Health and Social Care Budgets

Meg Hillier Excerpts

Tuesday 14th March 2017 Westminster Hall

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

I beg to move,

That this House has considered budgets for health and social care.

It is a pleasure, as ever, to serve under your chairmanship, Mr Bailey. I thank the Backbench Business Committee for granting this important debate about the funding of health and social care. I pay tribute to my fellow Committee Chairs—the hon. Member for Totnes (Dr Wollaston), Chair of the Select Committee on Health, and my hon. Friend the Member for Sheffield South East (Mr Betts), Chair of the Select Committee on Communities and Local Government—for their work, including with my Committee, to shine a light on the challenges of funding our health and social care system for the next generations. I also pay tribute to the Select Committee on Public Administration and Constitutional Affairs for its work in this area. The fact that four Select Committees, and three in particular, are focusing their attention on the issue demonstrates its importance to the nation and to the long-term health of our citizens.

The Public Accounts Committee’s view and concern, which is well documented in a dozen reports produced by us in this Parliament alone, is that there is a challenge with the funding settlement for the national health service. I will not repeat all the arguments that I made in the Chamber during the debate on the estimates the other week, but we are also in the grip of a crisis in social care. The NHS accounts are showing the strain again as we approach the year end.

Last year, as I am well documented as saying, the Comptroller and Auditor General put an extraordinary commentary on the Department of Health accounts, which were laid on the last day of Parliament’s sitting. Extraordinary measures were taken to get them into balance—again, I will not mention them all, but it was a difficult adjustment. The permanent secretary at the Department of Health has acknowledged that that was not good enough, and that such one-off measures should not be repeated. We are now hearing concerns that NHS trusts are delaying paying their suppliers in order to ensure that their budgets balance. We know that, once again, capital funds will be raided and converted into resource funding to keep the NHS on track.

My Committee has discovered that funding in every area of the NHS is facing increasing demand, including specialist services, diabetes and discharge from hospital, which we have considered. The increasing age of the population and advances in medicine mean greater demand on our national health service. When the Government tell us that they are putting more money into the NHS, we must treat that with caution: more money without consideration for the number of people using the service and those who will need it in future is not always enough. Not only is the money not meeting current need, but it will not meet the growing demand.

I will speak briefly, as I am aware that 15 or so Members are scheduled to speak in this debate. The Budget came up with some solutions, as the Chancellor sees them, for funding the NHS. Our concern is that, once again, piecemeal funding is being offered rather than long-term solutions. The Chancellor talked about putting £2 billion into social care, £1 billion of it in the next financial year, starting in April. However, the Local Government Association estimates that more than £1 billion every year is needed to fund the gap in social care. The 2% council tax, often vaunted as a great solution, is a challenge in some areas, particularly where the council tax base is low. My own local authority has increased council tax to cover it, which of course means that local taxpayers are helping fund the system.

[Catherine McKinnell (Newcastle upon Tyne North) (Lab)]

I congratulate my hon. Friend on securing this important debate. Dementia Care, a charity based in my constituency, has deep concerns about the current and future funding plans for social care. Dementia Care believes, and I agree, that funding should be based on need, not on a local area’s ability to raise council tax, which clearly disadvantages people in areas such as Newcastle. I know that my hon. Friend shares this view, but I wanted to reiterate on the record that charities providing vital services up and down the country share her concerns.

[Meg Hillier]

I know that my hon. Friend the Member for Sheffield South East will discuss the funding of social care in more detail.

[Caroline Lucas (Brighton, Pavilion) (Green)]

I, too, congratulate the hon. Lady. Does she agree that Ministers are engaged in wishful thinking? The ability to reduce the number of hospital beds relies on the availability of better and more social care, yet in Brighton our sustainability and transformation plan footprint means that we are being forced to find another £112 million in efficiencies specifically in social care. It just does not add up, and it is not sustainable.

[Meg Hillier]

One concern that our Committee has uncovered is the pressure to make 4% efficiency savings. That figure was used in the last Parliament, but has now been acknowledged to be too stiff a target. However, we are also seeing a move to 4% efficiency savings in STPs. That is challenging to achieve while going through transformation. One would expect the Public Accounts Committee to be no slouch in considering where efficiencies can be found, but even with efficiencies there is just not enough money in the system. It is being squeezed.

One welcome aspect of the Budget—I hope that the Minister can give us more detail—is that there will be a Green Paper later in the year on the future funding of social care; again, I know that my hon. Friend the Member for Sheffield South East will want to talk more about that. There are also other bits of money: £100 million to support 100 new on-site GP triage projects at accident and emergency departments in hospitals in time for next winter; £325 million in capital funding to support the implementation of sustainability and transformation plans that are ready to proceed; and a multi-year capital programme for health. That all sounds like a lot of money, but relative to the total NHS budget, it is a very small amount, and the concern is that it is not long-term and sustainable. That is what our Committee said. A long-term plan is necessary for funding the NHS.

After looking at this year’s accounts, we are concerned about the number of trusts in deficit; perhaps the Minister can update us on that. As of month 9 of this financial year, 74 of 238 trusts were in deficit, to the tune of £886 million total. Granted, that is less than the £2.5 billion last year, but it is still not a healthy situation. Raiding capital funds to pay for resource and other such measures is just not acceptable in the long term.

[Jason McCartney (Colne Valley) (Con)]

I commend the hon. Lady on working cross-party to find long-term solutions for the huge issues facing social care and the NHS. She highlighted the fact that capital money has been transferred to revenue. Does she agree that in places such as Huddersfield, in my area, that makes the prospect of looking for another disastrous private finance initiative deal to fund capital improvements more likely? The disastrous PFI at Halifax is now dictating disastrous changes at Huddersfield; services are being moved to fund that PFI deal.

[Meg Hillier]

The hon. Gentleman rightly highlights that the NHS is not new to challenges in dealing with capital projects. One of our concerns about taking out capital is that NHS buildings and equipment will deteriorate, costing more in the end. That is not good value for money, which is what my Committee considers. We should all be watching the situation. The consequences might not be apparent today, but they will become so as time goes on, and we as parliamentarians need to keep a close eye on what is happening in our local area. I am glad that the hon. Gentleman is doing so.

I will finish, as I am aware that an awful lot of Members want to speak. We must not forget that the situation has an impact on patients. For instance, the target for accident and emergency waiting times is 95%, but actual performance is just under 87%. Diagnostic waiting times have risen from 1% to 1.68%, and referral to treatment within 18 weeks has not reached its 92% target; it is just under 90%, at 89.41%. The number of people waiting more than 52 weeks for referral to treatment is 1,220. Those are just some of the figures demonstrating the impact of how NHS and social care finances are being managed and what is happening to patient outcomes.

[Ms Margaret Ritchie (South Down) (SDLP)]

I congratulate the hon. Lady on securing this much needed debate. Does she agree with me and other stakeholders that a comprehensive review is needed in which everybody—stakeholders, the Government and the Opposition—works together to find a way forward for a comprehensive funding solution?

[Meg Hillier]

The hon. Lady neatly brings me to my conclusion. That is what we need: a long-term, sustainable future for our national health service. The present situation will not last from Parliament to Parliament and from one governing party to another. We need to agree a way forward and have a national conversation. We did that with pensions. It was difficult, but we got there—I know that there are still issues, but we reached cross-party agreement. We cannot chop and change, and we cannot have Governments pretending that throwing a little bit of money at the problem in a Budget is a solution. We need a long-term, sustainable solution and a national conversation about what the NHS will deliver and what outcomes we want to achieve.

[Several hon. Members rose—]

--- Later in debate ---

[Meg Hillier]

I thank all hon. Members for their contributions to this thoughtful and reasoned debate. I do however need to challenge the Minister on his suggestion that there was strong support for the Budget measures. Let us not overplay it: there were “buts” in the speeches of nearly all hon. Members. Therefore, while those measures are a help, I think everyone agreed that they are not sufficient, because that is not long-term funding.

Let us be clear. We have had short-term funding though the better care fund, a recent announcement on money for GPs at A&E, the cash injection of £2 billion for social care front-loaded for the next financial year, and a precept increase of 2%. None of that is long-term sustainable funding. Let us also nail the issue of the £10 billion with which the NHS plan has been resourced. That has now been stretched by the Government over a six-year period, not five years—both my Committee and the Health Committee have highlighted that—while they continue to seek a 4% efficiency saving. It is not just the Select Committees saying that; the Comptroller and Auditor General said of the NHS accounts that there is not yet

“a coherent plan to close the gap between resources and patients’ needs.”

Ministers really need to get a grip on that.

