NHS

Baroness Keeley Excerpts

Wednesday 5th February 2014 Commons Chamber

[Mr Hunt]

I am afraid that my hon. Friend is absolutely right. Perhaps the situation is put into perspective when we know that those PFI deals are costing the NHS more than £1 billion a year: £1 billion that could have been spent on providing compassionate care and looking after patients with dignity and respect, but instead is having to finance Labour’s appalling mismanaged PFI contracts.

Let me return to the issues raised by the right hon. Member for Leigh. I think that a much more substantive argument relates to the things that he chose not to say. This is the day before the anniversary of the Mid Staffs report, and this is the day on which hospitals are finally putting behind them Labour’s appalling legacy of poor care. We have 14 hospitals in special measures—all of them, incidentally, with A and E departments—making encouraging progress after a very difficult year, with 650 additional nursing staff and 50 board-level replacements between them. Every single one of those hospitals had warning signs under Labour, but rather than sorting out the problems, Labour chose to sweep them under the carpet, sometimes because they had arisen during the run-up to an election. There are 5,900 more clinical staff in the NHS than there were a year ago, and there are 3,300 more hospital nurses than there were at the time of the last election. All those people are vital to the functioning of our A and E departments.

Bullying, harassment and intimidation were perhaps the ugliest features of Labour’s management of the NHS. Now we have seen courageous A and E whistleblower Helene Donnelly being given a new year honour, alongside brave campaigner Julie Bailey, who was literally left out in the cold when she came to lobby the right hon. Member for Leigh about poor care at Mid Staffs.

There is much to do—poor care persists in too many places—but with a new Ofsted-style inspection regime, in England but not in Labour-run Wales, we can at least be confident that poor care in A and E departments and throughout hospitals will be highlighted quickly, and not hidden away. We will keep people out of A and E departments in the first place—that is something to which the right hon. Gentleman referred—with the return of named GPs for the over-75s and integrated health and social care through the better care fund: precisely the joined-up, personal and compassionate care that was envisaged when the NHS was founded 65 years ago.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

Was not one of the key points that Francis made about transparency? The Secretary of State is making claims about staffing numbers which are not recognised. Ministers have had the opportunity to go along with a better scheme of transparency in hospitals, whereby they display every day on the ward their staffing ratios—as Salford Royal does. The Secretary of State will not accept that, however. If he thinks that putting out the totals of staff once a month is an adequate way of dealing with the Francis recommendations, he is fooling himself.

[Mr Hunt]

We on the Government Benches will take absolutely no lessons about transparency in the NHS from Labour after what it did for so many years. I think what we are introducing is a huge step forward, because for the first time every hospital in the country will, as a minimum, have to publish their ward-by-ward staffing ratios every single month. They can publish more—they can do what Salford does—but for every hospital in the country to do that every month is a huge step forward.

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[Grahame M. Morris]

I am grateful to the right hon. Gentleman for that intervention, because his point is germane to my argument. I shall develop that subject in the few minutes I have left when I talk about the consequences of what is happening in social care. I certainly feel that some of the policies that his Government have supported have contributed to the crisis. For example, the top-down reorganisation has had a damaging effect on A and E performance. I will address that point in a moment.

Other hon. Members have spoken today, in interventions on my right hon. Friend the Member for Leigh (Andy Burnham), about patients being ferried to hospitals in police cars. That has certainly happened in County Durham, and it must be a cause for concern. The A and E crisis can largely be placed at the Government’s door, because they have not faced up to some of the problems. It has rightly been pointed out that the number of admissions had risen by 633,000, not least because of demographic changes involving more older people and people with core morbidities and multiple conditions. That is placing a huge amount of extra pressure on A and E departments, but that pressure is being compounded by damaging cuts to local authority budgets.

