Accountability and Transparency in the NHS

Steve Baker Excerpts

Thursday 14th March 2013 Commons Chamber

[Steve Baker (Wycombe) (Con)]

My constituent Edward Maitland was a frail man who could not eat solid food following tongue surgery. He was admitted to Wycombe hospital from his warden-controlled accommodation suffering from dehydration, shortness of breath and weight loss, things from which he should have recovered. His son, a paramedic, clearly explained on his father’s admission that Mr Maitland could not eat solid food and he also provided liquids. About three weeks later Edward Maitland had died from aspiration pneumonia. At the post-mortem, Weetabix was found in his lungs.

Of course, the investigation was taken extremely seriously and the documentation is, up to a point, very professional. Under “root cause”, it states:

“The investigation found that there is no evidence to support robust communication between nursing and medical staff…No SBAR”—

situation, background, assessment and recommendations—

“documentation was used in EMC or in handover to Ward 6B this would have highlighted the patient’s nutritional needs.”

It proceeds to make some “recommendations”, but I want to highlight the “lessons learned”:

“To care for all patients with a holistic approach and the multi-disciplinary team must focus on all health concerns.

Better communications between all staff members, this should be ongoing and involve all the different professionals who may need to collaborate the care delivery plan. This collaboration and communication should involve the patient, family and the healthcare staff.”

Unfortunately, that is bread-and-butter, typical stuff—and managerial gibberish.

What I learned is that two words would have saved the life of Edward Maitland: “no solids”, written on the records at the end of his bed, on his wristband, and above his bed. The situation in his case is very simple. A man died who ought not to have died. He should not have died in these circumstances.

I have the hard task of saying, therefore, that I look to the courts, and the Francis report helps me. Recommendation 13 of the report, on fundamental standards, refers to:

“Fundamental standards of minimum quality and safety, where non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations.”

Elsewhere, the report discusses at some length—I do not have time to go into detail—a regulatory gap in relation to the Health and Safety Executive:

“It should be recognised that there are cases which are so serious that criminal sanction is required, even where the facts fall short of establishing a charge of individual or corporate manslaughter. The argument that the existence of a criminal sanction inhibits candour and cooperation is not persuasive. Such sanctions have not prevented improvements in other fields of activity.”

I took legal advice. I approached a retired circuit judge in my constituency, who in turn approached a firm of lawyers. I am most grateful for the guidance of Kate McMahon, of Edmonds Marshall McMahon, who has provided me with considerable free legal advice in relation to this case. The firm specialises in private criminal prosecutions. She has explained that, at least at the preliminary stage, there may be a corporate manslaughter case to answer, and liability for gross negligence manslaughter may well be attributable to one or more employees of the hospital.

I do not want people to be prosecuted unnecessarily, or to see taxpayers’ money wasted, but I do want accountability, and I believe that in the end the courts provide that crucial accountability. Edward Maitland’s son Gary now has this advice, and I have left it to him to decide whether to approach the police. I have briefed the police superintendent in Wycombe on the circumstances. I believe that the courts should be the ultimate way of sanctioning the NHS. Francis agrees, and I hope he will provide a policy in this area.

There should be more democratic control. I am delighted—

[Frank Dobson]

Does the hon. Gentleman not agree that one characteristic of involving lawyers is that there is a lot of money around, and it goes to them? Would it not be better spent trying to ensure that performance standards are enhanced, rather than employing lawyers to have a go at the people who got it wrong?

[Steve Baker]

Of course I would rather that the money was spent on standards and performance and not on prosecutions, because I would rather the problems did not occur. I do not wish to lecture the right hon. Gentleman, and I feel sure he did not quite mean it this way, but if we do not intend to apply the law of corporate and individual gross negligence manslaughter, let us repeal it, or amend it so that it does not apply to the NHS. I have to say to the right hon. Gentleman that it does apply to the NHS and that in certain cases, as Francis has said, things are so bad it should be applied.

I ask the Government to look at democratic control. I am delighted that the Secretary of State is reforming the Care Quality Commission, but how can we make sure that there is more direct accountability, perhaps to the health and well-being boards, and the overview and scrutiny committees? How can we give them the power to sanction or perhaps even, through due process, dismiss a board or a chief executive?

I think here of Paul Ryan, a man with vascular disease who had lost one leg already when he found himself sick. He had four days of GP visits and spent nine hours in accident and emergency on a Friday. He was then sent home, having had an MRI scan, after which he was expecting to lose his leg on the Monday. He was told to expect a phone call, but no phone call came. The Ryans eventually called 999 and were told that it was better to get a GP. The GP arrived and called an ambulance. It took two hours for that to arrive and Paul Ryan died in the ambulance with his wife on the way to hospital.

[Mr Cash]

Does my hon. Friend agree that accountability does reside also with the Secretary of State, as set out in the national health service legislation? That is essential in relation to our functions in this House and those of this Secretary of State and former Secretaries of State.

[Steve Baker]

I am grateful to my hon. Friend for his point, although it has been examined at length, so I do not want to go down that rabbit hole with him—I hope he will forgive me.

The post-mortem on Mr Ryan indicated that he probably would have suffered the same fate in any event, but the system let the Ryans down—Mrs Lyn Ryan made that point to me and to the local newspaper. Unfortunately, the case plays right into the fears of the public in Wycombe, because we lost our accident and emergency facility in 2005 and we recently lost our emergency medical centre. We have just had two similar repeat occurrences of the minor injuries unit failing to refer people across the car park into the excellent cardiology and stroke units. We have seen an enormous range of little problems, for example, an 85-year-old lady with dementia was sent home in a taxi at 2 am in just her hospital gown. This cannot go on, and the public’s concerns are justified. The trust is being investigated by Sir Bruce Keogh and although I have heard good reasons why its mortality levels are justified—they relate to running hospice care, in particular—this must be taken as an opportunity to improve things.