Will the Minister write to the Select Committee Chairs, outlining in more detail not just the timescale for the Green Paper’s publication but the proposed plans for discussions around that and when it will be taken further forward? Will he also write to us about the Care Act, phase 2, which has come up in the debate, albeit not mentioned directly? The permanent secretary at the Department of Health could not give an answer to our Committee. He talked about it being postponed, possibly to 2020. It would be helpful if the Minister would write to say what is happening with that element of the Care Act.

There is a strong view that there is a need for a long-term solution, and the Budget measures are not yet that. Health and social care are interconnected, and hospitals are not a great place for older people to be in. We need to ensure that we have a long-term sustainable solution to keep people out of hospital, keep them well as long as possible and keep them independent. That requires long-term thinking, not the sticking-plaster measures that we keep seeing unveiled by all Governments at the time of elections, especially in the light of cuts.

Motion lapsed (Standing Order No.10(6)).

Health and Social Care

Meg Hillier Excerpts

Monday 27th February 2017 Commons Chamber

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

May I pay tribute to the Chair of the Health Committee for her sterling work in this area and to the Chair of the Communities and Local Government Committee? Our three Committees are united in the view that we need to bring the agenda of how we fund health and social care to the front and centre of this House and this Government. It is important that we work together on that. It is quite unusual for three Select Committees to co-ordinate in such an effective way—at least we hope it is effective. Ultimately, the proof will be whether this view will bite with Government.

We are clear that integration of health and social care is vital. In fact, we rushed to the Chamber from Committee Room 6 where we were debating the first phase of the better care fund, which had been used as a way of taking health money to prop up the social care budget. Amazingly, the head of NHS England and the Department of Health, who were appearing in front of us, denied that there was any failure in the better care fund. They said that there were not really any targets; it was all about taking money from one pot to pay for another. If that does not underline the challenges that exist in the many initiatives that are coming forward and the lack of sustainability for long-term funding, I do not know what does. I echo the comments of the Chair of the Health Committee that we need a long-term generational shift in how we are going to deal with this matter. We cannot just keep lurching from crisis to crisis and funding situation to funding situation.

My Committee looks very closely at accounts for many Members of this House. It may not be the most enjoyable bedtime reading, but we lap up the accounts of different Government Departments. We were disappointed that the Secretary of State laid the NHS accounts on the last day of the parliamentary term in July. When we opened them, we realised why: those NHS accounts were within target only by a smoke and mirrors approach and a series of short-term, one-off measures to ensure that they balanced.

I remind the Under-Secretary of State for Health, the hon. Member for Warrington South (David Mowat), that last year the Public Accounts Committee, of which he is a former member and therefore is doubly thoughtful on this subject, gave the Department a yellow card warning that, if in 2016-17, these similar one-off measures and a similar approach to the Budget were carried forward, we would be giving it a red card. The Comptroller and Auditor General, Sir Amyas Morse, issued an unprecedented warning in those accounts, which had been audited by the National Audit Office, and laid out his serious concerns. As he told us, he walked down Whitehall to talk to the permanent secretary at the Department of Health to make it clear that he was concerned about those one-off measures.

To help the House, I will lay out how it was that, by some miracle, the Department managed to balance its books last year. First, £2.14 billion was set aside for sustainability and transformation funding, £1.8 billion of which was used to cover hospital trust deficits. The Department of Health did not notify the Treasury of the additional £417 million of national insurance receipts that it had received. It said that it was just a one-off reporting error. I am heartened to see that, in the current estimates, such a practice does not recur.

There was also a one-off super dividend of £100 million for the Department from the Medicines and Healthcare Products Regulatory Agency. That large cash balance was put into its capital departmental expenditure limit budget, which helped it to reach a final balance. Critically, it seems that this is becoming a long-term strategy for NHS budgeting—I hope the Minister will take this seriously and respond. As the Chair of the Health Committee has highlighted, we are seeing a trend of capital funding being pushed into revenue to keep the system going. That is not sustainable. Last year, in 2015-16, the Department of Health transferred £950 million of capital to revenue. The supplementary estimate that we are debating tonight shows that the Department will transfer some £1.2 billion of capital to revenue funding this year—so £250 million more than last year.

[Bill Wiggin]

I am particularly interested in the private finance initiative element of the capital funding, because certainly, for all the years that I have been a Member of Parliament, the PFI burden on Hereford hospital has always held it back. Has the hon. Lady’s Committee had a chance to look at that?

[Meg Hillier]

We have not looked at that directly, but we know that the biggest revenue cost for hospitals is staffing, which is followed, for some hospitals, by servicing a PFI deal. Early analysis suggests—I would not want the House to lay too much on this, because it comes from conversations I have had with auditors—that the challenge is that the cost of refinancing those PFI deals can swamp the potential savings. Perhaps Ministers could look into that further. A lot of technical work has been done to attempt it. The British Medical Association tells me that spreading the payback period over a longer time would reduce the day-to-day resource costs for hospitals, so that might be a way forward. However, I speak from work I have done outside the Committee Room, rather than strictly through the work of the Public Accounts Committee and the National Audit Office.

The supplementary estimate this year is worrying. The trend is going in the wrong direction for taking money out of the capital spend. As the hon. Member for North Herefordshire (Bill Wiggin) highlighted, a lot of the transformation in the NHS will require the reconfiguration of buildings and estate. Those sorts of capital expenditures are important to save money in the long term, so the estimate really is very short-sighted.

If we look at how NHS trusts are managing with their deficits, again we see a worrying trend. At the beginning of this financial year—2016-17—NHS Improvement committed to ensuring that the provider sector deficit did not exceed £580 million at the end of the year, which is now in a month’s time. However, NHS Improvement forecast a deficit of £644 million in quarter one. Its forecast declined further to a deficit of £873 million in quarter three. That pledge did not amount to very much, and it is moving very much in the wrong direction. NHS trusts have been overspending by approximately £300 million a quarter throughout this financial year. If that trend continues into the final quarter of the year, the overspend will be close to £1.2 billion. I have laid out the reality very starkly by picking out uncertain elements in the Department of Health’s consolidated accounts.

We hear a lot of discussion about how much money the Government are putting into the NHS. The Committee had an unedifying experience at a hearing on 11 January, in which the head of NHS England came before us on the very day that anonymous briefings in the national press from sources at No. 10 criticised him and NHS England. He defended his position in the Committee but, frankly, patients do not want anonymous briefings from people to save face when the Committee is actually looking at saving lives and treating patients. They do not want to see a ding-doing about the money. They need to know that the people running our health service, and the Government overseeing and channelling taxpayers’ money into it, are committed to long-term patient care and tackling future long-term challenges.

Let us be clear that protecting the NHS England budget is not the same as protecting the health budget. As the hon. Member for Totnes mentioned, Public Health England and Health Education England are being squeezed, and social care budgets—although not a direct national health cost—went down by 10% in the last Parliament. There are some clever measures by Ministers, saying, “Put up your council tax precept and it’ll all be fine.” That is still taxpayers’ money being found from somewhere to go some way towards solving the problem, but it will not solve it in the long term. Unless we tackle social care and health together, we will have an unsustainable future. There is too much robbing Paul to pay Paul—shifting money from one bit of the budget to another in a clever way that is not transparent to most people out there because it is buried in big numbers.

[Seema Malhotra (Feltham and Heston) (Lab/Co-op)]

My hon. Friend is making a thoughtful and evidence-rich speech, as always. One issue that is not often talked about, but that appeared in the media again today, is the rise in physical attacks on NHS staff. The budget of NHS Protect, which deals with a lot of security issues, is also being cut. That is part of creating the perfect storm, with evidence that a lot of perpetrators of such attacks are those with mental health issues. Unless we have the resources for an environment in which we keep NHS staff safe, the issue could get worse.

[Meg Hillier]

My hon. Friend makes her point well. It is important to protect staff. I echo the comments of the Chair of the Health Committee that staff cost more than anything else in the NHS and provide the direct patient care that is so important to its long-term sustainability. I will touch on workforce planning in a moment.

[Mr Jim Cunningham]

There is another dimension, which is that some people with mental health problems turn up at A&E units because there is no other place for them to go and they cannot get any other accommodation. The views and voices of the carers who look after these people are very often not listened to. I get many complaints about that.

[Meg Hillier]

That is one reason that we need to be really clear that we are looking at a long-term integrated health and social care system. Social services support should be there for people—whether they are a frail older person, someone with a particular disability and need, or someone with a mental health challenge—when they need it to prevent them from going to A&E in the first place.

