NHS (Contracts and Conditions)

Ben Gummer Excerpts

Monday 14th September 2015 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

It is a great pleasure to serve under your chairmanship for the first time, Mrs Gillan, as it was to serve under the previous Chair, Ms Vaz.

This is an important and exciting day because we are responding to the first e-petition under the new system. The hon. Member for Denton and Reddish (Andrew Gwynne) is quite right that it should have happened some time earlier. I hope that through what are pretty modest forays into social media we can make more popular the debates that take place in Westminster Hall, because they are often far more thoughtful and certainly more nuanced than some of the debates that one hears just a few hundred yards away.

I am grateful to the Chairman of the Petitions Committee, the hon. Member for Warrington North (Helen Jones), for her introduction. Hers was a vigorous opening argument and certainly did what it should have done, which was to spur a good and, at many points, enlightening debate. There is much to which I would like to respond, but at times the debate turned into a general critique of the NHS, so if I tried to answer every point, Mrs Gillan, I think we would be here beyond the 7.30 pm cut-off that you and, I imagine, other Members would not like me to reach.

The debate encompassed many of the issues and problems that confront the NHS, as do all discussions of seven-day services because they touch on contract reform and how we manage the NHS workforce. At the core of the debate was what we are trying to do: deliver exceptional, world-class care to every patient coming to an NHS institution, hospital, GP or community service in England and, by extension, the other nations of this country.

I, too, pay tribute to some shadow Front Benchers. I am grateful for the words of the hon. Member for Denton and Reddish. I almost wish he had not said what he did, because I wanted to say that I hope he keeps his Front-Bench position. He has always been a very reasonable defender of the Labour party’s point of view and a strong interrogator of the Government’s policies. That is exactly what opposition should provide. I should take the opportunity to say how much I will miss his colleague, the hon. Member for Copeland (Mr Reed), with whom I sat in this Chamber a couple of days ago for his last debate as a shadow Minister. I did not have the opportunity then—the moment escaped me, and I did not have knowledge or foresight about where he would be on Saturday—to wish him well and say how much I had, in my short time as a Minister, enjoyed debating important issues in the Chamber with him.

It is also entirely right to say that the right hon. Member for Leigh (Andy Burnham) has been Secretary of State for Health, a Health Minister before that, and a shadow Secretary of State for a long time. His contribution to debates about the NHS has been very important. It is clear from how he speaks that he cares passionately about the health service, and I very much hope that he delivers the same kind of force of argument in his new position as shadow Home Secretary.

It will be good to see what the new shadow Minister, the hon. Member for Lewisham East (Heidi Alexander), brings to her role. I hope that she will enter into arguments and debates on NHS reform with the spirit of openness and decency shown by the hon. Member for Central Ayrshire (Dr Whitford), who often attends these debates, bringing a great deal of personal experience from both this country and abroad, and who makes sure—no doubt because we often feel chastised if it goes any other way—that the debate is continued with a sense of decorum and a remembrance that our discussions are held in public. We must be aware of the fact that what turns people off political discourse more than anything is a silly repetition of party political positions with no meeting in the middle or discussion of the issues at hand.

It is in that spirit that I hope to address the central point of the presentation of the petition by the hon. Member for Warrington North. I am glad that we have these petitions, although perhaps a little less glad that this particular petition contains such stridency of language. Nevertheless, at the core, what concerns me is the point made very well by the hon. Lady: words matter. That was echoed by my hon. Friend the Member for Faversham and Mid Kent (Helen Whately). We must be very careful about the words we use—not only the manner in which we say them but how they might or might not be construed.

Hon. Members may not be surprised to hear that I have read—several times, as it happens—the Secretary of State’s speech on this matter. I have also seen the coverage on it, and there is dissonance between the two. At no point did he attack NHS staff or suggest that they are not working in conditions that are often heroic, and at no point did he suggest that we have ended up at this impasse because of a wilful wish on the part of NHS staff not to work at weekends. What was construed from that speech has unfortunately meant that our debate has been about a number of words and phrases that were not used, intended or even suggested.

Turning to the core of the speech, the Secretary of State began by saying that talking about seven-day services is not news to a large number of NHS staff, because nurses, porters, cleaners and many of those working under the “Agenda for Change” contract have, for the entirety of their professional lives, been working in seven-day services. His main contention was that, given the weight of evidence on excess mortality that can be attributed to differential working patterns at weekends and on weekdays, it is at least reasonable to ask what we are doing to ensure that if someone is admitted on a Saturday or a Sunday they can expect the same quality treatment and intensity of consultant and diagnostic support as they would receive on a Wednesday. That suggestion was not plucked out of the blue.