Finally, I wish to make a point on transparency. Yesterday, I spoke to Anne Eden, the chief executive of the trust. I am not going to put on the record the entire content of the conversation, but when I told her that I intended to raise this issue of corporate manslaughter on the radio this morning, I was told, in terms, “To protect the reputation of the Buckinghamshire trust, legal action would be sought.” This is a matter of public interest being raised by a Member of Parliament in good faith, but I have had to—[Interruption.] To be fair to her, she was talking about the radio. But I have had to rely on privilege to protect myself from being sued on this matter. It is not acceptable that such a matter should have to come to a Member of Parliament, simply to rely on privilege. The situation reinforces something I have experienced again and again since becoming an MP: second-hand rumours and half-truths about the state of health care in Buckinghamshire. I have encountered: people stymied; people thinking it is helpful to give half a rumour to a friend to repeat to me so that I can know how bad things are; and people’s frustration at not being able to do anything. I know that Buckinghamshire Healthcare NHS Trust is obviously close to your heart, Mr Speaker. I know that it expects to satisfy Sir Bruce Keogh, but it is really time for proper accountability and that must include the courts.

Accident and Emergency Departments

Steve Baker Excerpts

Thursday 7th February 2013 Commons Chamber

[Angie Bray]

I certainly think that a petition of that size cannot be easily ignored. However, as we pointed out when we encouraged people to take part in what was a massive and time-consuming process, I suspect that, technically and legally, the authority is obliged to register only the responses to the consultation.

Beyond what I have described, my role has been to make my objections, and those of my constituents, fully known to and understood by as wide an audience as possible in Government. After doing the rounds of meetings with the previous team at the Department of Health, I held meetings with the new ministerial team and the Health Secretary after last autumn’s reshuffle. I followed that up with a meeting with the Prime Minister, whom I left in no doubt that this issue was of the utmost importance to my constituents.

We all believe that the closure plan must be reviewed. None of us can believe that it is anything other than reckless. We wonder how the A and E departments that are left standing will be able to cope with all the extra pressure that will result from the closure programme. I explained to the Prime Minister in detail why the extra travel time to A and E departments further afield would be unacceptable. He listened carefully, asked a number of detailed questions, and told me that he would certainly discuss the issue this with Health Ministers.

Much of our campaigning has focused on the baffling way in which NHS North West London has chosen to present the proposals as a virtual fait accompli, without adequately explaining quite how they will work in practice. We are told that new “urgent care centres” will cater for everyone’s needs, but we have also learnt that there is a lengthy list of conditions, and that there are a number of possible problems with which they will not actually deal.

[Steve Baker (Wycombe) (Con)]

It is, in a sense, reassuring to hear that my hon. Friend is experiencing exactly the same problems as we are experiencing in Buckinghamshire. It is always made to sound so good, and then it is so awful. I hope that the Minister will be able to explain how things can change, so that instead of standing here complaining on behalf of our constituents we can actually make a difference.

[Angie Bray]

I entirely agree. The issue of trust is so important, but I suspect that we shall have to do a lot of work if we are to build that trust.

What I have just said about urgent care centres will not be at all reassuring for my many constituents who use the local A and Es. We must not forget that Ealing hospital’s A and E sees at least 100,000 people every year. Nobody is suggesting that we do not need to make long-term improvements to our health service and the way services are delivered, but we need better guarantees that the planned changes will provide an acceptable replacement for what we have at present.

It is unreasonable to expect my constituents to support the closure of their local much-cherished A and Es without any certainty that what they are told will be put in place will materialise. In the meantime, there is the practical question that everybody is asking: if the A and Es are closing at four hospitals, what will happen to the queues at the A and Es that are left open?

No one is under the impression that everything is rosy and that the way health care is delivered in north-west London is absolutely perfect. Clearly, in the longer term we will need to encourage more people to sign up to local GPs rather than depending on A and Es for all their health care needs, but that requires time and organisation. We cannot just close the A and E and expect people to cope. Looking forward, we clearly need to make sensible decisions on how we fund health care provision locally, to ensure money is available to meet all the rising costs associated with people living longer, new medicines coming on-stream and new costly treatments, but we have to take people with us as we approach change.

Understandably, people have an emotional attachment to their local hospitals and they need to be persuaded of the case for change. Given that the health reforms are about to put GPs in charge of local health provision, why are we not waiting to see what decisions they think would be appropriate, rather than pushing these decisions through now? The whole approach has been too rushed. Local GPs have hardly been queuing up, in public at least, to support these proposals. The impression my constituents have been left with is that the consultation was little more than an attempt to channel their views towards the preferred option, in what was a box-ticking exercise by NHS North West London.

There are too many questions left unanswered, and too much of the information provided in the consultation was too questionable. For all these reasons, I can only hope that if NHS North West London decides on 19 February to proceed as it currently intends, the Secretary of State will ensure that that is reviewed in its entirety. My constituents are deeply concerned.

Hospital Services (South London)

Steve Baker Excerpts

Tuesday 22nd January 2013 Westminster Hall

[Clive Efford]

The point made by my hon. Friend is self-evident, but if I may, I will not be drawn down the road, because I want to get the next point on record.

Lamenting the fact that local commissioners have not been listened to, Helen Tattersfield says in her article:

“No argument has any weight, however, against the needs of a failing trust, foundation trusts and potential private companies eager to expand their areas of influence, and NHS managers convinced of the merits of their model of fewer larger hospitals. Those of us who have spent hours acquiring the skills supposedly to lead commissioning have been shown that, in fact, decision-making and influence remains where it always was: with central managers, computer-derived models and reasoning that takes no account whatsoever of human behaviour in real life. We are little more than window-dressing for central planning geared to the needs of large foundation trusts, and open to the interests of the private sector.”

That comment alone just about sums up where we are.

I will finish soon to allow the hon. Member for Beckenham to speak, but I just want to ask the Minister whether she will consider a review of proposed A and E closures across London. We are seeing a piecemeal, salami-slicing of A and E services, which is putting the safety of Londoners at risk. As we know, we have seen a 50% increase in people waiting in ambulances for 30 minutes or more outside A and Es to gain access, and we have seen a 26% increase in those waiting for 45 minutes. We know that they are under pressure, so before we see any closures, that review must take place.