[Rachael Maskell (York Central) (Lab/Co-op)]

Will my hon. Friend give way?

[Meg Hillier]

I will, but I will then make some progress.

[Rachael Maskell]

I thank my hon. Friend for her excellent speech. I am disturbed when I hear that the Government are putting more money into mental health, yet I have just received the figures on Vale of York CCG mental health funding, which will be cut in the next financial year. The budget is dropping from £46 million to £45 million next year in a city that has real challenges around mental health, which shows that services are not catching up with what the Government insist is trickling down into the system.

[Meg Hillier]

My hon. Friend puts a face on the real challenge faced by many trusts and commissioners: they are having to make choices about where to spend the money. Despite the pledges about parity of esteem, there is a squeeze on mental health funding nationally.

The reality of the overall picture is that growing demand is outstripping the ability of the NHS to supply needs, which is having a direct impact on patients. There are now longer waiting times for GP appointments. I alert colleagues to the Public Accounts Committee’s hearing on GP services next week; any thoughts from hon. Members’ areas are welcome. People are waiting longer to see specialists, with the 16-week target being breached, and A&E targets are being breached too often. There is a real challenge.

NHS Improvement is a welcome body for trying to encourage best practice, because there is regional variation. It is quite right that any body as large and expensive to taxpayers as the NHS looks to perform as efficiently as possible but, once again, we are seeing NHS Improvement mask what look like cuts. A 4% efficiency savings target is once again being imposed. It was imposed in the previous Parliament by the then Chancellor, the right hon. Member for Tatton (Mr Osborne), and was acknowledged by the head of NHS Improvement, Jim Mackey, as particularly challenging. Worryingly, the reality was that everyone in the system knew that the target was too challenging, but there is a real lack of a culture of whistleblowing and calling it out in the NHS. It is difficult for people to speak truth to power, as we see over and over again. The head of NHS Improvement again acknowledged to our Committee recently, as mentioned in our report, which was published today, that the 4% efficiency savings required as part of the transformation programme are “challenging.”

Our report also describes a worrying correlation between the financial performance of trusts and their Care Quality Commission ratings, stating:

“Trusts that achieved lower quality ratings had poorer average financial performance, and the 14 trusts rated ‘inadequate’ together had a net deficit equal to 10.4% of their total income in 2015-16.”

That is a real issue.

I will touch on workforce planning before beginning to draw my comments to a close. We hear a lot about the cost of locums. Very often in the national debate, I worry that we fixate on smaller issues when we really need to look at the bigger picture. We often hear about the very high rates per hour or per day paid to individual locums. That certainly is a problem—paying someone several thousand pounds a day or a shift seems ludicrous—but the key issue is the sheer volume of locums needed.

Each year, the trust structures are set to meet the budget sent down to them from the Department of Health—our tax money, but not enough of it. From the beginning, they are just not set up well enough to meet demand. Trusts have to buy in locums to meet the needs of their populations, but that is not sustainable in the long term. There were challenges, with a reduction in the number of nursing places in the last Parliament, which is coming through now. We have recently seen the loss of the nursing bursary, which we hope does not mean a reduction in the number of nurses in the future. However, many women, particularly lone parents, in my constituency welcome the opportunity to better themselves and contribute to our NHS by taking that on. I hope the Minister will give us an update on the numbers of people going into nursing training now and, crucially, on whether the people taking those training places will stay and work in our NHS, especially given Brexit and immigration issues.

[Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)]

My local foundation trust, Northumbria NHS Trust, has taken to training its own cohort of nurses so that local people who want to join the nursing profession will be able to do so knowing that they will be able to work in that local trust, which has a great reputation and which is leading the way on the financial and medical changes we need to see.

[Meg Hillier]

I agree with the hon. Lady. My own hospital does the same, taking on healthcare assistants and bringing them up through the system. The challenge is: how many people will be put off without that bursary payment? We need a clear answer from the Minister about what analysis was done of the impact on the workforce of that change. The amount of money involved is relatively small compared with the challenges and problems of not being able to provide a health service if we do not have enough nurses.

[Helen Goodman]

False economy.

[Meg Hillier]

It may well be, as my hon. Friend says, a false economy.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The early figures that have come out from NHS England suggest a 23% drop in applications. Obviously, that is a significant change.

[Meg Hillier]

The key thing, of course, is how that figure comes through the pipeline and how we fill the gap. While the Minister is on his feet at the end of the debate, it would be helpful if he said what analysis the Department of Health has done of the impact of Brexit and any changes it may herald for our NHS workforce, because a high percentage of them are from Europe. We are hearing the right sounds from the Government, but we have not yet had any action on securing the future of those European citizens currently resident in the UK. If the Minister is able to give us any comfort on that, it would be very welcome.

I am heartened that so many Members are in the Chamber to discuss this important issue. I should mention that the Public Accounts Committee has also been working with the Procedure Committee to try to ensure that the House can discuss the financial details of estimates rather than just the general principles, although I have obviously strayed into those, too. Hopefully, we can base these debates on the figures we have spent so much time looking at in the Public Accounts Committee. It is unedifying for the public to hear anonymous briefings and public argument; that does not wash with them. We need to be on top of this issue so that we hold the Government’s feet to the fire and make sure that, every step of the way, they know we are watching the budget. We will not let you get away, Minister, with raiding the capital budget to fund the accounts this year.

[Oliver Colvile (Plymouth, Sutton and Devonport) (Con)]

The hon. Lady is making a very interesting speech. One thing we should make much greater use of is pharmacies, especially to try to take some of the pressure off GPs. We should also ask GPs to go into pharmacies and to be located in them.

[Meg Hillier]

The hon. Gentleman makes a good point, and I visited one of my local pharmacies only a few weeks ago and saw at first hand the work it does to help ease the pressure on GPs, where people are waiting a long time for appointments, and on A&E. The Minister has taken a keen interest in pharmacies, but there is nevertheless a cut to their base budget. While we are on that point, it is interesting to note that that base amount allowed them to have the certainty to employ a member of staff to conduct appointments directly with patients. If they rely just on the revenue income they get from selling products, they cannot be sure that they can maintain that salary every year. That solid base of funding was important in a constituency such as mine, where, for all sorts of reasons—culture, language and convenience—people often find their local pharmacy more readily than they do their GP practice, and they find it very useful. The Minister therefore has questions to answer on that point as well.

A cross-party group of us recently met the Prime Minister, and I was heartened that she at least acknowledged the need to look at the long-term issues around health and social care. She has made a pledge that her adviser at No. 10 Downing Street will meet a cross-party group of MPs to discuss this issue further. I hope that heralds a change of attitude in the Government that will see no more anonymous briefing and silly bickering, but a strong, concerted effort to make sure that we future-proof our NHS for us and our children and that it is the beacon to the world that we all believe it is.

[Several hon. Members rose—]

--- Later in debate ---

[Meg Hillier]

I was going to say that this had been a good-natured and thoughtful debate. It is a shame that a Minister who is usually thoughtful has resorted to seemingly blaming NHS England for the present situation. I think it important to be clear about the budgetary position: NHS England asked for a certain amount of money, which the Government have stretched over an extra year. Money that was meant to cover five years has actually covered six, and I think it important to put that on the record.

Members of all parties have made it clear that there are long-term financial challenges to our health system, and that we must have a long-term national debate about how we are to fund a health service that is fit for the 21st century. Last year, a series of one-off extraordinary measures allowed the accounts—just about—to balance, but today Members on both sides of the House have drawn attention to the movement of the departmental expenditure limit from the capital to the resource side of the budget. According to the estimate, the limit is projected to increase to £1.2 billion. An awful lot of money is being taken out of the long-term future of the NHS to pay for day-to-day problems. That is not sustainable, and it is a great shame that the Minister did not address it. I hope that the Government will view it as one symptom of the long-term challenges of funding.

This sticking-plaster will not solve the problem, but I hope that we can move forward on a cross-party basis, despite the Minister’s final comments.

Question deferred until tomorrow at Seven o’clock (Standing Order No. 54).

Oral Answers to Questions

Meg Hillier Excerpts

Tuesday 7th February 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

I am grateful to my hon. Friend for recognising the work that went into reopening the A&E at Chorley last month. I am delighted, in particular, by the work that was done by the Deputy Speaker and my hon. Friend the Member for South Ribble (Seema Kennedy).

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

T7. Last year, hospital trusts were urged by Department of Health officials to raid their capital budgets to cover resource funding. Does the Secretary of State think that is a good way forward, and what instructions is he giving officials this year?

