn his back on reform that he once believed in and should go back to believing in.

Adult Social Care

Chris Skidmore Excerpts

Thursday 8th March 2012 Commons Chamber

[Chris Skidmore (Kingswood) (Con)]

I start, like others, by congratulating my hon. Friend the Member for Truro and Falmouth (Sarah Newton) on securing this debate, bringing out the urgent need to tackle the issue of the future of social care, and ensuring that we face up to the responsibilities of looking after the elderly of today and tomorrow. We have heard humble messages from the Minister and the shadow Secretary of State about their willingness to work together. The spirit of cross-party agreement is encouraging.

As the right hon. Member for Leigh (Andy Burnham) said, these issues go right back to Beveridge in 1942, when the average life expectancy was 69 and social care was not an issue to be considered within the realms of the state. The right hon. Gentleman mentioned the “sixth giant”, and he is right that we need to revisit Beveridge for the 21st century and perhaps to look again at what Beveridge considered to be most important—the contributory principle. The contributory principle for social care will be all-important when we look at how to deliver social care reform.

As we know, reform is desperately needed. The arguments over the funding of our social care system are well practised, but let us rehearse some of the statistics, which are becoming more familiar with every debate we hold. The number of those aged over 85 will double by 2030, and during the course of this Parliament alone, more than 1.4 million people will turn 65—one in 10 of whom will have a long-term care need that will cost more than £100,000. We should also make it clear that this problem is not unique to the UK. Germany and Japan have recently taken radical action to reform their systems. However, the UK has a specific problem that makes finding a solution to the ever-growing problem of social care particularly difficult: most people simply do not understand the system. They do not understand that social care and the associated costs of getting older are not free, as the Minister stated, and nor have they ever been.

That point was made in the Dilnot report, and it cannot be stressed enough. I wish to highlight two of Dilnot’s recommendations. First, he states:

“To encourage people to plan ahead for their later life we recommend that the Government invests in an awareness campaign.”

Secondly:

“The Government should develop a major new information and advice strategy to help when care needs arise.”

The acknowledgement that more needs to be done to inform the public is welcome. In reality, until one is forced to interact with the system, there is a serious lack of information compounded by an assessment procedure that is often unrealistically complicated. For many elderly people, part of the shock that comes from being forced to sell their house to pay for care is the unexpected nature of that situation. In some respects, we are facing a problem of responsibility and of planning ahead. Although people are now accustomed to the idea of preparing for their old age with regard to pension provision, there remains an aversion to preparing for the eventuality of future frailty and ill health. Few of us wish to admit that we will grow old and frail and need help and support, before it is too late.

The solution to the funding crisis brought on by an ageing population will inevitably require individuals to pay more, and from an earlier age. Whatever we do to change the current system, it is absolutely essential that a much clearer picture of the relationship between contribution and entitlement—precisely as Beveridge set out—is at the heart of that.

Reform requires realism. Even if the Dilnot proposals are implemented in their entirety, they will not provide the full solution. Whatever cap on care costs is set, domiciliary care costs and annual living costs are not taken into account. A new system that is able to lever more private funding into the system will ensure that we can provide the best deal for the elderly, but it will require an understanding that we need to grow an insurance market to maturity that is then sustainable in the longer term. That will not happen overnight. This is a process that will take between 10 and 20 years.

The current Government have taken the first important steps to reforming the system. As hundreds of billions of pounds are being talked about in respect of the current euro crisis, it is easy to forget that the Government’s decision to give an additional £2 billion a year to social care in the 2010 comprehensive spending review was the greatest ever increase in social care funding, and will lead to a vast increase in resources. We are investing more than ever before in carers and respite care, recognising the huge contribution that they make to our country, selfless in their service to their partners, parents, families and relatives.

In addition, a greater focus on personalisation and individual budgets, combined with an increased use of resources such as tele-health, will put more control over care into the hands of individuals, ultimately allowing new providers to provide more tailored services, thereby driving down costs at the same time as improving quality. Placing the person at the heart of their care has the potential to transform social care services, which for too long have been led by inefficient monopolies.

