NHS: North-West London

Andy Slaughter Excerpts

Wednesday 24th April 2019 Westminster Hall

[Andy Slaughter (Hammersmith) (Lab)]

I beg to move,

That this House has considered the NHS in north west London.

It is a pleasure to serve under your chairmanship, Sir Christopher, and to see so many of my Labour colleagues from north-west London here to support this debate. It will be a relatively short debate on a rather lengthy subject, so I will try to keep my remarks concise, or at least as well ordered and structured as I can. To that end, I will touch on two subjects, and perhaps mention one or two other issues. The first subject is the collapse or withdrawal of the “Shaping a healthier future” programme, which was principally around the reorganisation of acute care; the second is the commercial Babylon GP at Hand service, which is distorting the primary care market, and not just in Hammersmith and Fulham, or indeed in north-west London.

I will begin by reflecting on how we got to where we are. In 2012, “Shaping a healthier future” was heralded as the biggest hospital reorganisation programme in the history of the NHS, but was quickly called the biggest closure programme in its history. It was a scheme for closing four of the nine type 1 A&Es across north-west London, and completely restructuring, demolishing and—in common parlance—closing two of its major hospitals, Ealing and Charing Cross, which is in my constituency. When the scheme was announced, it was unambiguous that it was about saving money. It was part of a programme to save about £1 billion, and we were told that if it did not happen, the NHS in that area would go bankrupt. Those were literally the words that were used. Much water has flowed under the bridge over the past seven years, until almost exactly a month ago, when the scheme was withdrawn wholesale in a rather hole-in-the-corner way.

This is something of a bittersweet debate. I do not know anybody in north-west London who is not delighted that the scheme for hospital closures has been withdrawn, yet because of the way those seven years have been wasted and how the scheme has been dealt with over that time, we are left with as many questions as have been answered. I do not have time to go through the whole history of those seven years. Suffice it to say that Charing Cross Hospital is the second-largest hospital of the nine in its sub-region; it has 360 beds, almost all acute. It was to be demolished. It was to lose more than 300 of those beds—more than 90%. It was to lose all of its major emergency services and its A&E, and effectively be replaced by what was called a local hospital, with primary care and treatment facilities. In other words, it would have been a very radical shake-up.

Throughout the process, there was a frustrating lack of honesty; there was no admission of what the scheme was, certainly not at a political level. If someone drilled down into the business plan or clinical strategy, it was clear what was being advocated. We were told that in some way, the increase in community services and primary care that was also part of the “Shaping a healthier future” scheme would make up for the loss of those hundreds of acute beds and those A&E facilities. It is now commonly accepted that this was always an entirely misconceived plan, as the King’s Fund—to give just one example—has said. Given the rise in demand, the best that could be hoped for was that if the increases in primary and other care services took place, we would be able to cope with the current amount of acute capacity.

The idea that we could dramatically reduce capacity was entirely misconceived. That is not conjecture; it was proven in 2014, when stage 1 of “Shaping a healthier future” went ahead, with the closure of the A&Es at Hammersmith Hospital and Central Middlesex Hospital. We were told that as those were not two of the main A&E departments, those closures would easily be coped with. However, demand at St Mary’s, Northwick Park and Charing Cross went up to such an extent that they had some of the worst waiting time figures of anywhere in the country. Since then, those figures have come down only slowly and gradually.

I hope that the Government and the health service will learn lessons from this scheme—that is probably the best gloss I can put on this. It has taken a huge amount of time and effort, and a huge amount of money wasted by the health service, to get to where we are today, which is effectively back to where we were seven years ago. In 2012, it looked as though the situation was hopeless, and I have to praise Ealing Council, which was then Labour-controlled. At that stage, Hammersmith and Fulham Council was under Conservative control, and from 2013 onwards it fully backed the closure strategy. Ealing Council stood absolutely solid and firm; it mounted a judicial review, and opposed those proposals from day one.

When there was a change of political control in 2014, that council was joined by Hammersmith and Fulham Council, which, together with surrounding Labour councils, set up the Mansfield commission under Michael Mansfield. That independent commission looked at the “Shaping a healthier future” proposals, and when it reported, it said that those proposals would be a health disaster for the area. By that stage, the sustainability and transformation plans had been introduced. In a way, it is regrettable—although it was the right thing to do—that both Hammersmith and Ealing councils refused to participate, because they knew how damaging “Shaping a healthier future” and the hospital closures would be for the area.