[Mr Hunt]

I recognise that it is not a sustainable position to have to do that. Pressures on the frontline meant that it had to happen, but we do need to invest for the future and I agree with the hon. Lady that capital budgets are very important.

Oral Answers to Questions

Meg Hillier Excerpts

Tuesday 20th December 2016 Commons Chamber

[Mr Dunne]

I agree with my hon. Friend that we need increased awareness and appropriate participation by all NHS staff in achieving this policy, but I also agree with one thing that Dr Mark Porter said—that sick and vulnerable patients must not be put off seeking necessary treatment, as this may be bad for their health and for that of the public in general. This has always been a clear feature of our policy, so to be clear, this policy does not withhold immediately necessary or urgent treatment, but it makes sure that the NHS is fairly reimbursed by those who are not entitled to free care.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

As the Minister will know, the Public Accounts Committee has looked in detail at this issue, and we were rather shocked to discover that the Government themselves are woeful at collecting money from EU citizens who use our hospitals and for whom the Government are then responsible for getting the money from their home Government. When will the Government get their act together to make sure that this money comes into our NHS?

[Mr Dunne]

I am always grateful for advice from the Public Accounts Committee, which looks into areas where the Government can recover moneys to which they are entitled. There was an article in today’s Times which referred to outstanding sums, and we are taking steps to try to increase recovery rates in the years ahead.

Reducing Health Inequality

Meg Hillier Excerpts

Thursday 24th November 2016 Commons Chamber

[Judith Cummins]

That is an interesting point. I shall deal with some of those issues later in my speech.

According to the latest figures, 32% of children in Bradford—nearly a third—have not seen a dentist for more than two years. Ideally, as Members will know, children should be given a check-up every six months.

Dental and oral health has been and continues to be the Cinderella of health service provision. It is seen as being “nice to have”—to be tackled once the good ship NHS has returned to calmer waters—and due for its much-needed extra funding only when the financial black holes elsewhere in the NHS have been plugged. Such inequality in dental and oral health is plain wrong. It is an unspoken injustice in today’s society, and the task of tackling it cannot and should not be kicked down the road like the proverbial can year after year.

Tooth decay is an almost entirely preventable disease. It is a scandal, without exaggeration, that tooth decay is the No. 1 reason for hospital admissions of children between the ages of five and nine. It is a scandal not only because it causes our children needless pain and suffering, but because, in this time of austerity, it wastes countless millions in NHS resources. However, its impact goes much deeper than that.

In an increasingly globalised and competitive world in which our children are expected to succeed at school, improve their skills and excel in internationally benchmarked exams, they all need to be healthy and energised to face the school day. Too often, however, pain arising from poor oral and dental health hinders their school readiness, impairs their nutrition and growth, and cripples their ability to thrive, develop and socialise with each other. A recent survey sadly confirmed that more than a quarter of our young people feel too embarrassed to smile or laugh due to the condition of their teeth. For our teenagers, the injustice is no less when they need to succeed and make their way in a competitive job market.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

In my constituency, I can tell the extent of someone’s poverty by the state of their teeth, so not only is there the issue of decay, but this is about not having the money to be able to get the necessary treatment—perhaps cosmetic treatment—which can then lead to embarrassment and a loss of confidence.

[Judith Cummins]

I thank my hon. Friend for making that valid and important point.

Disproportionate levels of poor oral and dental health, predominantly in deprived, low-income areas such as those in Bradford, hamper these young people from forging their careers. Survey after survey confirms that young people who suffer from poor dental and oral health face poorer job prospects. Dental and oral health plays, rightly or wrongly, an important part in selling ourselves in today’s competitive job market.

I have set out the depressing scale of the challenge, but what can we do—or, perhaps more accurately, what can and should this Government be doing—to tackle this scandalous health inequality? As I highlighted to the former Prime Minister Mr Cameron, when I challenged him about this inequality in my constituency and city, there are some simple steps that can be taken. The first of them is due to be implemented in the foreseeable future: a tax on sugary drinks. Although the Government’s final proposal was very much weaker than it should have been, it was nevertheless very much a welcome step in the right direction.

The Royal College of Surgeons faculty of dental surgery, a professional body that sees dental inequalities first hand in its day-to-day work, suggests a number of low-cost, easily deliverable measures that could readily be adopted by Government: tightening restrictions on advertising high-sugar products on television, for example by restricting advertisements before the 9 pm watershed; limiting price promotions in supermarkets for high-sugar foods and drinks, and excluding these products from point-of-sale locations such as checkouts and counters; and, most sensibly, limiting the availability of high-sugar foods and drinks in our school system.

Perhaps the most important measure that the Government could implement, as highlighted by the British Dental Association, would be to expedite changes to the current dental contract. Critical changes are long overdue, the first of which would be to incentivise preventive work through the contract. The second, and most important, would be to incentivise the dental profession to establish new practices in deprived areas. Such areas desperately need practices as people there typically face the least availability.

In my constituency, despite need being so high, there is a shameful shortfall of NHS dentist appointments. Very few NHS dentists have open lists, meaning that most people in search of dental treatment simply give up, and those who are determined end up finding a dentist outside the city boundaries. Surely that is not right. I understand that the Government hope to begin rolling out a reformed dental contract from 2018-19 onwards, but that simply is not soon enough.

I finish by asking a simple question: is it just and equitable that five-year-old children in Bradford, my home city, are four and a half times more likely to suffer from tooth decay than their peers in the South West Surrey constituency of the Health Secretary? I hope that the House agrees that the answer is no.

--- Later in debate ---

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

I join colleagues across the House in congratulating the hon. Member for Totnes (Dr Wollaston) and her Committee on their work in this area and on securing this debate. She brings a calm and clear knowledge to every health debate. We really do need a long-term vision in this area and I know that she, like me, wants to see that, whatever party is in government.

I speak today both as an MP for a constituency with large gaps in health, wellbeing and life expectancy, which are very much determined by place of birth, early years experience and poverty, and as Chair of the Public Accounts Committee, which in this year alone has published 10 reports on the national health service, some of which shine a light on this debate. Our reports show the huge pressures on the national health budget and the huge increases in demand on that budget. To take diabetes as an example, 4.8% of the population is currently diabetic, but that is set to rise to 8.8% in the next few years.

It is my role and the role of my Committee to look at funding. Specifically, our role is to look at the economy, effectiveness and efficiency with which the Government spend taxpayers’ money, so I will talk first about how we spend the money that is allocated to our health service and how that is key to tackling health inequalities. I will then turn to how we look at the impact of decisions, both in the health service and in other parts of Government, on health inequalities—what we in the Committee call “cost shunting”.

NHS budget spending is in the region of £110 billion a year. The Government are keen endlessly to remind us that they have injected £10 billion into the NHS over the six-year period to about 2016. At the same time, we see an ageing population, a large and increasing demand, including for specialised services, and a health service squeezed at each step of the journey. My Committee has heard evidence on general practice, specialised services such as diabetes and neurology, acute trusts and social care, all of which has shown the impact on the budget. That has all been caught up in what, sadly, has been a rather childish debate over headline figures and often very subtle changes in language from the Government about who is to blame. Ministers have moved from the mantra, “We’ve injected an extra £10 billion”, to saying, “The NHS has been given what it asked for”, as though they were scolding a naughty child, and, “We will manage this within the NHS”, as the Chancellor said yesterday when I asked him why he had not considered the NHS budget in the autumn statement.

In today’s Daily Mail there is an exhortation—this is quoting sources close to or in Government—that the NHS simply needs to manage its resources better and cannot endlessly be given more money. I am Chair of the Public Accounts Committee. This is taxpayers’ money. I do not think we should endlessly pour money into any Department without demanding quite a lot of it, and I am clear that there are always efficiencies to be found in a system so large and with such a large overall budget. Every pound saved is a pound to spend on something else. That is the key point. Every pound saved in the Department of Health budget can be spent on other things and ought to be spent on public health in particular. I will come on to that.

As I have highlighted, there are many pressures on the NHS budget. With all these discussions and figures being bandied around, we need to take a closer look. In 2015-16, the Department’s budget was projected to have a £2.45 billion deficit. The measures used in the last financial year to balance the budget were extraordinary and one-offs and led to an unprecedented three-and-a-half-page explanatory note from the Comptroller and Auditor General alerting all of us, particularly the Department, to his concerns that those were not replicable, long term or sustainable. He reiterated that point in a Committee hearing only a few weeks ago.