The Prime Minister’s recent call for greater integration of health and social care is equally welcome. I am a member of the Health Committee, and we called for that in our recent report. If we fail to address the social care problem, the NHS will end up picking up the tab. Every unplanned hospital bed admission for the elderly is a mark of the failure of social care to prevent that from happening in the first place. We know that if we can reduce demand for hospital beds by just 10%, that could free up £1 billion that could then be redirected into community-based care services. We must recognise that hospital is not always the best place for care to take place and redirect resources to reflect that.

In preparing for the Committee’s social care report, we visited Torbay, and I was particularly struck by the experience of integrated care there. Torbay’s primary care trust and adult social services have been combined into Torbay Care Trust, following which five integrated health and social care teams were established. They seek to be proactive in managing patients and to work in partnership with GPs. In Torbay, a team was also introduced that was specifically charged with monitoring patients in hospital and discharging patients where there is pressure on beds—again, the team is working closely with clinical professionals. That has helped to cut out unnecessary lengthy hospital stays and delayed transfers of care. As a result, Torbay now has the lowest use of hospital bed days in the south-west region, as well as the best performance on the length of stay. The chief executive of the NHS, Sir David Nicholson, has said:

“I have seen the future and the future is Torbay”.

He did so because it is the elderly who will benefit most from integrated care. Complex long-term conditions complicated by age can be properly managed only with a collaborative approach.

[John Pugh (Southport) (LD)]

Torbay has, for some time, been a model of good practice and the fact that this good practice has not spread much further than the confines of Torbay is something of an enigma. Would the hon. Gentleman care to comment on that?

[Chris Skidmore]

Torbay was one of the sites for the pilots set up in alliance with Kaiser Permanente, which came over in 2003. Interestingly, it is instructive that one of the problems the NHS faces as an institution is that, although it creates fantastic pilots and the NHS innovation centre is working hard on rolling them out across a wider area, that process encounters significant delays. Good models of care should be spread out far more widely and far faster.

What most elderly people want from their health care system is simplicity. They do not want to be moved around constantly from pillar to post, waiting for specialists to see them; they do not want to see a host of different medical professionals, each of whom is unfamiliar with their case; and they do not want to languish in hospital beds when they could be more comfortable at home. The most important change must be a cultural one. There may have been a tendency in the past for health care to be reactive, responding to medical crises as they arise, but the future must be very different. To paraphrase John F. Kennedy, we do these things not because they are easy but because they are hard. We know that we face a challenge that will define the landscape of health and care for the decades to come—it is a challenge that all in this House cannot be willing to postpone.

Health and Social Care Bill

Chris Skidmore Excerpts

Tuesday 28th February 2012 Commons Chamber

[Mr Lansley]

I think I made that perfectly clear not only in the course of the initial consultation on the White Paper, but then through the NHS Future Forum. Many thousands of NHS staff contributed their views to the NHS Future Forum, which made many recommendations and we accepted them all.

[Chris Skidmore (Kingswood) (Con)]

Is it not the case that the text of the letter merely reflects the Government’s amendments on Lords Report? The Opposition really should have done their homework, because it has been on the website since 1 February. They are four weeks out of date.

[Mr Lansley]

My hon. Friend is right up to a point. On Report in the other House, amendments reflecting the debate in Committee will be tabled. They might not all be Government amendments, but I am looking forward to constructive amendments. As I have said, if amendments from Liberal Democrat or indeed Labour peers are constructive and will help to improve the Bill, we will accept them.

NHS Risk Register

Chris Skidmore Excerpts

Wednesday 22nd February 2012 Commons Chamber

[Chris Skidmore (Kingswood) (Con)]

It is a pleasure to follow two of my fellow Health Committee members. The Chairman of the Committee wrote to the Secretary of State on 16 November 2011 to ask for the Government’s reasons for not publishing the risk register. In response, the Secretary of State wrote:

“It is important to understand that the risk register sets out all of the potential risks identified by the Department of Health for the entire range of areas for which it is responsible. These include financial risks, policy risks and sensitive contractual risks. It is a means by which the Department focuses on risks and acts to mitigate them. If the Department were to release risk registers in the future, there is a genuine possibility that the most significant risks will no longer be recorded, and no solution or mitigating action will therefore be identified. Any action that could deter staff from articulating and addressing business risk to their senior management and ministers carries with it the potential for highly damaging consequences.”