My own local authority, Durham county council, is experiencing cuts of £222 million between 2011 and 2017. I know that Ministers will say that social care is ring-fenced and that £3.8 billion is being transferred to the home care fund, to be made available to clinical commissioning groups and local authorities, but what that means in real terms for the people living in Easington is that EDPIP—the East Durham Positive Inclusion Partnership—which supports frail elderly people and young people in vulnerable families, is closing down because of a lack of funding from the local authority. Similarly, East Durham Community Transport, which provides transport to take the frail elderly—including my mother, incidentally—to day centres and elsewhere, has been severely curtailed.

The Government have been warned by experts that cutting the staggering £1.8 billion from council social care budgets in the first three years of this Government would have a knock-on effect for the NHS, particularly in accident and emergency departments. That point has been made in expert witnesses’ evidence to the Health Select Committee, on which I have the honour to serve. Because of the cuts to social care, fewer older people are getting adequate support in the community, and are therefore visiting A and E departments instead. The impact of that is twofold. First, it means that those with care needs are not getting the treatment they need. Secondly, it means that our A and E departments are being put under great strain. Directly and indirectly, the Government have ignored warnings that by slashing social care they would make it difficult to discharge patients with care needs because it would be unsafe to send them home.

[Barbara Keeley]

Perhaps it would be pertinent at this point to mention the comments of Sir Bruce Keogh to the Health Committee’s inquiry into urgent and emergency medicine. When I asked him if the cuts in social care bothered him, he said:

“Yes, it does bother us and I think it bothers everybody. We are trying to maintain a stable and improving service in the NHS at a time that our colleagues in social care are taking a massive hit to their baseline.”

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[Paul Burstow (Sutton and Cheam) (LD)]

May I start by agreeing with the right hon. Member for Rother Valley (Kevin Barron)? The issue of alcohol has been ducked by successive Governments for a very long time. He is absolutely right to campaign on it, and I absolutely agree that we need to see the introduction of minimum unit pricing. However, we should not in any way give the impression that that of itself is the entire solution to what is a broad societal problem. None the less, it most certainly would make a significant contribution. I hope that, at the next election, it will be part of my party’s platform on public health issues.

My hon. Friend the Member for Stafford (Jeremy Lefroy) was right to call for a debate on the Francis report. I hope we will be granted Government time to debate it. If not, I would certainly join him in an application to the Backbench Business Committee for a debate on the Floor of the House. We should have the opportunity to bring Ministers here to debate the report.

Before addressing some of the comments made by the shadow Secretary of State, I wish to place on the record my thanks to the staff at my local hospital, St Helier, for all the work they do not just over the winter period when the pressure is undoubtedly at its most acute, but right across the year. Having been in the hospital over the Christmas period singing carols, which hopefully did not discomfort people too much, I saw for myself just how that pressure can build. I also saw how well the staff are perceived by their patients.

I want to register a frustration with the Minister today about something that has been going on in my patch for several years now. For almost as long as I have been an MP, clouds have from time to time gathered over the future of my local hospital. In 2010, the previous Labour Government signed off an outline business case for the rebuild and refurbishment of St Helier’s hospital. That was great news, and a culmination of work by my right hon. Friend the Member for Carshalton and Wallington (Tom Brake), the hon. Member for Mitcham and Morden (Siobhain McDonagh) and me. We secured funding from the Government worth some £219 million. Then there was a change of Government; a coalition came in. Given the spending review and the desire to tackle the public borrowing problem, it was far from certain whether that funding would stay in the Budget. Again, the three of us lobbied hard, and we were delighted when my right hon. Friend the Chief Secretary to the Treasury was able to confirm the funding.

However, in the dying days of the primary care trusts, a review was launched of accident and emergency and maternity services in south-west London. It was called Better Services Better Value, but it offered neither. It has been an absolutely crystal clear case study of everything that is bad and wrong about NHS change management. There are some really good examples of change management, stroke care in London being the exemplar. However, we have to refer to that example too often, as there are too few other really good examples of change having been managed well. All too often the public feel left out of such processes, and it is no wonder they mount the barricades to oppose change of which they feel no ownership.

