NHS and Social Care Funding

Andrew Murrison Excerpts

Wednesday 11th January 2017 Commons Chamber

[Dr Whitford]

Money is not the only problem. I accept that part of it is about how things are done. The Secretary of State talks about variations and many hospitals performing well, but, as I said, only one trust is meeting the target and only nine are at over 90%, so it is not that the majority are doing well and a few are failing.

The ability to look at how we deliver the NHS is crucial, but change costs money. We must therefore invest in our alternatives so that our community services and primary care services can step up and step down to take the pressure off. One of the concerns about the STPs is that because people do not have enough money, a lot of them start by thinking that they will shut an A&E, shut a couple of wards, or shut community beds—even though those are what we need more of—to fund change in primary and social care. Then the system will fall over. We need to have double running and develop our alternatives and then we will gradually be able to send the patients there.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I always enjoy listening to the hon. Lady’s well-informed remarks. I agree that most people do not want to go to A&E if they can avoid it. Does she agree that part of the problem is that when people phone general practices, they tend not to be offered an appointment that they regard as being within a reasonable timeframe, or they cannot get to see the doctor with whom they are closely associated, which particularly applies to people with chronic and long-term conditions? As today’s National Audit Office report makes clear, we need to address that as a matter of urgency. Paradoxically, seven-day-a-week general practice may militate against being able to provide people with such continuity of care during core hours.

[Dr Whitford]

Many doctors in general practice would accept the argument for having access to a GP on Saturday morning, particularly for people who are otherwise at work. However, someone who cannot see their favourite doctor is very unlikely to go to A&E and wait eight hours to see a doctor they have never seen before in their life. This is not about that; this is about the fact that people feel they cannot find an alternative. If it takes three or four weeks to get any appointment with their GP and they do not yet have a community pharmacy offering such a service, they will eventually end up at A&E. It is therefore the service of last resort for people who go there and just stay there. We have to develop alternatives first, but as the hon. Gentleman says, no one in their right mind would choose to go and wait four hours in A&E if they could be seen in half an hour in a community pharmacy.

[Dr Murrison]

The hon. Lady is being very generous in giving way. I have to disagree with her, because winter pressures and the pressures we are seeing at the moment tend to involve not people with short-term, self-limiting conditions, but the chronically sick. Those people in particular, and with good reason, want to have a relationship with a particular practitioner who understands their needs and their family context. That is surely the essence of general practice.

[Dr Whitford]

I totally agree, but in fact the chance that their doctor will be on duty would actually be lower on a Saturday morning or a Sunday afternoon. One of the things we have done in Scotland with SPARRA—Scottish patients at risk of readmission and admission—data is to identify that 40% of admissions involve 5% of the patients. Those patients are all automatically flagged and will get a double appointment no matter what they ring up about, because it will not just be a case of a chest infection or a urine infection, but of having to look at all their other comorbidities.

That is the challenge we face; it is not a catastrophe of people living longer. All of us in the House with a medical background will remember that that was definitely the point of why we went into medicine, and it is the point of the NHS. However, we are not ageing very well. From about 40 or 50 onwards, people start to accumulate conditions that they may not have survived in the past, so that by the time they are 70 they have four or five comorbidities that make it a challenge to treat even something quite simple. My colleagues and friends who are still working on the frontline say that it is a question not just of numbers, but of complexity. Someone may come in with what sounds like an easy issue, but given their diabetes, renal failure and previous heart attack, it is in fact a complex issue.

That is part of the problem we face, and we need to look forward to prepare for it. We need to think about designing STPs around older people, not around young people who can come in and have an operation as a day case and then go away, because that is not what we are facing. Older people need longer in hospital, even medically, before they reach the point of being able to go home. It takes them a couple of days longer to be strong enough to do so. They probably live alone and do not have family near them, so they will need a degree of convalescent support and they may need social care. That is really where the nub of the problem lies. Social care funding has gone down, and therefore more people are stuck in hospital or more people end up in hospital who did not actually need to be there in the first place.