Over all that time, I do not think a week went by in which I did not deal with this issue, both here and in the constituency. There was a sustained campaign of what I can only call disinformation. A lot of money—£72 million is a conservative estimate—was spent on consultants, preparing for the “Shaping a healthier future” programme. All of that money was wasted. Despite the fact that we relied entirely on internal health service documents to prove what was being planned, I was constantly told by everyone from the then Prime Minister down that we were scaremongering, and that the proposals were sensible and helpful.

It is curious that when the Health Secretary announced the withdrawal of “Shaping a healthier future” a month ago, the Government withdrew support from the scheme, as if somebody else had thought it up. Until that point, we had been told every day and every week for seven years that it was a sensible scheme, which would only improve resources and services within the health service. It is to be regretted that the Government did not sit down with politicians, campaigners, local residents and the local health service to talk through where we were and where we were going. Instead, in a rather hole-in-the-corner way, they used the contrived trick of using a planted question from a Conservative Back Bencher to announce withdrawing from the scheme. That does not bode well for the future.

Although we are extremely pleased that the programme has been cancelled, and that both Ealing Hospital and Charing Cross Hospital will stay open, where do we go now? First, Charing Cross Hospital has the largest maintenance backlog—£300 million—of any hospital in the country. That was clearly not under consideration, because it was intended that the structure would be demolished. In actual fact, the capital moneys are simply not there to have done that in any event.

The other hospitals in the area, including West Middlesex, Chelsea and Westminster and St Mary’s, were promised that they would benefit from the closures, and that there would be substantial investment. My question to the Minister is: what is the plan going forward? For political expediency, the Government have bailed out of “Shaping a healthier future”, and we are grateful for that, but where do we go now? Certainly the clinicians and the managers in west London cannot answer those questions. This thing has been entirely derived and supported by the Conservative party and this Government. It is for them to answer that question, rather than simply leaving our local health service to stew in that way.

Before I move on, I want to say that some of the staunchest campaigners have turned up to listen to this debate. I last saw them at the victory party at Hammersmith town hall a couple of weeks ago. Without their contribution, we would not be here. They countered well funded, well resourced and entirely disingenuous statements about what would happen to the health service. Every week, rain or shine, they were out talking to and converting the local population. One could say that the local population might not need much conversion to preserve a much-loved, major local hospital that has just celebrated its 200th anniversary, but the reality is that that needed to be done, because millions were being spent on spinning the yarn that the changes would be good for local health services. The campaign was not based simply on sentiment or popular feeling. It was well researched, and well supported with independent clinical evidence. The campaign was based on the day-to-day, week-to-week, absolute dedication of people who worked for nothing, and had nothing in common other than their love of the national health service and their feeling that Government at all levels had got it wrong.

With that, I will move to another topic, GP at Hand, which the Minister probably does know something about. We have become increasingly alarmed at its trajectory. For those who do not know, GP at Hand is a digital app provided by a private company called Babylon Health. The service has raised an enormous amount of concern at different levels; I will narrow that to four points.

The first and most obvious concern is how GP at Hand works. It attaches itself to a particular bricks-and-mortar GP practice—in this case, a particular surgery in Fulham. It was an orthodox GP surgery with a list of around 4,000 patients before that association began. As of today, it is approaching 50,000 patients, and is one of the largest GP practices in the country. That distortion has a cost implication for the clinical commissioning group, initially in Hammersmith and Fulham. It is estimated that over the two years from 2018 to 2020, that distortion alone will cost the CCG about £26 million. There is no provision for that at the moment, and that has to be addressed. I would like to hear from the Minister that there is a scheme for addressing that, and that there will be full reimbursement of those costs.

For those who are not aware of how the system works, it is very straightforward. When patients sign up to a GP practice, the money effectively goes with them. What is not anticipated is that there will suddenly be a tenfold increase in a patient list over one or two years. Why is that money not simply redirected? It has been, to some extent, to the CCGs in west and north-west London, but the money is not provided to the much wider catchment area—GP at Hand now serves not only Greater London and a wider travel area, but has expanded to Birmingham—because those other CCGs are saying, “Hang on.” A digital app of this kind attracts a certain type of patient: younger, fitter patients—effectively those without complex medical conditions or co-morbidities. They do not take up a lot of the GP’s time, as their issues are relatively simple and straightforward to deal with. Often they do not contact the GP at all for long periods.