My right hon. Friend the Member for Carshalton and Wallington and I were repeatedly told during the process by the then chief executive of the primary care trust, Ann Radmore, that the rebuild of St Helier was a fixed point in the whole process. It was not to be touched; it was sacrosanct and the rebuild would happen regardless. I have to say, however, that the events of the past three years have left me feeling betrayed and lied to. As a result of the uncertainty caused by BSBV, three years on—despite GPs having now declared BSBV’s proposals unviable, and having gone back to the drawing board—my local trust and clinical commissioning group are saying they cannot proceed with that £219 million. They lack the will and vision to take it forward, and I hope the Minister can confirm today that the £219 million is still in the Department’s budget lines and that he will encourage my local NHS to work with my local councils and Members of Parliament to bring forward these plans.

The motion moved by the shadow Secretary of State today feels a bit thin, and a little like a re-editing of its previous two incarnations in an attempt to create the sense of a febrile environment of a looming and predicted crisis and calamity that is about to engulf us all. That tactic has been adopted by the Opposition time and again, and time and again it has not been borne out on the ground. The analysis of the right hon. Member for Leigh (Andy Burnham) is deeply political, and let me give just one example. He lays the blame for delayed discharges principally at the door of budget pressures on social service departments. That is not true. If he looks at the figures, he will see that the bulk of the pressure is caused by delayed discharges in the NHS, not social services. I do not pretend for one moment that there are not parts of the country where social service cuts are impacting on delayed discharges, but the picture is more nuanced and complicated, and I wish the shadow Secretary of State had the courage to say that, rather than repeating a uniformly gloomy picture that is not true.

[Barbara Keeley]

I refer the right hon. Gentleman to the Select Committee on Health’s report on the matter. The data were completely conflicted. Again and again, individuals from the NHS told us that social care was the problem, as Sir Bruce Keogh, whom I quoted earlier, said to me just a few weeks ago. Our report said that NHS England should sort this out. There are figures that the right hon. Gentleman could quote and figures that my right hon. Friend the Member for Leigh (Andy Burnham) could quote, and we should not be confused about this.

[Paul Burstow]

I entirely agree that if there is any doubt about the figures, it needs to be resolved, but there seems to be a disconnect between what people think is happening and what the figures show. I have been to events at which clinicians have said that the problem is the local social services, but when they are shown the figures they are surprised. Perhaps that is why we need, as the hon. Lady says, to ensure that there is an agreed way in which such things are reported, which is what, I think, was put in place by the previous Labour Government. These figures have been collected for a long time, and they have consistently shown that social care is not the principal driver of delayed discharges.

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[Barbara Keeley (Worsley and Eccles South) (Lab)]

The Health Committee has held a number of inquiries into urgent and emergency services. The College of Emergency Medicine told us in its evidence that increased demand, combined with a more complex case mix, was the driver that had led to departments struggling to meet the four-hour target. We were told that type 1 emergency departments, which offer a consultant-led 24-hour service with full resuscitation facilities, had

“reached the limits of their compensatory capacity.”

We heard that there were

“more people out of hours, more after midnight, more ambulance and more elderly.”

I checked that with the chief executive of Salford Royal hospital and have checked again in the past 24 hours. He told me that the trends that I first reported in our debate last summer have continued at the hospital. There are now 14 more ambulance arrivals each day—reflecting sicker patients, not self-referrals—which is an increase on last summer. There has been a 13% increase in admissions for stays lasting longer than 72 hours, with a drop in shorter stays, a 31% increase in triages into the hospital’s resuscitation area, and an 11% increase in admissions into critical care. There is now a different mix of patients being admitted. The chief executive, Sir David Dalton, tells me that those trends now appear to be year-round, rather than a purely seasonal impact of winter pressures. He said—my hon. Friend the Member for Stretford and Urmston (Kate Green) might touch on this—that Salford Royal is also now experiencing additional pressures from north Trafford patients.