I will not spend too long on the budget figures—the debate needs to move on—but I will touch briefly on the overall figures this year for acute trusts alone. From April to September, trusts overspent by £648 million and the deficit for the first six months forecast to the year end is £669 million. This trend was increased largely because of the decision in 2011 to allow for 4% efficiency savings across the NHS by the then Chancellor of the Exchequer. Everybody in the system knew that that was not realistic on a long-term basis. People knew that there would be a problem with the budget two or more years out from the crisis in the budget settlement in the last financial year, yet there is no openness in discussing how we spend money in the NHS, what we spend it on and what we focus on.

That brings me to public health. Too often, public health budgets are raided to deal with day-to-day crises and money is taken out of NHS education. The plans for service transformation are not necessarily a bad thing, but the danger is, if they are done in the wrong climate and with the wrong tone, that they are seen as an excuse for cuts. They can be so much better for patients, especially if focused on preventive work and the more efficient spending of taxpayers’ money, but too often they will be driven by financial pressures. A lot of pressure was put on finance directors of acute trusts in particular at the end of the last financial year. Many were encouraged, for example, to move capital funding into the resources side of their budget in order to balance the books—a short-term measure that can lead to underinvestment in facilities that, if invested in, can actually save money and improve the patient experience.

This short-term, year-on-year, or even spending review period planning will not tackle health inequalities effectively. We need a longer-term approach. We need to prevent more ill health and treat fewer patients. As others have highlighted, the age of death is increasing—we have an ageing population—but the age of disability remains broadly similar. Public Health England released a report towards the end of 2015 highlighting some of these figures. The cost of treating illness and disease arising from health inequalities has been estimated at around £5.5 billion a year, and then there is the issue of cost shunting, which is a big concern.

If we do not tackle these things, it will not just be individual patients or their families who suffer, or the taxpayer funding these services; there is a wider impact on society. Productivity losses are estimated at between £31 billion and £33 billion per annum. Lost taxes and higher welfare payments cost in the region of £28 billion to £32 billion per annum.

To go back to what the hon. Member for Totnes said about smoking, if we tackle tobacco issues in my neighbouring borough of Newham alone, that would save about £61 million per annum. That would make a big contribution to the local health budget in east London. If we replicated that across just east London, just think what we could contribute to the NHS budget.

About 1.3% of workdays a week are lost to sickness in London alone, which is lower than in many parts of the country. All these things contribute to our productivity gap and have a big effect, so if we are to do what the Chancellor said yesterday and ensure that our workers produce in four days what they now produce in five, we need workers who are well and can work until the increased retirement age that is demanded. It is quite shocking that the hon. Member for Glasgow East (Natalie McGarry) and other colleagues from Glasgow represent a city where people will die before the age at which they qualify for their state pension. There are certainly many people in my constituency who face that, although they are not the average. That is a sign of the failure of preventive work to tackle health inequalities at the right point.

When it comes to joining up Government, we need to look not just at the silos in various parts of the health budget, but at ensuring a healthier wider society. Let us take, on the one hand, the land disposals that the Government are undertaking to provide public land to build new homes. My Committee has looked at that a great deal, although I will not divert the House today too much. In my area we have St Leonard’s hospital, the site of a former workhouse in Hackney. When the most recent reorganisation of the NHS took place in 2011, the site was moved to the central PropCo, the property company that the NHS holds centrally to manage its estate. We therefore no longer have local control of what to do on that site. Given the state of homelessness locally, if we could provide families with more good-quality homes on that site that were not overcrowded, we would do more for public health and health inequalities than a lot of the fiddling around we do over whether a service should be based here or there and all the treatment work we are doing.

Departments are now taking account of other “strategic objectives”, as they put it, in land disposals, but that is still ill-defined. My Committee will continue to push on this matter because from the perspective of my constituency, where we have extraordinarily high house prices, if we can release land and provide homes for key workers, that would contribute to the outcomes of those Departments. I am determined that the Government are clearer in their outcomes, because in constituencies such as Taunton Deane—or perhaps not, as the hon. Member for Taunton Deane (Rebecca Pow) highlighted—the need might be for green space or other facilities that would improve or promote health. However, if we do not have a wider view of what we are doing with our public assets, there is a danger that we will just sell to the highest bidder and lose the chance for several generations, because once land is gone, it is gone.

Finally on this issue, it is important to touch on the increasing challenge of homelessness, particularly in London and in my constituency. London households in temporary accommodation now account for around three in four of all such households in England. That is not a surprise, given increasing house prices and rents, and the impact of the benefit cap, which means that people cannot now rent a three or four-bedroom home on housing benefit anywhere in London or the south-east of England. I have people coming to see me now who even five years ago, and certainly 10 years ago, would not have come to me about their housing. They were managing okay, they were living in the private sector, they were paying their rent and they were working.

Now, one woman who came to see me had lost her job because she had been ill. She had hoped to go back to work. She had a good job with professional prospects, although not a well-paid job. She became ill and her rent went up, so she fell notionally into arrears while she was trying to find another home, as her rent was no longer covered because of the housing benefit cap. She tried to find somewhere in Hackney and the neighbouring six boroughs but could find nowhere, until eventually a landlord said he would take her in on benefits. However, because of the complexities in how housing benefit is allocated, he would not take her unless he had a guarantee a month before she moved in that she would be able to receive housing benefit. However, the system does not allow for that. As a result, a woman whose health was challenged anyway was suffering mental health issues through no fault of her own.

My constituent was of course very concerned, anxious and depressed about what was going to happen in her situation, and she is just one of many. This is the worst situation I have experienced in over 20 years as an elected member at local or national level. The stress of poor, uncertain and overcrowded housing has a huge impact on health. If someone is homeless, it increases by one and a half times the likelihood of their having a physical health problem, and it makes them 1.8% more likely to have a mental health problem, although it seems to me from my experience of speaking to people face to face that those figures are underestimates. Perhaps they mask the temporary housing problem, compared with the reality of what I am seeing. This has a huge impact, focused, yes, on the absolutely poorest, but also on people such as the woman I mentioned—people who have just hit a bit of a rocky patch in their life, where something has gone wrong and caused a spiral downwards towards homelessness.

There are so many hidden households in my constituency —families living on the sofa in the living room. It could sometimes be a family of an adult and two children in that situation while another family is living in the bedroom. For various reasons, they do not qualify for council housing, or they are on the waiting list—a bit of a misnomer when people wait a lifetime for a council property. Sometimes they cannot afford, on their income, to rent privately and they have no other options.

Temporary accommodation is now costing Hackney council about £35 million a year. I commend the Hackney Gazette, which has done a lot to highlight the conditions in temporary accommodation hostels in my borough and across London. We have the Homelessness Reduction Bill, which is passing through Parliament, but that is only part of the picture. Saying that councils must accept people who are homeless is fine, but unless we have the homes available to provide to those people at an affordable level, we will not solve this problem.

[Rebecca Pow]

I believe that the Government provided £10 million yesterday for homes, particularly in London, so things are being done and they are on the move. I just wanted to put that on the record.

[Meg Hillier]

The hon. Lady pre-empts my next point. I welcome the fact that the Government have begun to make some moves on housing, particularly taking away the “pay to stay” provisions. I am making sure that all my local housing associations are not going to buy into this on a voluntary basis—I hope they would not in London. The autumn statement freed up housing associations to use Government money for affordable housing as defined locally, rather than as set nationally. The idea that in my constituency affordable would be 80% of private rents is nonsense; it is well out of the range even of people who are well above the minimum wage. Most young people in Hackney share a home, because they could never afford to rent somewhere privately and they certainly cannot get on the housing ladder. It is going to take a generation to solve this housing problem, so although I welcome what the Government have done, much more could have been in their six years of office.

I am pleased that we now have a Housing Minister who is a London MP and who understands London issues. We London Members often speak about housing here, and it is as though we are in a different world from others. However, we have this very big problem of homelessness, overcrowding and excessive use of temporary accommodation.

Let me finish with a story that should never be true in our world. It is a story of a woman who was living with her toddler and her husband in a hostel because she was waiting to get some council housing. Even three years ago, I used to say, “Hold on and hang on in there for six months, and we’ll find a home for you.” Nowadays, it is increasingly a year or 18 months. The woman went into hospital to give birth and had to come back, with her new-born baby, her toddler and her husband, to that one room in the hostel. The people living in that hostel are among the most vulnerable—not an ideal environment in which to bring children home. Many people with a lot of problems are crowded into one place, without the support they need. This is not, I am sure, what any Member wants to see. We must tackle the issue, because the health problems that that spins off for the next generation of children are immense. I add a plea from my local constituency perspective as well as from my national perspective as Chair of the Public Accounts Committee—tackling homelessness is a vital issue to tackling health inequalities.