We can pray in aid what the Lord Chancellor and Secretary of State for Justice said. The headline on the relevant article read: “Hunt faces Cabinet split over A and E closure after Justice Secretary blasts plans as ‘sticking two fingers up’ to patients”. We also have the right hon. Member for Sutton and Cheam (Paul Burstow)—the former Minister of State, Department of Health—who lamented, when he was still a Minister, the proposed closure of St Helier:

“This is a flawed conclusion from a flawed process. There is still a lot of water to flow under the bridge before final decisions are made. The panel have ignored the pressure on all the A and Es and maternity units in south west London.”

We can pray those people in aid to defend our A and Es, and the Government should go back and look again.

To make one last point, we have seen the closure of an A and E, despite the promises of local Conservatives. The Leader of the House of Commons, when he was shadow Secretary of State, was going to save the A and E at Queen Mary’s, Sidcup, but it never came about. Under “A Picture of Health”, there was a proposal to have overnight stay, elective surgery at that hospital. It was promised to my constituents, who welcomed it and wanted to see it. I ask the Minister to reconsider removing that planned service from that hospital, because it was beginning to work and people welcomed it. It will be a serious cut to the quality of health care.

[Steve Baker (Wycombe) (Con)]

Will the hon. Gentleman give way?

[Clive Efford]

No, I will not, because I want to allow the hon. Member for Beckenham to speak. It will be a serious cut to local services, and we should not allow that cut to go ahead.

Vascular Services (Wycombe Hospital)

Steve Baker Excerpts

Monday 14th January 2013 Commons Chamber

[Steve Baker (Wycombe) (Con)]

I am most grateful to you for that, Mr Speaker. I am also grateful to my hon. Friend the Minister for being here at this hour to discuss vascular services in Wycombe hospital, as I know he has thought carefully about the subject. It is a subject that will be of interest to your constituents, Mr Speaker, so I am glad to see you in the Chair, and to my right hon. and learned Friend the Member for Beaconsfield (Mr Grieve), a number of whose constituents campaign vigorously on the issue, so I am glad to see him here supporting this case. The nub of the issue is that we in Wycombe have been told repeatedly that it is in our interests for hospital services to be centralised away. There is today a clear momentum to centralise vascular services for the Thames Valley in Oxford, yet Wycombe enjoys better results and Oxford has been subject to a range of criticisms, as I shall set out.

We need to look at the historical context to understand why the opposition to what is happening is so vociferous. Wycombe hospital is in a position perhaps typical of a generation of district general hospitals: we lost our accident and emergency unit; we lost consultant-led maternity, retaining a midwife-led unit as a concession; we lost paediatrics; and in 2012 the emergency medical centre—the EMC—was downgraded to a minor injuries unit, repeating much of the local outcry about the loss of the accident and emergency unit. At each stage, campaigners expressed fears that the withdrawal of services would lead eventually to the closure of the hospital. At each stage, those fears were vigorously stoked by dissenting voices among the affected medical staff. At each stage, the NHS management no less vigorously denied that such an outcome could ever occur, and after each stage the NHS management went on to propose further service withdrawals. It is no wonder so many local people fear closure.

In Wycombe, we do have the Buckinghamshire units for cardiology and stroke, which treat two of the biggest killers, but, scandalously, the minor injuries unit recently failed to admit a lady who arrived with suspected heart trouble—the Minister will recall taking my question in the House on that occasion. It is now being suggested by some clinicians, specifically those within the vascular unit at Wycombe, that losing vascular services at the hospital could threaten those excellent services we have left.

I feel sure that the Minister will appreciate the excruciating sensitivity of this issue. The long, grinding decline of our hospital has sown anger, despair and cynicism, not least because the public have come to appreciate that NHS consultations seem to be exercises in manufacturing consent—or perhaps the appearance of consent—rather than providing democratic accountability and control.

The recent “Better Healthcare in Bucks” consultation on the downgrade of the EMC mentioned vascular services, supporting the view that vascular should remain in Wycombe until a review in 2014. We are now approaching that review and a series of leaked documents has shown two important points: first, vascular care in Wycombe is superior to that in Oxford; and, secondly, the transfer of vascular services to Oxford is essentially a done deal.

Let us consider how vascular services have changed, because I know that it has affected many of my hon. Friends and Opposition Members. Diseases of the arteries and veins used to be treated by surgery only, but problems are now reached via other blood vessels using techniques known as interventional radiology. Vascular surgeons and interventional radiologists support cardiology, cardiac surgery, stroke and other disciplines. The new vascular specialty was approved by Parliament in March 2012. Vascular is now listed as a specialty on the General Medical Council website, although the approved curriculum and assessment system was not available today. There is also a Vascular Society.

According to the authors of a report on the centralisation of vascular services in Oxford,

“the advent of separate specialty status for vascular surgery together with speciality commissioning plans for 2013 onwards…will reduce the number of hospitals providing vascular surgery to about 50 in England and Wales”

from 150, and

“commissioners will not purchase arterial interventions except from arterial centres.”

I think that is why the issue has affected so many of my colleagues.

[Eric Ollerenshaw (Lancaster and Fleetwood) (Con)]

I congratulate my hon. Friend on securing this important debate. In north Lancashire, the situation is similar. It is perhaps not the policy that is the problem but the implementation of it, because if it is implemented some of my constituents, particularly in rural areas, will face transport times of more than one and a half hours. The national target for improvement is just one hour, which is why, unfortunately, I have to support my local hospital, the Royal Lancaster infirmary, which has reached the point of considering taking the implementation of the policy to judicial review.

[Steve Baker]

My hon. Friend raises an important point about transport, which will be an issue for many of our constituents, not least because they will not have cars.