I am concerned that the current crisis in A and E will continue, and indeed worsen, as a result of continued cuts to social care budgets. We have heard a certain amount of complacency from Ministers today about this winter. It has not yet been a hard one, and there is plenty of time for flu pandemics. Sandie Keene, the president of the Association of Directors of Adult Social Services, has warned that

“it is absolutely clear that all the ingenuity and skill that we have brought to cushioning vulnerable people as far as possible from the effects of the economic circumstances cannot be stretched any further, and that some of the people we have responsibilities for may be affected by serious reductions in service—with more in the pipeline”.

That is the really worrying point, because we are not even at the end of the cuts we have to make.

As I have said before—I make no apology for mentioning it again—my local authority has already lost £100 million in funding since 2010, and it will lose another £75 million by 2016. It has had to cut its adult social care budget by 20%. This is a crunch year for us, because we have had to change our eligibility criteria from “moderate” to “substantial”, which is a difficult cut to make. About 1,000 people are predicted to lose their council-funded care packages, and another 400 who would have qualified under the “moderate” eligibility criteria will not now do so.

The work to reassess those people is ongoing, but Sir David Dalton tells me that

“following the initial scoping there is clearly a risk of more frequent attendances, increased admissions and a prolonged length of stay for this cohort of patients.”

Salford Royal is having to review the possible increased work load for community nursing teams, especially the district nurses, who the chief executive feels

“may need to pick up increased duties for these patients.”

It is clear that there is a straightforward shift: as those people in Salford lose their care packages, the hospital is having to pick it up.

Nationally, the number of people over 65 receiving publicly funded care has fallen from 1.2 million to fewer than 1 million. All across the country there has been a serious fall in the number of older people receiving publicly funded care. Some of those who have lost that care will fund it themselves, but in other cases the work load will fall on unpaid family carers. We have been warned about that in surveys. Carers UK found that 55% of carers are caring for someone who has been admitted to emergency hospital services in the last three years, and a significant number of them said that additional support could have prevented the emergency admission.

We also know—this is a worry for those who are concerned about carers—that full-time carers are themselves more than twice as likely to be in poor health as people without caring responsibilities. The Care Bill has not yet completed its passage through the House, but it does not do enough to support full-time carers, particularly given the funding situation for social care. Carers are the first line in prevention, so properly identifying and supporting them can prevent an escalation in demand. However, identification of carers is not happening and the Care Bill does not do enough to change that.

Macmillan Cancer Support has found that 70% of carers of people with cancer come into contact with health professionals. GPs and hospital doctors should identify carers and signpost them to information and advice, but in many cases they do not. Many hon. Members will encounter such people in their casework. The Care Bill gives a carer a right to a local authority carer’s assessment, but that is meaningless for a carer who has no contact with a local authority. In fact, 1,000 fewer families this year will have that constant contact with, and support from, their local authority.

Carers UK yesterday published a report on caring and family finances, which found that almost half of carers are cutting back on food and heating and that over half have reported that money worries are starting to take a toll on their health. The report quotes one carer:

“With the cuts I have cut down to eating one meal a day so I can ensure my husband has enough food to keep him well.”

We know that the caring that unpaid carers do saves our economy billions of pounds every year, but we have to face the fact that they are choosing between heating and eating, and in some cases eating only one meal a day. As was noted earlier, there is also the lack of funding to pay for prescriptions. Carers UK has warned—we should take note of this—that if this country’s 6.5 million carers are not supported, we will be pushing them to breaking point. In my authority, for example, if they are left unable to care, they will not be able to go to social care and will have to go straight to the NHS.

We know that the NHS is struggling in the wake of unnecessary reforms that redirected £3 billion from the front line. The cost of living crisis is clearly starting to have an impact. This is cold homes week, and it is estimated that people suffering from the cold costs the NHS an extra £1.36 billion a year, and that figure might continue to rise with fuel bills.