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[Dame Rosie Winterton (Doncaster Central) (Lab)]

The debate so far has shown the huge level of concern from the public and NHS staff about the crisis in the NHS and social care. The hon. Member for Totnes (Dr Wollaston) reflected some of the views of the Select Committee, but I ask all Government Members to take those concerns seriously and not to dismiss them. All hon. Members must surely be receiving representations from staff and patients about what is happening locally.

I want to pay tribute to all the health and social care staff in Doncaster, in particular those at Doncaster royal infirmary whose work I have seen at first hand. I know how dedicated and committed they are to caring for patients in these most difficult of circumstances. At the end of December, they had managed to achieve 90% against the 95% target and had good ambulance handover times, as well as good support from the council and community partners, but they are facing real pressures and they are fearful about the pressures still to come, especially if, as predicted, there is a cold spell. That is why the mixed messages from the Secretary of State have been extremely damaging.

I was a Health Minister for four years and had responsibility for emergency care. I know how important it is to work with NHS staff to help to implement targets, and not to give the impression that the NHS is somehow giving up on those targets. The lead from the top is incredibly important. There has always been controversy about targets, but as a Health Minister I visited many, many A&E departments. There is absolutely no doubt in my mind that the A&E target led to improved care for patients and that it reduced waiting times dramatically. The evidence is clear: it shows that that is what happened. One striking thing about those visits was seeing how consultants, nurses, ambulance teams and all members of the healthcare team worked together. For example, they would work out protocols so that emergency nurse practitioners could take over some of the work previously done by consultants, to ease the burden and share the work among the team. Triaging—seeing who needed urgent treatment by a consultant and who could be seen by a nurse practitioner—became the norm.

I would ask staff, “Is the target getting in the way, or is it helping?”, and invariably the answer would come back, “It helps us to work together more effectively.” I vividly remember a nurse practitioner saying, “Please don’t abandon the target, because it is making the consultants sit down with us and look at the whole team.” For patients, the difference was crucial, as it was for practitioners’ working lives, because they were not having to see patients who had been sitting around for hours and were feeling thoroughly depressed and demoralised. That made a difference to the healthcare team as well, because it improved their working life as well as patient care.

[Dr Murrison]

Does the right hon. Lady agree that it is not so much meeting the target that is important as getting patients seen expeditiously and well? There is not an A&E department in this country that does not want to improve its position in the league table of response times. The difference that now applies, and which perhaps did not apply quite so much when she was a Minister, is that the level of informatics and comparison is much improved. I suggest to her, ever so gently, that while the four-hour target was important when she was a Minister, its importance has degraded over time, because everybody is trying to see patients more quickly.

[Dame Rosie Winterton]

I do not agree with the hon. Gentleman. The four-hour target led to much better diagnoses and much improved provision of the type of treatment that people needed, as well as better interaction with communities. And I want to come on to that point because the Secretary of State has been trying—perhaps the hon. Gentleman is guilty of this as well—to separate the target for A&E departments from what happens outside, whereas I see the importance of putting the two together. Providing alternative treatment, which is perhaps part of what the hon. Gentleman was getting at, means having proper support in the community. It was bringing those two things together that made it possible to achieve the target, so it was a driver.

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[Sir Simon Burns]

The hon. Lady is absolutely right. There was a wage freeze for those who were earning more than £20,000 a year, but that was in keeping with the policy throughout the public sector, which included Ministers and other Members of Parliament.

The important point is that it was possible to achieve that saving by a variety of means. One of them was a pay freeze, but others were improving the delivery of service, cutting out inefficiencies and ineffective ways of operating and getting rid of nearly 20,000 surplus managers, so that the NHS could concentrate on enabling clinicians, nurses, ancillary workers and everyone else to work on patient care. That is the right way forward, and we cannot give up on it. We must continue to think about where we can make savings.

[Dr Murrison]

Will my right hon. Friend give way?

[Sir Simon Burns]

I am afraid not, because I am about to finish.

Much has been said about the STP programme. We have an STP in Mid and South Essex, and I strongly support it, because it is completely focused on improving and enhancing the quality of accident and emergency care. What annoys me is that people wish to politicise it for grubby political reasons. [Interruption.] Funnily enough, I am not talking about Opposition Members.