That is remarkably similarly to an answer given in Hansard on 23 March 2007 by the right hon. Member for Leigh (Andy Burnham) in response to a parliamentary question tabled by my hon. Friend the Member for South Holland and The Deepings (Mr Hayes). The right hon. Gentleman stated that the Department’s risk register dealt with

“emerging risks to the Department’s programme and the national health service, and what can be done to control and mitigate these risks. It also informs discussions between the Department and top management in the NHS about addressing key issues in policy, resourcing and service management. Putting the risk register in the public domain would be likely to reduce the detail and utility of its contents. This would inhibit the free and frank exchange of views about significant risks and their management, and inhibit the provision of advice to Ministers. We therefore cannot agree to place a copy of the current version of the register in the Library.”—[Official Report, 23 March 2007; Vol. 458, c. 1191W.]

We had a similar example on 31 July 2008, when the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) responded to a freedom of information request by stating:

“Putting the risk register in the public domain would be likely to reduce the detail and utility of its contents. This would inhibit the free and frank exchange of views about significant risks and their management, and inhibit the provision of advice to Ministers.”

The Department of Health also refused a freedom of information request for copies of any presentations given by the director of public health concerned with the risk of not delivering on targets to reduce health inequalities, so it is not only risk registers that the Department has previously refused to reveal.

Members have talked today about the risk register in apocalyptic terms, as though it were a document that should remain within the confines of MI5 or MI6. The Health Minister, Earl Howe, has revealed details of the broad issues that are covered by this risk register. I should like to read them out, so as to set the debate properly in context. They include:

“how best to manage the parliamentary passage of the Bill and the potential impact of Royal Assent being delayed on the transition in the NHS; how to co-ordinate planning so that changes happen in a co-ordinated fashion while maintaining financial control; how to ensure that the NHS takes appropriate steps during organisational change to maintain and improve quality; how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively, including the risk of replicating what we already have; how to minimise disruption for staff and maintain morale during transition; how best to ensure financial control during transition, to minimise the costs of moving to a new system, and to ensure that the new system delivers future efficiencies; how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board; how stakeholders should be engaged in developing and implementing the reforms; and finally, how to properly resource the teams responsible for implementing the changes”.—[Official Report, House of Lords, 28 November 2011; Vol. 733, c. 16.]

[John Healey]

The hon. Gentleman is right to draw the House’s attention to that fact, but does he accept that that is information that has not been published elsewhere and that the Secretary of State’s argument that the impact assessments that have been published are sufficient therefore simply will not wash?

[Chris Skidmore]

It is interesting that the right hon. Gentleman raises that point, because Earl Howe was mentioning the transition risk register, which is continually updated. That is an important point, because the appeal to the Information Commissioner to release the risk register was made on 29 November 2010, in the autumn when the register was live. The Information Commissioner made his ruling based on the fact that there was an issue of public interest at the time of the request. If the risk register is released today, it will be the risk register from autumn 2010 rather than that from February 2012. That is the moment when the wheels come off the bandwagon. The Opposition are asking the Information Commissioner to release the risk register from autumn 2010, not the risk register from February 2012. The risk register that would be released is that from the time of the White Paper, before the changes were made and before the listening exercise. It is complete nonsense. If the document was released, it would be out of date, inaccurate and would scaremonger among the population.

[John Healey]

So the hon. Gentleman agrees with Lord Henley, the Minister in the House of Lords, who told the House in January that if the Government lose the appeal next month they will publish not only the risk register from November 2010 but the updated risk registers, too?

[Chris Skidmore]

The Government do not have to publish the updated registers on the basis of the Information Commissioner’s verdict, which was on the autumn 2010 register. That is the Information Commissioner’s advice that is referred to in the motion. The Opposition are asking for an out-of-date document—we might as well give up and go home.

[Rosie Cooper (West Lancashire) (Lab)]

Is the hon. Gentleman aware of the comments made by David Nicholson, the chief executive of the NHS Commissioning Board, who said:

“I’ll not sit here and tell you that the risks have not gone up. They have”?