Oral Answers to Questions

Meg Hillier Excerpts

Tuesday 15th November 2016 Commons Chamber

[Mr Hunt]

May I commend my hon. Friend for his great persistence in flying the flag for homeopathic medicine? While we must always follow the science in the way we spend our money on medicines, as I know he agrees, he is right to highlight the threat of antibiotic resistance and the need to be open to every possible way of reducing it.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

Today I publish my first annual report as Chair of the Public Accounts Committee, in which I conclude that there is a sustainability crisis in the funding of the NHS. Surely the Secretary of State will agree—he has made some comments in the media that suggest he is becoming aware of this—that he will need to lobby the Chancellor for a better settlement in the autumn statement. Will he update the House on his negotiations?

[Mr Hunt]

I am sorry to disappoint the hon. Lady but I do not update the House on Government discussions which happen in the run-up to every Budget and autumn statement. What I would say to the hon. Lady is that I am not someone who believes that the financial pressures that undoubtedly exist in the NHS and social care system threaten the fundamental model of the NHS. What they remind us all of is that what we need in this country is a strong economy that will allow us to continue funding the NHS and social care systems as we cope with the pressures of an elderly population. That, for me, is the most important challenge—the economic challenge that will allow us to fund the NHS.

Junior Doctors: Industrial Action

Meg Hillier Excerpts

Monday 5th September 2016 Commons Chamber

[Mr Hunt]

I have a stunning new ministerial team, two of whom I am pleased to see here today, but I wish to take this moment to say how much I enjoyed working with my right hon. Friend last year. Then, as now, his advice and thoughts are very wise. The Government have made 107 concessions, and the BMA might like to think what signal it sends if that many concessions are made, an agreed deal is reached with the union leadership and the reaction then is for the most extreme strike in history to be called. What encouragement will that give to other Ministers to be moderate and reasonable in their negotiations with unions? The position being taken is preposterous and many other choices could have been made when dealing with losing the ballot, but he is right in what he says.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

A lack of workforce planning and weak financial management have led to staff shortages, which have been a major contributor to this dispute. The Department of Health accounts and NHS England accounts, which came out on 21 July, underlined that weakness in financial planning, with the Comptroller and Auditor General saying clearly that he had real concerns about the future sustainability of NHS funding. We have, however, heard the Secretary of State say again today that the £10 billion available is to solve the issue about the seven-day NHS, but we have also heard that money promised for many other things by the head of NHS England. Does the Secretary of State really have a plan for the financial sustainability of the NHS? If so, what is it?

[Mr Hunt]

We do and we are implementing it. I know that the hon. Lady has looked at this in great detail, and I simply say, in broad terms, that following the tragedy of what happened at Mid Staffs the NHS was very honest about how some of the poor care there was happening in other places and NHS trusts decided that they needed to have more staff in their hospital wards. The poor workforce planning that she talked about, which goes back many decades in the NHS, meant that the result was an explosion in the use of agency staff, the cost of which rose to more than £3.5 billion in the last financial year, which has put huge pressure on finances. The lesson that we must take away, not just for the junior doctors’ strike, but for financial sustainability, is that we need to be better at workforce planning and training up the number of doctors and nurses that we need.

Oral Answers to Questions

Meg Hillier Excerpts

Tuesday 10th May 2016 Commons Chamber

[Mr Hunt]

I think the hon. Gentleman is right that we have historically not trained enough staff to work in the NHS and been over-optimistic about the staff needs. That is why, in this Parliament, we will be training over 11,000 more doctors as a result of the spending review, and 40,000 more nurses.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

In the Public Accounts Committee, which I sit on with the hon. Member for Southport (John Pugh), we have repeatedly come to this question about agency staffing. The key thing is, as he says, that the establishment level for acute hospitals is always under par, because the budget set from the centre is never enough to meet it. Will the Secretary of State go and take a serious look at this issue, and stop this myth that it is just down to the rates paid? That is part of the problem, but it is not the main problem.

[Mr Hunt]

Perhaps I can give the hon. Lady some comfort. I recognise that there is a big mountain to move, but the changes we made last year were not just about changing the rates paid to agencies. They were also about capping the amounts agencies can pay their own staff, because we think it is incredibly divisive inside hospitals to have two nurses doing exactly the same work, but one being paid dramatically more than the other. We are also capping the total amount hospitals can spend on agency staff. The result is that the monthly spend on agency staff is now falling and we are on track to reduce the agency bill by about £1 billion in this Parliament.

NHS in London

Meg Hillier Excerpts

Thursday 24th March 2016 Westminster Hall

[Wes Streeting]

They may well be the judge, but I am standing down as a councillor in 2018. I was elected to Parliament while serving as a councillor, which is a good indication.

Seriously, the London Borough of Redbridge has the fourth lowest public health grant in London. Given the diversity of our population, and the pressures that that brings, it is a cause for concern. In that context, I was even more disappointed to find that the Government have cut our public health grant in-year. As a former cabinet member for health and wellbeing in Redbridge, and as the former chair of our health and wellbeing board, I know that we were already struggling to meet our statutory duties on public health, not least the new responsibilities we have been given, such as for health visiting, for which the allocation received from the Government was not sufficient. We managed to squeeze some extra funding out of the Government, but we are still struggling.

The reduction is disappointing, particularly in the context of London, where people’s healthcare needs and lifestyles are placing pressures on the NHS. Public health investment is an upfront investment in people’s lifestyles that will reduce NHS costs in the longer term, as well as improving people’s health and wellbeing. I cannot understand why, in that context, preventive budgets such as public health budgets are bearing the brunt of cuts. I hope Redbridge’s public health allocation in particular is something that the Department of Health will revisit.

I have talked about the financial challenge for local authorities, and I will now address the financial challenge facing the NHS and our local health economy. I was concerned, as everyone else was, to read David Laws’s revelation at the weekend that, far from the £8 billion that keeps being mentioned as the hole in the NHS budget, Simon Stevens actually identified a £30 billion hole, of which he said £15 billion could be found through efficiencies and improvements. My maths makes that a £15 billion hole in the NHS budget, and it is a source of concern that the £8 billion promised by the Conservatives at the last election is still not there. We have seen the Chancellor having to shuffle money around. Earlier, my hon. Friend the Member for Lewisham East (Heidi Alexander), the shadow Secretary of State for Health, talked about the reallocation from capital to revenue in terms of the health budget.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

The Public Accounts Committee recently considered the health budget following a National Audit Office report. There is a £22 billion gap, and one of the key drivers of that is the 4% efficiency savings year on year. Simon Stevens has himself acknowledged that that is too high and that 2% would be more reasonable. The head of NHS Improvement also acknowledged that it is a cause of acute hospitals’ deficits at the moment.

[Wes Streeting]

I am grateful to the Chair of the Public Accounts Committee for giving us that insight, which gives me even greater cause for concern about our local situation in Redbridge. The overall gap in funding for the NHS should be a concern to the whole country.

In my borough in particular, I am concerned by a report produced for NHS England by McKinsey & Company in, I believe, July 2014. The report has just been released by NHS England following a freedom of information request, and it identifies a Barking, Havering and Redbridge system gap of £128 million for commissioners and £260 million for providers. I am concerned by several things. One is that one way in which McKinsey identified that the BHR system will be able to address that gap is through acute reconfiguration of King George hospital, where the accident and emergency department is threatened with closure. I am deeply disappointed that, at a recent meeting of the Ilford North Conservatives attended by the hon. Member for Richmond Park (Zac Goldsmith) for his London mayoral campaign, the Conservatives once again stood up and said, “People should not worry about the accident and emergency department, because we always say it’s going to close and it never does.” The only reason why the accident and emergency department at King George hospital is still there is not because of a positive decision to keep it but because the NHS trust and the local health economy are in such a mess that it would not be clinically safe to close it at this time; the accident and emergency department is still very much at risk.

--- Later in debate ---

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Ms Buck. I congratulate my hon. Friend the Member for Ealing Central and Acton (Dr Huq) on securing the debate, and I thank the Backbench Business Committee for granting it.

I represent the Homerton hospital, which is a foundation trust, and a clinical commissioning group in Hackney that has good, clear clinical outcomes in a very deprived population. The level of deprivation is such that we have underlying population health outcomes that are not good despite the good healthcare available locally.

There is huge pressure on GP surgeries across east London in particular and London in general. Funding for the minimum practice income guarantee is under threat, and recruitment of GPs is very difficult now. Too often, committed but demoralised GPs, many of whom are older, are—in line with national trends—retiring early. We also have a devolution model that is being piloted in Hackney.