Our STP involves three hospitals with three A&E departments. Not one of those departments is to be closed under the proposals, yet as soon as they were published, and on the assumption—correct, I suspect—that most people had not read them, word went out that my local A&E department was to be closed down by the Department of Health because of this nasty Government’s proposals to save money. The exact opposite was the case. If one read the document, one could see that all three A&Es are remaining open.

What will happen is building on what happens now. If someone has a heart attack, they are immediately taken to Basildon hospital, because that is the specialist for cardiothoracic treatment. If someone needs treatment for burns or plastic surgery, they come to Broomfield hospital in Chelmsford, because it has one of the finest units in the whole of Europe. If someone has a head injury, they will go down to Romford in the east of London, because that is the specialist area for people with head injuries. If I had any of those conditions, I would want—and I would want for my constituents—the best possible treatment from the best experts available. That is what is happening and that is going to be built on, enhanced and improved. That is an improvement. That is not a cut; that is not taking away services from local communities. Those people who have an agenda and want to play politics will tell people anything in the hope that they believe it, or to frighten them by trying to discredit the work of the NHS.

I am pleased we have had the opportunity to discuss this matter. It is very tricky, and there is no simple answer—what is happening is not unique; we frequently have winter crises, particularly because of the ageing population and the increasing demands on health services in recent years—but we must not lose sight of the fact that we have an NHS and a Government who are determined to improve further and enhance the quality of care and the safety and standards of care for all our constituents, aided and abetted by a first-class workforce who are often working under very difficult circumstances.

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[Mr Harper]

The whole point of the STP process is to ensure that we have capacity across the health sector. One important thing that the Secretary of State talked about is the other changes to the health and social care system—indeed, that is mentioned in the Prime Minister’s amendment, which is why I will support it. In that I agree completely with the Chair of the Select Committee. We have to look at the two things together.

Unlike what the hon. Member for Central Ayrshire (Dr Whitford) said, in Gloucestershire we are lucky to have a single CCG and a single county council, which work well together with lots of joint working, and they increasingly want to bring health and social care together. That is exactly what the Chair of the Select Committee said, it is the right thing to do and it is what the hon. Member for Central Ayrshire said is being done in Scotland to help deliver a better service.

My hon. Friend the Member for Cheltenham (Alex Chalk) is right that, the more we can improve capacity in the system to ensure that people can access primary care where they need it and can access social care where they need it, we will take pressure off the accident and emergency system. Indeed, when I visited the A&E department, it had a good triage system in place, with general practitioners based in the department to ensure that people with conditions that can be treated by general practice are signposted and treated in an appropriate setting, rather than damaging the service’s ability properly to deliver acute care to those who really need it. We need to consider such steps, going forward.

[Dr Murrison]

Would those people fall within the four-hour target? That lies at the heart of the debate. Should the four-hour target cover both urgent and more elective problems that people present to casualty departments?

[Mr Harper]

I do not know the detail of how the statistics are measured, but the important thing is to ensure that people who walk through the front door of an A&E department but who do not need urgent care receive care in the appropriate setting and are properly signposted, whether to community pharmacies, general practice or the information services that the NHS provides online or on the telephone. It is about making sure that people go to the right setting. The Government acknowledge that that is not perfect at the moment, and they are doing a lot of work to improve it in the future.

Finally, the Government’s moves to devolve spending power and decision making to local areas, particularly given what will happen in Greater Manchester, to bring health and social care together is the way forward, and I have certainly encouraged my local authority, as it leads the formulation of our devolution proposals, to make an ambitious ask of the Government on health. I hope the Government will look at that very seriously in the months ahead.

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[Dr Andrew Murrison (South West Wiltshire) (Con)]

This has been an absolutely first-rate debate, with a number of extremely fine contributions. I was particularly taken, as ever, by the remarks of my hon. Friend the Member for Totnes (Dr Wollaston), the Chairman of the Select Committee. She rightly pointed out that we are all living longer, which is a great thing, but that unfortunately our healthy lives are not expanding. This causes real problems for A&E, which has to deal with that. Although we talk about large numbers of people passing through A&E departments—they are dealing with more people all the time—the truth of the matter is that it is those with chronic long-term and complicated conditions who tend to assume the lion’s share of A&E resources and those of the rest of the secondary care system. As we get older, there will be more and more of such cases. We need to prepare for them.