Last Friday I met a couple in their 50s who said that they could afford to have their heating on for only an hour a day—last Friday was absolutely freezing, as Thursday had been. It is interesting to reflect on how we could maintain our health if we could afford to have the heating on for only an hour a day. Since 2010, 145,000 more older people have had to receive hospital treatment for cold-related illnesses and respiratory or circulatory diseases, which is a real worry.

On NHS staffing, the Health Committee inquiry highlighted the fact that only one in five emergency departments have the right level of consultant cover for 16 hours a day. That worrying situation is not set to improve because, despite increased recruitment, very few higher trainee posts in emergency medicine are being filled—156 out of 193 such posts were left unfilled in the latest recruitment round. Even Salford Royal, which is an excellent hospital, is experiencing recruitment difficulties. I understand that it still has 2.3 full-time vacant posts, against the eight consultant posts it should have in emergency medicine. That is a good record compared with 52% of posts that are vacant in most hospitals.

As my right hon. Friend the Member for Leigh (Andy Burnham) said earlier, the president of the College of Emergency Medicine feels that we are suffering “decision-making paralysis” across the NHS. The college said recently that it felt that its position was akin to that of

“John the Baptist crying in the wilderness”.

It is a great pity that the warnings it made three years ago about understaffing were overlooked while attention was focused on NHS restructuring. I do not think that the recruitment drive the Secretary of State keeps talking about is the answer, because it will not address the high drop-out rate. We have to recognise that the increasing pressure on A and E will remain a strong disincentive to a career in emergency medicine.

In conclusion, the Government’s unnecessary and costly NHS reforms, combined with the swingeing cuts to social care budgets, are responsible for the crisis, and accident and emergency departments have been left to try to pick up the pieces. I support the motion and urge other Members to do the same.

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[Valerie Vaz (Walsall South) (Lab)]

I am grateful to the hon. Member for Strangford (Jim Shannon) for being so concise in his remarks. It is always a pleasure to follow him.

This debate takes place against a background of confusion and contradiction in the NHS. I hope that we will not end up with a national health disservice. We read all the documents and hear all the announcements about efficiency savings, but we still have not heard the lesson that people and patients should be at the heart of the NHS.

Many of the policy makers in the health service who appeared before the Health Committee warned us that there was not much detail in the lead-up to the Health and Social Care Act 2012. There was no pre-legislative scrutiny and then there was a pause. Not for the first time, the Government rushed to get legislation through without proper scrutiny and without an electoral mandate.

That played into the hands of the people who think that this Government and this country are up for sale to the highest bidder, and that there is no commitment to the people of this country. The Shard is an example. I understand that a number of its floors have been allocated to a private hospital. That is somewhere where pearly kings and queens cannot afford to live—they cannot even afford to go up to see the view.

I am pleased to see a number of my colleagues on the Health Committee in the Chamber. We hear a lot of first-hand evidence. At a time when there are concerns about A and E, the Government seem to be intent on fiddling about with name changes. The NHS Commissioning Board is now known as NHS England. The integration transformation fund is now known as the better care fund. Interestingly, the Chancellor announced in the spending review in July that the £3.8 billion that has been allocated to the integration transformation fund—aka the better care fund—will only be available in 2015-16. However, the problem needs to be addressed now.

That £3.8 billion is not extra money, but money that has been underspent in the NHS over the past few years. The underspend was £2.2 billion in 2013 and £1.4 billion in the previous year. When I asked the Secretary of State on 26 November last year why the underspend was not used for the NHS, he said that I should ask that question of Labour Ministers. I do not know whether he meant that I should do so in 2015. As I pointed out in an aside, which was not picked up by the Official Reporters, I am not a time traveller like Dr Who and was only elected in 2010. The rules of the House say that I should have had a proper response, rather than a dismissive one.