Those patients effectively subsidise older and sicker patients. There is a perfectly understandable resistance from local GPs and CCGs to allowing those patients to escape, leaving them only with the most demanding and least cost-effective patients. If the issue is not addressed, the problem that results for my CCG is an annually increasing bill, going from £10 million to £16 million and who knows what beyond that, with no provision for that in any way.

The second concern, which has been expressed by clinicians and those who have simply tested out the app, is whether the app—like other apps, it is based on algorithms and diagnostic tools—is accurate and good enough. Has it been sufficiently tested? It is growing logarithmically across the country. It is not a question of it perhaps being tested in a small area and got absolutely right before it moves on. It could be in your constituency tomorrow, Sir Christopher, and it could be across the entire country in a year or two.

The third issue is that GP at Hand is driven entirely by a single commercial provider. It is a way of doing digitisation, but it is the way of the wild west to simply allow one particular firm to start from one location and expand across the country at a rate that it determines, controlled only by its advertising budget and its ability to attract customers. In my submission, there is no thought behind how that is done. The NHS is jumping to the tune that is being played by GP at Hand. One might suggest that it should be the other way around.

The fourth and perhaps most contentious issue is the fact that this particular private provider has had the support of the Secretary of State for Health from the beginning. He is a subscriber and has written about it in glowing terms. Whenever the matter is raised in the House and he is responding, at Health questions or wherever else, he has only praise to give it, but he is parti pris to this. Not only is that of concern in itself, but it means that when one is talking to local, regional and even national organisations within the NHS—this is now a national issue—they are looking over their shoulder, because their boss or their boss’s boss is saying, “This is the future and this is what is going to happen.”

With the support of a number of colleagues, I have written today to the Chair of the Health and Social Care Committee, asking the Committee to undertake an investigation into GP at Hand. I know that she shares a lot of my concerns, so I am hopeful that that investigation will follow. I ask the Minister to give what assurances she can on those four points that I have raised.

Sir Christopher, I can see you are looking at the clock, and my colleagues are looking at me with daggers drawn, so I will speak for one more minute and then sit down. That means that I cannot go into detail about the other local health service issues, which will have to wait for another day. Suffice it to say—I will give a lightning portrait—that in Hammersmith and Fulham, we have a number of failing GP practices that are either suspended or require improvement. We have planned substantial cuts to our CCGs of £30 million. We have cuts planned to palliative care, community care and the hospital sector, including a proposal to close the hydrotherapy pool at Charing Cross Hospital. Everybody who has been involved in that has told me that it provides an invaluable service.

The overall picture is one of declining and reducing services. Only yesterday, a letter informed us that the “Beyond places of safety” scheme, which is very good, has been suspended because the funding is not there. There is no pretence any more that we are restructuring services, or reducing such things as management costs—that has all been done. What is being cut now are basic and essential services from the community, primary and indeed acute sectors.

I will conclude, as colleagues want to contribute to the debate. I hope that the Minister appreciates the seriousness, complexity and universality of the cuts that are happening across the health service. I hope that she will be more magnanimous than some of her colleagues in admitting the mistake that was made over “Shaping a healthier future”. We can turn the page and move on. We all want to work together for improved health, but first, some of these issues have to be addressed.

[Several hon. Members rose—]

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Seema Kennedy)]

It is a pleasure to serve under your chairmanship, Sir Christopher. I thank the hon. Member for Hammersmith (Andy Slaughter) for securing this important debate, and all hon. Members for speaking so passionately. I welcome the campaigners, who have been following our deliberations this afternoon. Everybody has spoken passionately about NHS services in north-west London, and the hon. Gentleman spoke about his area of Hammersmith and Fulham. I am under considerable time pressure, and if I do not answer all the questions that hon. Members raised, which ranged over primary and acute care, I am happy to write to them later.

I would like to start by thanking everybody who works in the NHS—in primary, secondary and community care—for everything they do, particularly in north-west London, which is a busy area with a lot of demand on services. It is exposed to unique pressures, but there are also unique opportunities. It has some of the country’s busiest services and is used by an increasing, complex and dynamic population. Our capital city challenges our NHS, but it is also home to transformation and innovation that has delivered important benefits for patients.