I have two points to make. Given that the petition is an ad hominem attack on the Secretary of State, it is right to say that I have never encountered anyone in a ministerial post who has acquitted himself with as much passion about a point on which he wishes to concentrate—patient safety—as the Secretary of State. The right hon. Member for Leigh recognised that when he was shadow Secretary of State, and it is recognised even by those who often oppose the Secretary of State in the BMA and other professional representation bodies. The fact is that the Secretary of State is passionate about patient safety. He cares deeply about it, which is why he takes an intense interest in gathering evidence about differential mortality rates.

I want to run through in detail where NHS England’s thinking comes from and why the Government have decided to act as they have. As the hon. Member for Central Ayrshire knows, there have been various academic papers from the United States and some from the United Kingdom on differential mortality, and they contain many of the questions and answers that have been alluded to today. It is certainly true that people are admitted sicker at weekends, which points in part to the need to do something about community and GP services at weekends. That is part of the reason why people are being admitted sicker. If somebody with a serious acute illness is seen on a Wednesday, they will receive a level of service—both diagnostic and consultant support—that they are unlikely to receive in many hospitals on a Saturday or Sunday.

[Helen Jones]

The Minister is making a sensible point, but could he enlighten us about exactly which services the Government foresee working seven days a week? Has the Department for Health assessed how many extra staff will be required to ensure that happens? NHS staff have got to have days off sometimes, so if they are working at the weekend they will have to have a day off in the middle of the week. How many more staff will we need?

[Ben Gummer]

Those are very reasonable questions. If the hon. Lady will allow me to continue with what I was setting out, I will certainly answer them.

That assortment of academic research, together with the wide anecdotal evidence from people who have experienced poor care in good hospitals, either for themselves or for their relatives, led NHS England to conduct the Seven Days a Week forum in 2013, which gathered together clinicians to look at the challenge. It produced a clear strategy for dealing with differences in care quality at weekends, compared with the week, and set out 10 clinical standards that it believes hospitals must meet to eradicate the difference between weekday and weekend working. Many hospitals are implementing the 10 clinical standards on a variable basis during weekdays, so the work done for weekends was helpful in determining a standard clinical approach for maximising the ability to reduce avoidable deaths for weekend and weekday admittances. The product of that forum was taken forward by NHS England and incorporated into its five-year forward view, in which the NHS, separately from the Government, made a commitment to seven-day services. It did so not because of the benefits to patients—as my hon. Friend the Member for Sutton and Cheam (Paul Scully) said, that is a secondary reason for pursuing the agenda—but purely because of the need to reduce excess mortality where possible.

This is a challenge on the scale of infections in hospitals. It is our duty not only to find out precisely why excess deaths are happening—as the hon. Member for Central Ayrshire correctly said, further work is needed and the data must be understood—but to do what we can as quickly as possible to reduce them where we think they are preventable. That is why NHS England incorporated the seven-day service into its five-year forward view. NHS England asked for an additional £30 billion of spending between 2015 and 2020, of which it said £22 billion can be achieved through efficiencies within the service. It is important to point out to the hon. Member for Warrington North, who made that point, that they are not cuts but genuine efficiencies within the organisation. On top of the £22 billion of internal efficiencies though a better use of IT, to which she alluded, and better job rostering—I will turn to that in a minute—there will need to be an injection of £8 billion to make up the rest of the £30 billion. That package will implement the five-year forward view, which includes seven-day services and many other things of great importance and about which all parties agree, such as shifting resources from providers to primary care, social care and the community sector.

This programme was not invented by the Secretary of State in a speech given to annoy doctors and consultants, much as that might be the impression given by some people on Twitter. It is the policy response of a Government taking seriously the clinical evidence and advice of NHS England, led by Professor Sir Bruce Keogh. We are responding to give NHS England and the providers tools with which they can deliver a seven-day NHS service in hospitals and GP practices.