People in need of vascular care will include those with abdominal aortic aneurysms, a life-threatening weakness of the main artery that must be repaired, and those who have had strokes or mini-strokes—transient ischaemic attacks. After a stroke, drugs are administered immediately, but they need to be followed up with a procedure to clear the carotid artery, called a carotid endarterectomy or, mercifully, a CEA. Other people requiring care will include those with poor blood supply, including smokers and diabetics, who might endure serious complications that might even lead to amputation.

Wycombe hospital provides the full range of services. It is proposed to move them all to Oxford university hospitals on the basis that the present arrangements are “not sustainable”, but I have yet to see evidence that supports that assertion. Leaked documents suggest that Oxford provides worse outcomes and is struggling to be ready.

[Tim Farron (Westmorland and Lonsdale) (LD)]

I am extremely grateful to my hon. Friend for giving way and congratulate him on securing the debate. Further to the point raised by my hon. Friend the Member for Lancaster and Fleetwood (Eric Ollerenshaw), in the north-west the number of units will go down from four to three. Folks in Morecambe bay will no longer be able to go to Lancaster but will have to go to Carlisle, Blackburn or Preston. Does my hon. Friend the Member for Wycombe (Steve Baker) agree that the majority of vascular surgery these days is not elective but acute, following road traffic trauma and incidents such as coronary emergencies? We are talking not about elective surgery but about acute emergency provision, so it is vital that the services are close at hand.

[Steve Baker]

My hon. Friend is possibly inviting me to stray beyond my expertise, but perhaps the Minister can deal with that point. The concern in Wycombe is about elective treatment of aneurysms, and particularly the treatment that goes with stroke services. The key concern is that it is an excellent service that will be degraded if it is moved to Oxford, according to the clinical evidence.

I am grateful to Dr Annet Gamell, chief clinical officer of the Chiltern clinical commissioning group. She has given me a clear explanation of the position in Buckinghamshire, which is that things are waiting on the outcome of the review in 2014. Once a new theatre is open at Oxford, it is proposed that all complex elective vascular surgery will go there. It is planned that outpatient and diagnostic services will remain at Wycombe. CEA services would be subject to review in 2014, and I understand from Dr Gammell that the group would support moving CEAs to Oxford only if results indicated that patients would benefit from it. The Chiltern clinical commissioning group would take into account the impact of such moves on other services. Dr Gammell points out that if it is agreed to transfer CEAs to Oxford, there would be another local consultation, but on the basis of recent experience it is not clear to me what end that consultation would serve. The decision would have been made and it is clear that there is vast momentum to take services in that direction, despite the clinical evidence.

The key performance indicators for the south central cardio-vascular network show that in the first two quarters of the 2012-13 reporting year, Wycombe performed 17 aneurysm repairs and Oxford 16. Wycombe carried out 31 carotid endarterectomies to Oxford’s 47. Almost half of patient records at Oxford did not provide the dates of patients’ symptoms. Eighty per cent. of CEA patients at Wycombe received the procedure within two weeks of referral. At Oxford, the figure was just 23%, although patients seem to have received their treatment within 48 hours of symptoms. At Wycombe, 58% of patients were treated within 48 hours. Oxford achieved a ratio of total vascular interventions to amputations of 4.55:1, whereas at Wycombe the ratio in the period was 8:1, which shows a considerably greater degree of success in maintaining people’s limbs in very difficult circumstances.

The clear clinical evidence in that period is that Wycombe outperforms Oxford, and it does so with fewer clinical staff. All this is not mentioned in the “Oxford University Hospitals Review of Phase 1 of the Centralisation of Vascular services”, which has been sent to me under cover of a letter dated 12 August from the chief executive of NHS Berkshire. It was among a number of documents leaked to me. The report describes the resignation of a vascular consultant, Mr Peter Rutter, following significant difficulties associated with the move from Wexham Park to Oxford. Those difficulties including antiquated theatre instruments, poor quality theatre lighting and patient safety issues.

Mr Rutter observed:

“Vascular surgery is not very important in Oxford and would take 5 years to bring up to standard.”

He also said that vascular had no champion at Oxford, which is confirmed in other documents. Other remarks in the review include, for example,

“Many outlying district general hospitals have better endovascular facilities”,

“Oxford is not a modern endovascular hospital”

and

“Oxford has no culture of multidisciplinary working”,

which is essential when vascular supports those other specialties. Furthermore,

“Little thought had been given to the effect on Interventional Radiology in DGHs”

and very worryingly, an

“Oxford senior surgeon threatened to make Bucks vascular surgeons redundant unless they toed the line.”

A comment in the review implies that Wycombe’s excellent interventional radiologists would join Oxford University Hospitals only if CEA and bypass surgery stayed at Wycombe, which has been rejected. Presumably, these valuable experts who make the excellent service possible will resign and go elsewhere.

In summarising, the review explains that the impression had been given that OUH had not properly thought through the implications of centralisation. In discussing theatre upgrades, it concludes that

“there remain concerns about the quality of lighting, ventilation, anaesthetic facilities and sterility.”

I am only a humble aerospace and software engineer, but it seems to me that these are fairly basic concerns. Despite all this, the review clearly states:

“It will not be possible for carotid surgery to remain in Wycombe as CE and CAS will not be commissioned from Wycombe beyond 2013.”

Surely this is a matter for the commissioners.

The reviewers are clear that it is not viable for Wycombe to keep carotid surgery and bypass, but they do not state the evidence for their assertion beyond the new status of vascular as its own specialty. Before making recommendations, the review says:

“OUH practices Vascular Surgery more like a DGH than an important Teaching Hospital. Several of the surrounding DGHs, currently being centralised into Oxford, probably provide a better endovascular service.

Vascular surgery at OUH seems to be safe but has not developed in the way that it has in other hospitals in the United Kingdom. It seems to be positioned about ten to fifteen years behind the best.”