“Shaping a healthier future” looked at the pressures on the NHS in and around the hon. Gentleman’s constituency. It achieved significant benefits for patients in north-west London. It delivered 24/7 urgent care centres in every local borough and improvements in maternity and emergency paediatric care, and introduced a range of initiatives to help people obtain the specialist care they need closer to home. The NHS in north-west London is now in agreement to move on from the “Shaping a healthier future” programme. The hon. Gentleman asked specifically what the future will hold. In January, the Government announced that there will be an extra £20 billion a year for the NHS by 2024. As part of that, every area in the country will need to develop its own local plan for the next five years for how to spend the extra money. The north-west London sustainability and transformation partnership, working with clinicians and the public, will develop a new long-term, five-year plan for how best to spend that money, working together as a single health system.

I want quickly to address the points that the hon. Gentleman made about the lack of honesty in the north-west London process. Reconfiguration processes are, by their very nature, contentious, and raise many passions locally and nationally. His passion was evident from his contribution. The consultation process in north-west London involved extensive public consultation and clinical engagement throughout. It is important to recognise the high level of clinical engagement. It was never a political exercise or a fait accompli. Its underpinning principle was what was best for patients with the available resources. We need to support NHS staff and managers as they face the challenges before us. We must help them to manage service change responsibly. General practice primary care is the front door to and the cornerstone of the NHS, which is why the long-term plan addressed it when it was published in January.

I want to speak about Babylon GP at Hand. The hon. Gentleman raised a number of issues, and I will do my best to answer them. He spoke about the cost to the CCG. I wrote to one of his council colleagues this morning about the issues he raised. I understand that the CCG has reported that it overspent by £10 million in 2018-19, specifically in relation to GP at Hand. NHS England will of course have to look at the year’s final accounts and any overspend in more detail to understand better the precise financial impact of changes in the borough. For 2019-20, the CCG’s target allocation has increased, all else being equal, in line with the growth in its overall registered population up to the 12-month average for November 2017 to October 2018. NHS England does not believe that the CCG has had to scale back services because of any extra financial burden from GP at Hand, but we will continue to work with the CCG and other partners to explore options for maintaining the robustness of the commissioning system, both now, while GP at Hand is focused in London, and in the future.

I just want to address the hon. Gentleman’s point about safety.

[Andy Slaughter]

I suspect the Minister was referring to my colleague, Councillor Ben Coleman, the cabinet member for health and adult social care, who wrote to the Secretary of State on 15 April specifically asking for the money spent—£10 million—to be refunded, and for a commitment to reimburse the CCG fully for the cost of GP at Hand. I did not hear the Minister say that, so will she give that assurance?

[Seema Kennedy]

I cannot give that reassurance, and I would only reiterate what I have just said to the hon. Gentleman.

On the safety of the app, all NHS providers are held to account through a robust network of systems, including, and not limited to, the inspections of the Care Quality Commission. Any apps providing video consultations must be evaluated and regulated to ensure that the patients who access those services can be confident that they receive safe, effective and high-quality care. Hammersmith and Fulham CCG, along with NHS England, has commissioned an independent evaluation of GP at Hand, which will report shortly.

I question what the shadow Minister said. Digital technology is part of the solution, but the Department is looking at other ways of transforming primary care. We are looking at how we look at partnership models and at how we pivot to primary in future. All patients will have a right to digital-first primary care, including web and video consultations, from April ’21. All patients will be able to have digital access to their full records from 2020. They can, from this month, order repeat prescriptions electronically as the default.

By the end of the next decade, digital innovations are likely to have transformed the NHS. They will allow clinicians to work more efficiently and flexibly so they have more time to spend caring for patients. Every pound spent will go further. That will allow for greater responsiveness and personalisation for patients. We need to design services for patients and things that are available for people when they want them and at times that are convenient for them. I am pleased that the Government have committed to saying that all patients will have access to digital-first primary care from April 2021.

I acknowledge the hon. Gentleman’s concerns about the effect of GP at Hand on primary care as a whole in his constituency. The challenge for the Government and NHS England is to ensure that the way we commission, contract and pay for care keeps up with the opportunities digital innovation offers, ensuring that the new technology is safely integrated into existing pathways without unduly destabilising the services it works alongside. Two important principles within the NHS are that a patient can choose which practice they register with, and that funding follows the patient. The emergence of digital-first providers, which register patients who may live some distance from the practice, raises the question of whether these funding arrangements are fair. This year, NHS England is analysing and reviewing the out-of-area registration.