Another issue is that people have been fired and then rehired. One in five of the 19,000 staff who have been given redundancy payments has returned to the NHS. That is more money that has been wasted and that should have been spent on patients. Primary care trusts were disbanded and then re-formed with a different name. Urgent care boards were set up—their name was then changed to working groups—to ensure that there was a forum to replace the PCTs. All of that has strained resources and made staff suffer, without any increase in pay. There is job creation. However, it is not in front-line services, but in the appointment of a chief inspector, which was not suggested by the Francis report, and of assistant chief inspectors. There may well be assistant assistant chief inspectors as well.

The Select Committee heard evidence that the pay policy was significant in enabling the NHS to fill the gap, and NHS England said that, so far, around 25% of efficiency gains had come from pay. Ask A and E doctors who are struggling with working unsocial hours while locums without continuity in patient care are paid more, and they will say, “We need more staff; it is more money wasted on locums and agencies.” Perhaps Ministers should think about golden handcuffs for A and E staff, or the equivalent of an A and E special allowance to recognise the work of those doctors and staff in A and E. That might go some way towards ensuring that we keep them in their place and provide a safe service while doctors are trained. The College of Emergency Medicine has made repeated calls for such measures, and the emergency medicine taskforce made recommendations in 2011, yet we are still waiting for action.

Many Members will know from their own hospitals that patients are suffering from delayed discharge. I have seen that first hand at Manor hospital after the closure of the accident and emergency department at Stafford hospital, where perhaps the relationship with local government is not at the same stage as it is with the local authority in Walsall, for example, and it takes longer to discharge patients. We are still waiting for the £4 million that is needed because we have had to take the strain of the closure at Stafford hospital.

When giving evidence, Sir Bruce Keogh, the NHS medical director, acknowledged that 20% to 25% of people in hospital should have been discharged. The Secretary of State said that himself, having spoken to chief executives of hospitals with approximately two wards full of people who could be discharged. Our House of Commons Library says there have been £1.8 billion of cuts in social care, but apparently, the boffins at NHS England have not “dissected out” why people are in hospital when they do not need to be there. They are working on it now—that serious work on delayed discharges has apparently only just started, despite there being a problem for some time.

The urgent and emergency care review suggested that there should be emergency centres and major emergency centres. Sir Bruce said that NHS England was still listening to that proposal, but in a contradictory view, the Committee was told in the same evidence session that the clinical commissioning groups and other working groups are organising their networks to ensure that that is the outcome. Worse still, it was admitted that they have no intention of stopping any reconfigurations during that review.

[Barbara Keeley]

Will my hon. Friend give way?

[Valerie Vaz]

I am sorry; I have no time. The Secretary of State wants to reconfigure but he does not want a national debate. He gives himself extra powers if he does not like what the courts and local people say. We need that debate. We need to tell people the truth based not on ideology but on fact, because it impacts on the type of medical work undertaken, and on how we train the next generation of doctors, nurses and health care professionals and what specialties there will be.

The Nuffield Trust gave evidence to the Select Committee and said that people have made the easy savings and now they are running out. People’s memories are long. They have paid their taxes and expect the state to look after them when they need it; not to have to show their credit card as soon as they walk into an emergency centre, or a major emergency centre—whatever it will be called. People do not want prime NHS property in the centre of a city to be sold off so that they have to travel further to get to hospitals.

Chaos, confusion, contradiction, and finally, from the Secretary of State an admission. In evidence last December he said that hospitals want to employ another 4,000 nurses compared with a year ago—an admission that 4,000 nurses have gone missing on his watch. The shadow Health Secretary, my right hon. Friend the Member for Leigh (Andy Burnham), made it clear that he does not want a further top-down reorganisation, and he started the conversation about whole-person care in the 21st century in a speech in January last year. Finally, Margaret Mead the anthropologist said:

“Never doubt that a small group of committed citizens can change the world…indeed, it’s the only thing that ever has”

We have in the staff, patients and people of this country a group of citizens who want to save their NHS.