Given the time and to give the Minister the chance to respond, I will jump to some of the questions that I want to put to her. I will refer to the McKinsey report that has just seen the light of day today, although it was published in July 2015. It is very worrying. I do not have time to go into the report in detail, but it raises issues about my area that are similar to those raised by my hon. Friend the Member for Ilford North (Wes Streeting). It gives an indication of the gap in the health economy and the funding. We have looked at this type of gap in the Public Accounts Committee, holding three hearings on these issues in recent months. Those hearings have underlined the crisis in recruitment, poor retention of experienced staff and particularly the financial crisis in the NHS.

The PAC, which of course is a cross-party Committee, is not alone in looking into this situation; the National Audit Office has, too. The NAO tells us that in 2014 NHS commissioners and providers overspent for the first time, with a deficit of £471 million. It must have been around that time or before then that McKinsey was commissioned to do its work. We know that the position is deteriorating, despite the efforts of consultancies to come in and save the day—let me make it clear for the Official Report that I am being slightly ironic. The position is deteriorating so much that the total deficit in NHS trusts and foundation trusts is projected to be £2.2 billion.

As I highlighted in my intervention, in a PAC hearing on the subject, Jim Mackey, the head of NHS Improvement —we have also heard from Simon Stevens, the head of NHS England—acknowledged that the 4% efficiency savings target that was established by the Department of Health in 2010-11 was unrealistic. In fact, that target was set by the Chancellor, so I should perhaps absolve the Department of Health a little, as it was clearly set by the Treasury. Both Jim Mackey and Simon Stevens acknowledged that. Simon Stevens has said on the record that he would call delivery of 2% efficiency savings “more reasonable” for trusts. As I have highlighted, we have said in our report that there is not really a convincing plan for closing the £22 billion gap in NHS finances now looming.

I will come back to the McKinsey report as it relates to my own area, referring again to huge financial gaps in the NHS budget locally. However, it also refers to how to deal with those gaps, and that is what really concerns me and it is what I am seeking an answer from the Minister about. The report refers to the engagement that McKinsey had:

“an intensive series of meetings and engagement…with material senior time and…complemented this with numerous sessions with Chairs, CEOs, Clinical Leaders and Finance Directors.”

So McKinsey has been getting people round the table, which is all well and good. However, the report continues:

“This engagement has been focused on building alignment around the case for change”—

so change is looming—

“on forcing the pace of this work and also in scoping future governance changes to sustain more rapid future delivery.”

Will the Minister be clear about what the plans are for “future governance” of health services in my part of London? I am sure that other Members will be interested to hear about their parts of London, as well. I ask her directly: is there a plan to amalgamate CCGs or to establish sub-regional health commissioners in London? We need to know what is happening and what the timescale is for any proposed changes.

Also, while we are considering the budget and the gaps in the budget, what commitment can the Minister make about NHS land? That has been a constituency concern of mine for some time. The PAC has heard fairly recently that the capital released to balance the budget deficit that we are seeing among trusts factors in some land for homes for health workers. So the full dividend of sale will not be taken and some land will be used to build homes for health workers, but figures were very light on the ground. If the Minister is able to respond today on this issue, I would be very grateful; if not, I would welcome a detailed letter from her on it.

In particular, I would be grateful if the Minister provided more information about the list of NHS sites released under the Government’s land disposals programme. The programme was overseen by the Department for Communities and Local Government and required every Department to come up with a list of sites that could be provided to build new homes. So far, it has been difficult to identify the sale of land and how many homes have actually been built. Again, that may not be something that the Minister has answers on today, given that another Department is the lead, but I think her Department should have some figures. Once again, if she cannot tell me about that today, I ask her to write to me about it, because housing for health workers is a key concern.

[Heidi Alexander]

My hon. Friend is making a very important point. I intervene to put on the record my desire to be copied in to the response that she receives from the Minister.

[Meg Hillier]

I am sure the Minister will do that, but I am happy to share anything I receive from her. I am sure she will not be writing me secret letters, and even if she told me that she was I would ignore her, so I hope she provides information that is fully public.

There is a real concern about health workers being unable to afford to buy homes. When a group of local MPs met officials from the Barts trust after one of the trust’s more recent crises—it was around the time of, or just before, the general election—we asked them about the release of land for health workers. We got the distinct impression that those running the trust at the time—we have had new management in since—did not think that it was their responsibility to provide housing; the process was just about disposing of the land to fill the black hole in the trust’s budget. However, we know that health workers cannot afford to live in London and work locally; that is often true of doctors on good salaries, let alone anyone on a lower salary. There will be a real crisis if we cannot recruit health workers, and I will touch on that issue in a moment.

NHS England is keen to lay the blame for the financial crisis in acute trusts at the door of agency staff costs. The Secretary of State announced a cap on the pay rate in October, but the National Audit Office found that that is not the underlying problem. We also touched on the matter in a Public Accounts Committee hearing. It is the volume of agency working, rather than the rate paid, that is the bigger problem—the vacancy rate, requiring backfilling with agency workers, rather than the amount that they are paid. No doubt there is an problem there and the NHS should begin—I hope that it is beginning—to use its purchasing power to tackle that, but the foundation staffing model for hospitals, which is designed to fit the budget allocated by the Department, often has too few staff to deliver the required health outcomes. The NAO has uncovered the fact that 61% of temporary staffing requests in 2014-15 were to cover vacancies, not emergency cover.

[Mike Gapes]

Is my hon. Friend aware that the NHS employers and London NHS partnership have this week sent out information stating that nursing vacancies in London are running at 17%, which is 10,000 nurses? The NHS and local trusts are going all over the world to recruit, but the Home Office is bringing in a requirement for people to earn £35,000 before letting them in. Does not that contradict what the NHS is trying to do?

[Meg Hillier]

My hon. Friend anticipates what I was going to say—or perhaps it is just that we are all dealing with the same problems. Will the Minister outline what conversations her Department and NHS England have been having with the Home Office about the issue? We have seen many changes in the immigration rules, and they affect what happens. We should be recruiting and training British citizens and enabling them to earn a living, although I have no problem with other people working in the NHS. When we have problems with recruitment, of course it is right to look overseas, and many of our hospitals are well staffed by people from all round the world; but if those people cannot meet the threshold, they will not be allowed in, and that will cause a problem. I know that it is also causing concern to NHS England. No doubt the Minister is being lobbied; perhaps she can advise us. The cost to hospital trusts of the agency staff who fill in the gaps—they could be full-time workers from overseas or from the UK—has risen from £2.2 billion in 2009-10 to £3.3 billion in 2014-15.

I do not have much time to discuss GPs, but we know that that is a big issue, given the demand on the health service at primary care level in particular. On national figures, recruitment of new GPs is slow and early retirement is a looming crisis. If the Minister has not been alerted to that problem, I hope she will look into it. It is not a new phenomenon, but it is getting worse. Between 2005 and 2014 the proportion of GPs aged between 55 and 64 who left approximately doubled. In addition, there is an increasing proportion of unfilled training places—the figure was 12% in 2014-15—and an increasing number of younger GPs are leaving because the job is becoming untenable, with 12-hour days typical. Many GPs just do not want to do that. We need good access and support in primary care to make it work.

The Public Accounts Committee has recently looked at another issue that is worth highlighting, which is the management and supply of NHS clinical staff. We would acknowledge, although our report is not yet out, that in an organisation the size of the national health service, getting things exactly right will always be complex. The figures and the available data about who is needed, together with the problems that I have mentioned to do with GPs and recruitment of hospital and other health workers, could have been predicted. That is something on which I want the Minister to respond: surely, if there is a prediction, there is a need to be able to react quickly, so that training places are available and people are encouraged to take them up. That way, we would ensure that there were enough health workers.

To return to the issue of housing, it is at crisis point in my constituency. Someone on quite a good income cannot afford to buy or to rent in the private sector and will not have a hope of getting social housing, so we have a vast turnover of people. Young people come and live like students, but when they want a home of their own, a spare bedroom for a child, or just a lifestyle that they think befits their status and age, they move out. We have a crisis across the board, but particularly for the NHS. I hope that the Minister will answer some of my questions about how housing can become a key concern for her Department as well as the Department for Communities and Local Government, which delivers housing. My worry is that if the Minister and her colleagues do not lobby hard, the problem will be forgotten in the overall housing crisis and will become a major crisis for public health and health and wellbeing in London.