Notwithstanding the evidence of superior performance at Wycombe and shortcomings at Oxford, the review insists that vascular services must transfer, ultimately on the basis that it is inevitable that vascular services will be co-located alongside Oxford’s major trauma unit. That is a blatant rejection of the principle that is constantly used to justify centralising services away: clear clinical evidence. All the time that Wycombe provides better care and the team can provide it sustainably, in its opinion, and while local commissioners are prepared to buy it, why surrender to Oxford’s desire to be the Thames valley super-hospital, whatever the cost to patients?

Any responsible Member would admit that the trend in health care is towards specialisation. When my hon. Friend the Member for Bracknell (Dr Lee) was describing his Thames valley super-hospital proposal in Marlow, he said that any politician who claimed that they could restore A and E to a district general hospital would be a liar. I am grateful that I have not fallen into that trap, but it illustrates a point. Politicians are accountable to their electorates and businesmen are accountable to their customers, but managers and clinicians in the NHS who follow rules and guidelines seem to account seriously only to one another and, significantly, to do so on the basis of who carries the greatest authority through prestige.

In the midst of all that, senior NHS executives keep circulating. Stewart George and Fred Hucker—irrespective of their individual merits—who chaired the Bucks and Oxfordshire PCTs, became joint chairmen of the cluster. Mr George is now moving to the CCG, and Mr Hucker to Buckinghamshire hospitals trust. A new era of openness, accountability and genuine public involvement seems unlikely, and continuity seems a dreary inevitability, but all that ought not to be.

Vascular services in the Thames valley appear to be not so much sleepwalking into disaster as positively driving towards it. Vascular services in Wycombe are not some ditch and gatepost operation to be salvaged by the great Oxford University hospitals, as Wycombe outperforms them with a smaller team. In this regard, it is the John Radcliffe that needs saving.

Let me ask the Minister some specific questions. Is the Chiltern CCG able to insist that it will purchase vascular surgery from the Bucks health care trust at Wycombe despite national guidelines? What are the roles and authority of the NHS Commissioning Board, the local health and wellbeing board and the south central vascular network? Crucially, has the elevation of vascular surgery out of general surgery and into a specialisation of its own led to such things as turf wars, demarcation disputes and office politics? What formal influence are locally elected representatives—councillors and MPs—supposed to have?

Wycombe has had its own hospital since 1875. The current hospital was not founded by the NHS; it was built in 1923 with donations from local people, which were mostly given in pennies, as a memorial to the men we lost in the great war. The public are therefore right to be incandescent with rage at changes that appear to be driven by remote sectional interests, not local patient care.

Recently, my right hon. Friend the Secretary of State said:

“I need to say this to all managers: you will be held responsible for the care in your establishments. You wouldn’t expect to keep your job if you lost control of your finances. Well don’t expect to keep it if you lose control of your care.”

What is needed is real accountability. Let us get health under the control of the people who pay for it and start by keeping vascular at Wycombe for all the time that that remains in patients’ best interests.

--- Later in debate ---

[Dr Poulter]

Yes. I assure my hon. Friend that when a referral is made by a local overview and scrutiny panel the Secretary of State will look at it and decide whether to refer it to the independent reconfiguration panel. That is often the decision that is made in these cases, but it lies initially with the Secretary of State, who will then have to consider whether to refer it. I am happy to write to my hon. Friend further to outline these steps if that would be helpful.

It is worth highlighting the national parameters that are being set for the delivery of good vascular surgery by the NHS Commissioning Board, which takes over full responsibility for commissioning from April this year. The board published a draft national service specification for vascular surgery for consultation. The consultation commenced in December 2012 and will conclude on 25 January 2013. It identifies the service model, work force and infrastructure required of a vascular centre. It says:

“There are two service models emerging which enable sustainable delivery of the required infrastructure, patient volumes, and improved clinical outcomes. Both models are based on the concept of a network of providers working together to deliver comprehensive patient care pathways centralising where necessary and continuing to provide some services in local settings…One provider network model has only two levels of care: all elective and emergency arterial vascular care centralised in a single centre with outpatient assessment, diagnostics and vascular consultations undertaken in the centre and local hospitals.

The alternative network model has three levels of care: all elective and emergency arterial care provided in a single centre linked to some neighbouring hospitals which would provide non arterial vascular care and with outpatient assessment, diagnostics and vascular consultations undertaken in these and other local hospitals. All Trusts that provide a vascular service must belong to a vascular provider network.”

In essence, this is about making sure that we deliver high-quality vascular care. There are two or three circumstances in which someone would require vascular care. First, there is emergency care—for example, when there is a road traffic accident, or when someone has a leaking aortic aneurysm, which is a very severe and potentially life-threatening emergency. We know from medical data that such service provided in an emergency is much better provided in a specialist centre—an acute setting such as the John Radcliffe, which would be the hub and the central focus. There is also good evidence that trauma care in any setting, including the requirement for neurological specialists potentially to be involved, is better served in a specialist trauma centre. A specialist centre provides better care in emergencies.

At the same time, it is clear from those models that there can also be a strong role for other hospitals as satellites of the central hub at the John Radcliffe. My hon. Friend clearly made the case for the high-quality outcomes at Wycombe hospital for carotid endarterectomies and other vascular services. I would suggest that there is a role for challenging local commissioners if they wished to remove some elective procedures from Wycombe when there is a case that they can still be delivered in a high-quality manner and to a good standard for patients.

[Steve Baker]

I apologise for intervening on the Minister when there is so little time left, but I can see the campaigners leaping up and down and saying that the clinical evidence in this case is that Wycombe is doing better than Oxford on aneuryism repair.

[Dr Poulter]

The evidence on the outcomes of patients from many trials does stack up over a period of time. Generally speaking, all surgeons need to do a minimum number of procedures in order to maintain regular competency, and to maintain continually high and good outcomes for patients when carrying out aneuryism repair. That is the reason for the service reconfiguration. The argument can be made, as my hon. Friend has done, that Wycombe should continue to provide those services, but we know that the national data and best evidence point to the fact that the services are best provided at specialist centres.