[Chris Skidmore]

I am, as I have the parliamentary Labour party brief—I can see that that is on the back of it.

[Mr Robert Buckland (South Swindon) (Con)]

My hon. Friend’s point about the Information Commissioner’s decision is vital, because the public interest test is the test applied at the time of the request. That makes the decision interesting but, frankly, historical rather than relevant to the issues raised by Members today.

[Chris Skidmore]

Absolutely. We are debating whether we should release a register that is no longer relevant and that was written in autumn 2010, at the time of the request on 29 November. The topic is completely irrelevant, as the debate has moved on. We ought to be talking about reform and why we need it. We have wasted six hours of parliamentary time today discussing an out-of-date risk register.

[Margot James (Stourbridge) (Con)]

Does my hon. Friend envisage that some of the amendments and changes to the Bill that the Government have introduced since that time would deliberately have taken account of some of those risks and that the situation would therefore have moved on?

[Chris Skidmore]

Yes, the situation has moved on. We have had the listening exercise under Steve Field and various Select Committee on Health reports. The name of the commissioning bodies, which were called consortia, has changed. Nurses have been added and we have opened things up so it is not just about GP commissioning.

[Yasmin Qureshi (Bolton South East) (Lab)]

If the register is as irrelevant as the hon. Gentleman says, why not publish it?

[Chris Skidmore]

The Opposition are asking—[Interruption.] The shadow Secretary of State has already said that risk registers should not be published because they are confidential documents that must be used by policy makers. The Opposition are asking for a risk register that is out of date when what we should have been discussing today was reform of the NHS and how we can deal with an ageing population at the same time as dealing with a rise in chronic diseases.

I thought that it was striking that the shadow Secretary of State said at the end of his remarks that he would put the NHS first, without any mention of the patients. That is what these reforms are here for. They are allowing patients to be put in the driving seat and to sit down with their doctor, to understand what treatments they need and to have a choice of treatment through the opening up of providers. We could have had that debate—we could have spent six hours discussing that instead of this irrelevant document that you want to have a look at, which is out of date and from November 2010 when it is now February 2012. You are two years out of date, you are out of time and you are out of touch. I urge everyone to vote down the motion, simply because it falls outside the point.

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. I remind the hon. Gentleman that I am not out of touch, and I am sure that he was not suggesting that I was. Others might think so, but I want to reassure him that I am not.

Oral Answers to Questions

Chris Skidmore Excerpts

Tuesday 21st February 2012 Commons Chamber

[Paul Burstow]

I have not had such conversations with the university to which the hon. Gentleman refers. However, this Government, right from their first Budget, have indicated their commitment to prioritising research into dementia—both the basic research that gives us the targets for detailed research and the translational research. We have put in place all the building blocks that will allow this country not only to maintain its pre-eminence but to accelerate the pace of research.

[Chris Skidmore (Kingswood) (Con)]

14. What progress he has made on reducing the costs of PFI schemes in the NHS.

[The Secretary of State for Health (Mr Andrew Lansley)]

We have made a lot of progress. All PFI schemes are having their contracts reviewed for potential savings following a Treasury-led pilot exercise. We are providing seven of the worst affected PFI schemes with access to a £1.5 billion support fund, and we are working with 16 other trusts to address long-term sustainability. As I said, in November last year the Treasury announced plans for a complete reform of the current PFI model, using public-private partnerships, private sector expertise and innovation, but at a value-for-money price for the taxpayer.

[Chris Skidmore]

I thank the Secretary of State for that answer. The new Southmead hospital in Bristol will cost over £400 million, to be funded by PFI, yet it will take over 30 years, at £37 million per year, to pay that off. That cannot be good value for money for the taxpayer or for the NHS. What more can the Government do to ensure that these contracts can be renegotiated in future?

[Mr Lansley]

My hon. Friend will be aware of the difficulties involved in the contracts that we inherited; that is true for PFI, as well as for the NHS IT contracts and many others. We have to try to use PFI contracts more cost-effectively; on average, the Treasury exercise demonstrated a 5% saving on their costs. Beyond that, we have to ensure that from now on the NHS delivers a much more value-for-money approach to using private sector expertise, including proper transfer of risk.