We also need to militate against those cases. One thing that has not been discussed very much this afternoon is prevention and public health: our need to ensure that we deal with things that are avoidable. The Prime Minister, in her excellent speech on Monday on the shared society, rightly said:

“We live in a country where if you’re born poor, you will die on average 9 years earlier than others.”

That is absolutely appalling and we should all be ashamed. Half that health inequality is due to tobacco consumption. Someone in a manual occupation is far more likely to be a smoker or to smoke more than a professional or managerial person. We have to be serious about controlling the scourge of tobacco. I encourage Ministers to produce the tobacco control plan, which is now overdue, as soon as possible, as we need to deal with this issue. I hope that the plan will contain some helpful remarks on the tobacco duty escalator and the licensing of retailers and involve serious conversations with supermarkets. The aim must be to reduce the availability of tobacco, reduce consumption and therefore reduce the burden of diseases that are affecting our NHS and having appalling consequences for citizens.

I very much support the Government’s amendment to the motion. I was not present when the hon. Member for Central Ayrshire (Dr Whitford), who speaks for the SNP, was speaking about community hospitals. I am sorry about that, because community hospitals are particularly important to me and I would have liked to respond to some of her remarks. I have community hospitals in my area. In particular, there is one serving my constituency at Shaftesbury that is threatened with bed closures under the STP. We need to be very careful about short-term funding cuts that might appear expedient, when we have not properly costed the service. Providing that the case mix is right—and traditionally case mixes have been pretty appalling in the NHS—community hospital beds can provide a cost-effective means of treating people, particularly the elderly, in a setting close to their homes rather than in large acute hospitals, which are the wrong places for elderly sick people. Community hospitals can deal quite effectively with some of the delayed discharge problems currently afflicting our system. As Members of Parliament, we are all sometimes faced with the political choice of whether to oppose, for our own expediency, the closure or reorganisation of services. I have faced that in my constituency. I was pleased to hear my right hon. Friend the Member for Chelmsford (Sir Simon Burns) say that sometimes we need to be brave when approaching such matters.

If we want to drive up standards and outcomes in our NHS, we will have to look increasingly at specialist centres, which will inevitably mean service reconfiguration and probably some closures. That will be disagreeable to many colleagues, but specialist centres certainly improve standards and outcomes for things such as cancer, strokes and heart attacks, and that implies regional and sub-regional services. I would not be one to oppose a closure, reorganisation or reconfiguration for its own sake. We have always to understand that resources are finite and that we need to get the best service and outcomes for the money available.

I say gently to the Minister that we need to look at funding. He will be aware of the campaign by the right hon. Member for North Norfolk (Norman Lamb), which I support, in relation to a commission or convention. It seems a non-partisan way of trying to approach the very difficult conundrum of how we will fund the NHS going forward. I commend it to the Minister. I was pleased to hear the Prime Minister say at lunchtime that she was prepared to meet colleagues concerned about the issue to see whether this proposal could be a productive and helpful way forward. We do not spend as much on the NHS as we need to. That is the bottom line. It is no good people saying we spend 1% above the OECD average. That is not good enough, given that the OECD includes countries with which most people in this country would not wish to be compared. As the Government of the day made clear several years ago now, we need to close the gap with the EU 15, particularly with countries such as Germany, France and the Netherlands, whose outcomes are much better than ours. It is no coincidence that they spend much more on healthcare.

Today, the chief executive of the NHS is being examined by the Public Accounts Committee. I hope he will be examined on the £22 billion efficiency measures that he felt might be achievable in the five year forward view. Two years in and it is clear that those savings will not be met—they never were going to be met. We need to determine how we are going to make up the delta—the difference—between the efficiency measures that the NHS can reasonably achieve and those projected two years ago.

I want to finish by congratulating the Minister and the Government on achieving what they have. We have heard how things have improved in recent years, particularly in relation to such things as activity and hospital infections, but there is much more to do. In particular, I hope he will look closely at the funding issue.