However, there is a good case for my hon. Friend to take forward to the local commissioners about ensuring that more of those elective procedures and elective amputations remain local, and I am sure that he will do that. I am sure that he will also want to talk to his local health scrutiny committee to ensure that it refers cases to the Secretary of State for review, if required. I thank him once again for raising the matter in the debate.

Question put and agreed to.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 27th November 2012 Commons Chamber

[Norman Lamb]

The specialised commissioning groups will receive advice at their December board meetings and are expected to finalise their advice on the clinical and cost-effectiveness of Kalydeco early in the new year. The aim is to provide consistent national advice on the use of the drug for a sub-group of patients with cystic fibrosis.

[Steve Baker (Wycombe) (Con)]

Aylesbury constituent Mrs Evans-Woodward is a young woman who has had five heart attacks. One evening her husband drove her to Wycombe’s heart attack unit with a racing pulse, but she was turned away to the minor injuries unit, which again turned her away to the accident and emergency unit in Stoke Mandeville, before suggesting that she sit outside and call an ambulance, which she duly did—all of this with a racing pulse of 180. This is not good enough. It is an appalling prioritisation of bureaucracy over simple human care and compassion. Does it not show that the NHS needs to become much more accountable to patients?

[Dr Poulter]

My hon. Friend is absolutely right, and I am very sorry to hear of the case he outlined. Clearly the care that his constituent received was more than substandard. If a patient needs immediate treatment, they should always receive it. This Government are quite rightly ensuring that we embed good care in everything we do. We have beefed up the role of the Care Quality Commission to improve the inspection of care quality throughout the NHS and the care sector. We are also introducing a friends and family test to pick up on examples of bad care, so that the NHS can properly learn from them locally and so that these things do not happen.

Acute and Emergency Services

Steve Baker Excerpts

Friday 26th October 2012 Commons Chamber

[Dr Phillip Lee (Bracknell) (Con)]

NHS hospitals face mounting financial, work force and demographic pressures. The stark reality is that health care provision in the future will require consolidation of acute and emergency services in fewer locations, and an increase in the provision of chronic care in the community through locally based clinics. That is not a political choice, but a clinically driven reality. It is widely believed among those in the medical profession that the reconfiguration of hospital services can provide a powerful means of improving quality in an environment where money and skilled health care workers are scarce. In some places, reconfiguration and changes to hospital services are already a necessity, not an option.

That is the case in the Thames Valley region, of which my Bracknell constituency is part. That is why I have recently introduced a strategy proposal for the provision of health care in the Thames Valley region, in which I call for a consolidated hospital—what some have described as a super-hospital—on the M4 at junction 8/9. A “Royal Thames Valley hospital” at this location, if it is ever built, would have crucial advantages. The existing transport infrastructure means that services could be provided, within easy reach of people’s homes, to a population of the greatest possible size. This model has a multitude of benefits, which include economies of scale and sharing of medical information and manpower, and it is supported by many senior medical professionals as being the key to saving the national health service.

Nevertheless, I sense a lack of the strategic leadership that is required to deliver the change that we all need. A major stumbling-block in many hospital reconfigurations is public concern about change, and the political opposition that follows. Politicians will have to make decisions on the basis of the quality, safety and efficiency of health care, while retaining strong public engagement in decision making. That is why I have already begun to hold regular public meetings throughout the Thames Valley region.

[Steve Baker (Wycombe) (Con)]

As my hon. Friend knows, he has set a number of hares running in my constituency. Will he concede that a number of NHS professionals, managerial and clinical, differ with him and think that a network of hospitals is an effective and incremental way forward?

[Dr Lee]

I thank my hon. Friend for that intervention. Yes, I concede that some—not many—local clinicians share that view. Whenever one presents something different that is a challenge to the status quo, one will come up against vested interests, particularly in the national health service. Many of my colleagues in the Chamber need to start engaging with the public on the issue. It is coming round the corner, and we should all try to provide the political environment in which the change can take place.

I would like first to set the context, say why I support this change, and talk about the current difficulties in our health care system, and those that we will face in the future. In the past 50 years, according to the King’s Fund, the number of acute hospitals has reduced by 85% and the number of sites at which elements of highly specialist care is delivered has reduced even further. In England, general acute care is now delivered in just over 200 hospitals, and at the same time the average size of hospital has grown from 68 beds, according to a Ministry of Health document in 1962, to just over 400 beds. The average acute trust has just over 580 beds. These changes reflect developments in medical practice.

Advances in medicine and surgery have driven clinical staff and equipment to become more specialised. As skilled specialist staff are scarce and budgets are limited, services have been centralised on to fewer, larger sites, in order to ensure that patients are cared for by staff with the necessary skills and supporting specialist equipment. In addition, there has been decreasing reliance on bed rest as part of treatment; for example, most routine surgery is now undertaken as day surgery. The average length of stay in hospital is currently just less than six days and 80% of all patients have stays of less than three days.

Having surveyed both NHS trusts and the public on service change, the Foundation Trust Network found that 90% of NHS trusts said that a major change, such as a hospital merger, closure or changing the way in which services are provided, was necessary in their area in the next two years. Critically, eight in 10 trusts felt that a reconfiguration in their area would lead to maintained or improved patient outcomes which would not be possible if the change did not take place. Of those NHS trusts indicating that a reconfiguration would be necessary, 35% felt that there was a consensus locally about how this should take place. Local councillors were felt to be a barrier to service change in 49% of cases, as were other NHS trusts in 48% of cases, and MPs in 40% of cases.

Finally, market research organisation ICM’s polling of the public shows conflicting views. Four out of 10 people initially stated that they would prefer to be treated locally, but when asked to rank the importance of having services close to home versus accessing specialist care when being treated for a serious condition, more than half said that it was more important to be treated in a unit that specialised in their treatment area. That number rose to 60% if the respondent was talking about a loved one receiving the treatment rather than themselves. Three in 10 said that it was most important to have a hospital close to where they lived in such a case, suggesting that while people value the convenience and accessibility of local care, ultimately access to specialist expertise matters more where a serious condition is involved.