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[Heidi Alexander (Lewisham East) (Lab)]

It is a pleasure to serve under your chairmanship, Ms Buck. I know that, on another day, you would be participating in this debate yourself. I congratulate my hon. Friend the Member for Ealing Central and Acton (Dr Huq) on securing the debate and for introducing it in an engaging and wide-ranging way. I commend the excellent contributions of my hon. Friends the Members for Hammersmith (Andy Slaughter), for Edmonton (Kate Osamor), for Ilford North (Wes Streeting), for Hackney South and Shoreditch (Meg Hillier), for Ilford South (Mike Gapes), for Brent North (Barry Gardiner) and for Eltham (Clive Efford). They all expressed their concerns about the quality of care that their constituents receive. It is really good to see my hon. Friend the Member for Ilford South back and to hear his reflections on his experience of the seven-day service. I am not medically qualified, but I want to offer him a bit of advice to help his continued recovery: he should limit his time on Twitter.

Many of us in this Chamber have discussed the NHS in London previously. I cannot but reflect on the fact that, back in 2010, when I was first elected to this place, the NHS was hardly ever raised with me on the doorstep, but at the previous election it came up on every road that I canvassed. It is clear from the many contributions today that the NHS in London is under real pressure. We heard about the huge financial pressure, crumbling buildings and difficulty accessing GP services—and that was just from the Conservative Members.

As a London MP, I know that some of the health challenges that our city faces are specific to the capital. Others, such as the rising hospital deficits and declining staff morale, are symptomatic of problems that affect the whole country and can be traced back to decisions made by this Government and their coalition predecessor.

Let me start with the issues that are specific to London. London is a fast-growing city. More than 1 million more people are living here in 2016 than in 2006. The birth rate is higher in London than in almost every other major European city. London is a city of huge economic contrasts. Some of the wealthiest parts of the country are here, and also some of the poorest.

The vicious cycle that links poverty and poor health is all too evident in the advice surgeries that London MPs hold weekly or fortnightly. Overcrowded, damp housing and low incomes cause depression and anxiety, which place significant strain on the mental health system and the NHS more broadly. London contains diverse communities with different needs, from City workers dealing with stress to recent migrants from war-torn countries, so the NHS in London faces multiple and complicated challenges.

The huge contrast that characterises our city also creates problems in the delivery of health services. The lack of affordable housing, which my hon. Friend the Member for Hackney South and Shoreditch mentioned, and the instability of the rental market makes staff recruitment and retention a particular challenge. The London Health Commission found that NHS staff cited the high cost of living and the lack of affordable housing as two of the biggest barriers to living and working in London.

The sister of a very good friend of mine used to work as a cancer nurse at the Royal Marsden. She lived outside London and commuted into Clapham Junction by train. She then cycled from Clapham Junction because she could not afford the fare to a zone 1 station. Her daily round trip took four hours. It is probably no surprise that she has now moved to a new job in Huddersfield.

Nurses in my constituency rent single rooms in flats, so they can live close to the hospitals where they work. Nurses with families are desperate for social housing because private rents are unaffordable and owning a property is a pipe dream for them. We should use the NHS’s large footprint to solve that problem.

[Meg Hillier]

My hon. Friend underlines my concerns. Is she also concerned about the advent of PropCo? It took land away from Hackney, and we now have no control of it locally. It would do more for health outcomes to turn that hospital land into good-quality housing, rather than luxury flats, which are unfortunately becoming the norm in Hackney.

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[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It is a pleasure to respond to a debate under your chairmanship, Ms Buck, I think for the first time.

The debate has been extraordinarily rich, with many excellent speeches from my fellow London Members of Parliament. We have a reasonable amount of time left, so I will try to respond to as many points as I can, but certainly on some I would prefer to write a response after the debate. In particular, I would not wish to give my friend, the hon. Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, anything but the best information, so I will write to her afterwards about some of the details.

I congratulate the hon. Member for Ealing Central and Acton (Dr Huq) on securing the debate with cross-party support. I echo the words of the shadow Secretary of State: it is a great pleasure to see the hon. Member for Ilford South (Mike Gapes) back in this place. He made typically generous remarks about the NHS staff who cared for him, and we, too, thank them, because he is a popular Member in all parts of the House. We are delighted to see him back.

I am a London MP, so the debate is about my constituents as well. Rightly, hon. Members have taken this important opportunity to champion their local populations and their healthcare needs. However, some consistent threads have run through many of the speeches, in particular on the long-term strategic direction given the nature of London and its population. As well as responding to specific points, I want to give Members a sense of the strategic direction that the NHS wants to take in London, and some of the thinking around that.

The NHS in London serves a population of more than 8 million and spent £18 billion last year. As the shadow Secretary of State and others have said, London’s population is younger than the national average and more mobile, and its transient nature often makes continuity of care harder to achieve. In Battersea, I represent the youngest seat in England, and I see that transient, mobile population all the time, whether they are shift workers or young professionals. There are wide variations between and within boroughs in the health of the population, life expectancy and the quality of healthcare.

I will not attempt to respond to all the detailed points that have been made about housing, immigration and some of other wider determinants of health, but I fully acknowledge the interaction of all such important factors when it comes to the health of our constituents, and those factors are rightly at the forefront of the ongoing mayoral election campaign. It is inconceivable that the next Mayor of London, whoever is elected, will not have right at the top of their agenda issues such as housing in London, especially for key workers and the people who keep our important public services going. That is entirely right. I acknowledge that some of the issues that have been highlighted are important for the future of London. The population of London is projected to increase to more than 9 million by 2020, with the largest proportional increase expected in the over-65 age group. Members clearly know what that means for the increasing demand for healthcare.

The leaders of the national health and care bodies in England have set out steps to help local organisations plan over the next six years to deliver a sustainable, transformed health service. I accept that there was controversy in the last Parliament, and that the majority of Members present in the Chamber today disagreed with many of the measures enacted. Nevertheless, we have since had a general election and a majority Conservative Government were elected, having stood on the NHS architecture as it is. At the heart of the Conservative manifesto was an acceptance of the NHS in England’s own plan for its future, the five-year forward view. In a fixed-term Parliament, that gives us the opportunity for a stable system, which can look ahead across five years at how it provides sustainable and transformed services.

As in previous years, NHS organisations will be required to produce individual operational plans for the next financial year. Obviously, that work has happened for 2016-17. In addition, every health and care system will be required, for the first time, to work together to produce a sustainability and transformation plan, which is a separate but connected strategic plan covering October 2016 to March 2021. Many Members have highlighted the frustrations felt between the acute sector and CCGs, and some of the other stresses and strains between the different parts of the system. This year will be the first time that the NHS has required all parts of the local health and social care system to sit down together to draw up a five-year plan. That is strategically important in understanding how the system responds.

Those local plans represent an ambitious local blueprint for implementing NHS England’s five-year forward view locally. My hon. Friend the Member for Sutton and Cheam (Paul Scully) and many others talked about the need for long-term planning.

[Meg Hillier]

I thank the Minister for giving way, because I know she is trying to cover a lot of ground. Long-term planning is sensible, but is she not concerned about a five-year plan when at the same time major transformation is being required of acute hospital trusts through NHS Improvement—again, not a problem in itself, except that it is to be in very short order? Is there not a contradiction between a five-year plan and the short-order demands of the improvement plan for trusts, just to make their books balance?

Junior Doctors Contract

Meg Hillier Excerpts

Friday 20th November 2015 Commons Chamber

[Alistair Burt]

My hon. Friend is right. One difficulty with this is getting through what has built up during the course of the dispute, and getting to the heart of this issue, which is shared by everyone. There is no doctor in the land who does not want to work in safe conditions or for their patients to be treated safely. There is no Member of Parliament who does not want safety to be at the heart of this, and no one from the royal colleges or in senior executive positions in the NHS wants to compromise on safety. That is why we need to cut the number of legal hours, and ensure that doctors cannot work the number of consecutive nights or long days that they can work currently. The contract was outdated and it needs to change, and that is why people should sit down together.

[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

Members of the Public Accounts Committee hear repeated reports about the challenges of recruiting some of the very junior doctors who will go on strike. Not only is the Government’s game of brinkmanship causing problems with morale and patient safety, it could lead to a longer term crisis in the NHS as doctors choose not to work here. Will the Health Secretary just get on with it and get around the table? It is within his gift to get talks started again and avert this strike.

[Alistair Burt]

The hon. Lady speaks with great background knowledge on this issue. She is right to say that we should all just get on with it, but she is not right to say that it is within the Secretary of State’s gift—if it was, we would not be where we are. The Secretary of State wants a negotiation based on independent recommendations and on three and a half years of work, which is not an unreasonable position. The hon. Lady’s view that this issue should be settled in a way that means negotiations continue and the strike does not happen is correct.