Demographic changes and the shifting burden of disease will require a fundamental shift from the hospital as the core focus of health service delivery to the community, to provide elective care and minor treatments from the community level in much-cherished community hospitals, and all major surgery and acute care from a central hub hospital, ideally located on a motorway.

In any reconfiguration of hospital services there are four drivers: quality—that is, better health care—work force, cost and access. The challenge is to try to arrive at a configuration that optimises all those elements as far as that is possible, given the complex trade-offs that exist between them. Quality considerations include access to highly trained professionals in all disciplines, compliance with clinical guidelines, and access to diagnostic technologies and other support services, as well as strong clinical governance. More recently, there has been pressure on trusts to meet challenging funding needs, which is putting greater emphasis upon operational systems and environments to work together to meet the targets and improve patient safety in acute care settings. There are also interdependencies between services—for example, withdrawal of paediatric services can threaten obstetric services, which rely on paediatricians to provide care for the newborn child.

There is wide variation in the quality of care delivered by NHS hospitals. Reconfiguring services can be a powerful means of addressing this variation. An often cited successful example is here in London. It has been estimated that the recent reconfiguration of stroke services will save more than 400 lives a year. This is through the establishment of stroke networks that have concentrated specialist stroke expertise and diagnostics in fewer units, while retaining local access to stroke rehabilitation services in local community hospitals. Other examples include vascular surgery, where the mortality rate is lower in high-volume hospitals than low-volume hospitals, and paediatric heart surgery, where there are plans to cut the number of hospitals undertaking surgery to improve outcomes.

With reference to stroke mortality rates across acute hospital sites across England, it is estimated that there would be 2,117 fewer deaths per year from stroke in England with increased ambulance services to specialist centres. That clearly demonstrates that centralisation of stroke and trauma centres would benefit a larger proportion of the population and would reduce mortality rates and thereby improve the quality of care.

Alongside those changes, there is a need to shift the location of care for older people who do not require specialist care in a hospital setting. The Royal College of Physicians estimates that almost two thirds of people admitted to hospital are over 65. People over 85 account for 25% of bed days. As we have noted, older people make up the majority of patients in hospital beds, yet many could be cared for elsewhere if appropriate facilities were available. In particular, end-of-life care illustrates the inappropriate use of hospitals. Notwithstanding recent increases in the proportion of people dying at home, many still die in hospital even though they would prefer to be cared for in a hospice or their own home. One of the challenges in this regard is to make community services available 24/7, to stop hospitals becoming the default setting because of a lack of other options.

I will move on to work force pressures. Since the application of the European working time directive to junior doctors, there has been a 50% increase in the number of junior medical staff required to fill a rota and provide 24/7 care, which many units have struggled to achieve. According to a report by the Royal College of Physicians, three quarters of hospital consultants report being under more pressure now than they were three years ago and more than a quarter of medical registrars report an unmanageable work load. I draw colleagues’ attention to the report, “Hospitals on the edge? The time for action”, which is well worth a read and should be borne in mind when discussing or defending local hospital services.

Recruiting into emergency medicine is also becoming difficult and application rates into training schemes involving general medicine are also in decline. According to the RCP, there is an increasing reliance on locums and unfilled consultant posts. That will have a negative effect on emergency care, which is vital to all. There is also an increasing recognition that services such as emergency surgery might be unsafe out of hours, and the provision of those services needs to be concentrated in fewer centres that are better able to provide senior medical cover.

Improving the quality of care often entails making available senior medical cover in some services on a 24/7 basis. That in turn means reducing the number of hospitals providing those services, to enable consultant medical staff to operate effective rotas in the evenings and at weekends. That would also reduce mortality rates, as most deaths happen on poorly staffed wards at weekends. The most contentious issues concern changes in the provision of accident and emergency and maternity services because of the importance attached to those services by patients and the public. Many of the changes derive from work force shortages, for example among consultants and midwives, making the current model of care unsustainable. That is leading to increasing differentiation in how services are provided. For example, some hospitals provide midwife-led maternity care and others no longer provide accident and emergency services at night.

I will now move on to cost. The merger of particular services, such as intensive care, A and E services and cardiac surgery, could improve quality and save money. NHS London, for example, has demonstrated that the recent reconfiguration of stroke services has achieved an improvement in quality as well as significant cost savings. The Department of Health estimates that in the last quarter of 2011-12, 10 out of 72 NHS acute and ambulance trusts were rated as “underperforming” or “challenged” on their financial performance. Of 143 foundation trusts, Monitor reports that 10 had a financial risk rating of 1 or 2—on a scale of 1 to 5, 1 being high—and that 11 were in breach of the terms of their authorisation on financial grounds. Twenty trusts have declared themselves unviable in their current form, including Heatherwood and Wexham Park Hospitals NHS Foundation Trust, which serves part of my constituency.

One of the most comprehensive reviews for clinical and financial evidence was Lord Darzi’s review of the NHS. He argues that future technological advances will result in an expanding number of diagnostic tests and therapies that could be provided more cost-effectively in a smaller number of regional specialist centres, such as the one I have suggested for junction 8/9 on the M4, rather than a large number of low-volume district general hospitals, which is currently the pattern in large parts of the country. For example, the Audit Commission has identified 25 operations or admissions and estimated that 75% of surgeries should be carried out as day cases. It estimates that if all trusts achieved an average 75% day case rate across these procedures, at least 390,000 bed days could be freed up. That would save £78 million, based on £200 per elective patient bed day.

Lord Darzi further explains that minimally invasive techniques will continue to improve. In the next 10 years, endoluminal surgery—entering the body through its natural holes, such as the throat—will become the standard method for treating many complex cases. Better diagnostics will also help most surgery to become non-invasive. Minimally invasive surgery means smaller scars and less risk of post-operative infection, which means patients will also recover more rapidly.

Furthermore, there is an argument for reducing the number of administrative staff required, which will be more cost-effective and save money that could be better spent on the quality of care. Hence, reconfiguration can deliver improvements in quality and safety without significant additional cost.

There are strong political and policy pressures to sustain, and where possible increase, local access to services, particularly those needed in an emergency such as A and E and maternity care. We have an ageing population, and the majority of hospital users will rely on public transport to take them to hospital. Transport systems will have to be put in place so that people can access the central hub hospitals.

How do we achieve the utopia I am seeking in the location and structure of national health service hospitals? I fear that we will need something that we do not currently have: some central direction. This project will take many years to achieve, and we need a cross-party committee to draw up a plan that applies to the whole of England and Wales, so that we can decide where the hospitals, including the community hospitals, are required. If we do that, I am convinced that we will be in a position to deliver the best care in the western world to all our constituents.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 27th March 2012 Commons Chamber

[Mr Lansley]

That is complete rubbish. The legislation is absolutely clear that it does not lead to privatisation, it does not promote privatisation, it does not permit privatisation and it does not allow any increase in charges in the NHS. It simply creates a level playing field so that NHS providers will not be disadvantaged compared to the private sector, as they were under a Labour Government.

[Steve Baker (Wycombe) (Con)]

The present Wycombe hospital consultation has proceeded with a number of hiccups, not least because of the false sense of local accountability engendered by Labour’s top-down system of health management. Will the Secretary of State meet me and a small delegation of my constituents to discuss how things will improve under his reforms?

[Mr Lansley]

Of course. I will be glad to meet my hon. Friend and his constituents. I recall how he has been an advocate on their behalf in the past and a vocal advocate of services in Wycombe. I emphasise to my hon. Friend that we are looking towards not only the clinical commissioning groups, but the local authorities injecting further democratic accountability so that in his constituency and those across the country we see much greater local ownership and accountability for the design of services.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 18th October 2011 Commons Chamber

[Mr Lansley]

I welcome the hon. Gentleman to the Opposition Front-Bench position. We are looking forward to the exchanges with him and his colleagues, including during questions today.

Twenty-two trusts have told us, in the course of our looking at where the impediments are to their financial sustainability for the future, that the nature of the PFI contracts entered into by the previous Government is a significant problem in this respect. It is absolutely right for the NHS to build hospitals, which is why we are, for example, building a new hospital at Whitehaven in the hon. Gentleman’s constituency. [Interruption.] I beg his pardon—in the constituency of the hon. Member for Copeland (Mr Reed); we are building so many new hospitals. The nature of the PFI projects we enter into must be to provide value for money and be sustainable in the future. That is something that the previous Government failed to achieve.

[Steve Baker (Wycombe) (Con)]

3. What representations he has received on the reorganisation of urgent care in the past six months.

[The Minister of State, Department of Health (Mr Simon Burns)]

A search of the Department of Health’s database revealed that 131 items of correspondence, and five parliamentary questions relating to the reorganisation of urgent care were received in the past six months. In addition, I have received three requests to meet MPs on this subject.

[Steve Baker]

Wycombe hospital is currently going through a consultation on a change to urgent care services, and it is doing so in the context of the betrayal felt after “Shaping Health Services” in 2004, which removed our accident and emergency department. I would like to escape this cycle through mutuality. What is the Government’s position on mutuality? Will the Minister join my call for directly owned community health services?

[Mr Burns]

The Government have supported the right to request, which has enabled 45 staff-led social enterprises to be established. This policy has supported approximately 25,000 staff into social enterprises, with contracts of roughly £900 million. NHS staff have been assisted by a wide-ranging programme of support from the Department.

NHS Future Forum

Steve Baker Excerpts

Tuesday 14th June 2011 Commons Chamber

[Mr Lansley]

I am sorry the hon. Gentleman tried to characterise that as he did. The joint committee of primary care trusts is conducting a consultation. The Government are not doing it; I am not doing it; the committee is doing it, and the consultation closes on 1 July. People across the country are quite properly making representations to the consultation, including on the Royal Brompton and other units. The committee has not made recommendations to me; it will come to its conclusions after that consultation, which has absolutely nothing to do with the structure of the proposals I am referring to today.

[Steve Baker (Wycombe) (Con)]

My constituents will not be interested in hard left, old school scaremongering. They simply want to know whether the Bill will put local health services under a greater degree of local control.

[Mr Lansley]

My hon. Friend will know that many of us in the House were deeply frustrated in the past that Ministers would say at the Dispatch Box that primary care trusts were responsible for local decisions, and then nobody found locally that the PCT was in any practical sense accountable to them or the population they represented. In future, there will be proper accountability: clinical accountability through the commissioning groups and democratic accountability through local authorities.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 8th March 2011 Commons Chamber

[Rehman Chishti (Gillingham and Rainham) (Con)]

14. What steps he is taking to improve NHS cancer services.

[Steve Baker (Wycombe) (Con)]

17. What steps he is taking to improve NHS cancer services.

[The Minister of State, Department of Health (Paul Burstow)]

We published our cancer strategy in January, which set out a range of actions to improve cancer outcomes and cancer services. We set out our plans to improve earlier diagnosis, access to screening, treatment and patient experience of care.

--- Later in debate ---

[Paul Burstow]

My hon. Friend is right to draw attention to that survey, which has produced invaluable data. More than 65,000 patients took part in the 2010 survey, and it is proving to be an invaluable tool in enabling trusts and commissioners to identify areas where there is scope for improvement locally. The cancer strategy that we published in January commits us to repeating such a patient experience survey, and we are exploring the options at the moment.

[Steve Baker]

What is the Government’s policy in relation to those charities that provide indispensable services to cancer patients and their families? I have in mind, in particular, Macmillan and Marie Curie.

[Paul Burstow]

My hon. Friend is absolutely right to describe the contribution of Macmillan, other cancer charities and, indeed, charities in the health sector more generally as indispensable. I recently had the pleasure of visiting Macmillan’s headquarters, where I did an online chat with a number of cancer sufferers and their families and saw the helplines and other support services that it provides. In our cancer strategy, we are very clear that such charities have an invaluable role to play.