I turn to the changes in the contracts, which are at the heart of the petition and the speech of the hon. Member for Warrington North. The contract terms are based on a review by the doctors and dentists pay review body, which identified a number of areas where contract reform is needed, including the systems of opt-out and on call. It asked a completely reasonable question: why should it be that some members of the workforce, who are expected to work at weekends as part of their normal shift patterns, do not have the option of an opt-out from their contract, while others—who tend, as it happens, to be far more highly paid than those who do not have the option of an opt-out—do? It proposed a series of changes, which in our view make up a far better contract for both junior doctors and consultants. On balance, we feel that it presents a real opportunity for consultants and doctors to improve not only their working conditions but, in some cases, their pay.

To take some salient examples from the consultants’ contract, we want a far more equitable and reasonable distribution of clinical excellence awards—many consultants are privately critical of how they are awarded—within not a cut to the total consultant budget, but exactly the same existing pay framework.

[Dr Philippa Whitford]

To point out a slight difference, we do not have those awards in Scotland. We have local discretionary points, but the national clinical awards have been done away with for quite some time. Much as we also struggle with staff, we have not been haemorrhaging them south on that basis.

[Ben Gummer]

The hon. Lady points out that contractual differences already exist between NHS Scotland and NHS England. Officials have looked with interest at the experience of NHS Scotland—one of the pleasures of the devolved NHS system is that we can all learn things from one another. I hope that the new replacement of the clinical excellence award will be perceived as far fairer by clinicians and will reward those surgeons who are giving their utmost in academic research and the professional development of others. That is a tangible improvement to consultants’ terms.

It is important to point out, as several of my hon. Friends have done, that we are talking about ensuring that, at most, consultants work no more than one weekend in every four. That is the basis on which they will be contracted to work in a seven-day NHS. We are not talking about seven days at a time, but about shift rotas and patterns, as many people in professional life already recognise, not least some of those who have spoken in this Chamber. We need to get to a situation in which NHS professionals at the top, as well as those at the bottom, are trusted to organise their life and work patterns according to the professionalism they hold so dear. Many consultants in the NHS want to move to contract reform so that they may express their professionalism in that way, and we need to ensure that it happens so as to bring them with us, rather than its being forced on them.

For that reason, I am delighted that the consultants committee of the BMA has agreed to rejoin negotiations. It has seen that there is a basis for reaching an agreement, which suggests—contrary to some of what has been said by Opposition Members—that things are being done with a sense of collaboration. We have wanted to enter the negotiations for some time. The BMA, for reasons no doubt connected with the election—probably understandably—decided to withdraw from negotiations, but it has now come back. We and the consultants committee can reach a good position on the proposed contract.

The junior doctors’ contract is a proposal of great strength, not least because we include a significant increase in basic pay rates, which should be welcomed across the board. The contract addresses one of the points made by the hon. Member for Warrington North and does something important for the way in which junior doctors are perceived by their management. Instead of offering, in effect, danger money for excess hours, which is surely not the way to manage a workforce, it gives junior doctors a right to a review of their hours, so that they may properly manage their work rotas and patterns. For the first time, that will be enshrined in their contract. They will have far more predictable work patterns; providers—employers—will be forced to think seriously about work-life balance when constructing the roster; and, on pay and on the offer to juniors for their working life, the proposed contract will produce a far happier outcome.

I had hoped that the juniors committee would already have agreed to come back to the table, and I remain hopeful. The committee is meeting imminently—in six minutes’ time, in fact—and I hope that it is listening to the words in this Chamber, because hon. Members and others listening have heard nothing from both Government and Opposition Members but unalloyed praise for NHS staff and a real desire to work cross-party to secure the kinds of advances in quality that everyone wishes to see. With the juniors at the table, we could reach a constructive and reasonable resolution to the need to change their contract. That need was impressed on Ministers not only by the DDRB—the review body on doctors and dentists remuneration, but by the NHS’s own independent pay review body. Many in the service, perhaps more quietly than those who have been most exercised on Twitter, know that it is necessary.

[Helen Whately]

Is the Minister aware that if we compare the number of staff in a particular NHS service with the demand for that service over time, we can see that demand is sometimes highest when staff numbers are at their lowest? Demand and staff numbers do not match well. Is there not an opportunity to look at changing staff shifts and rotas to ensure that there is the greatest number of staff when demand is greatest?

[Ben Gummer]

My hon. Friend is entirely right. The whole purpose of what we are doing through contract reform is to match the professionalism of doctors, consultants and those working on agenda for change contracts—nurses and so forth—with the demands of any particular hospital. That cannot be decided by me or NHS England, but has to be decided in each setting, because of the differences—sometimes subtle and sometimes wild—between hospitals. In a study of some 15 hospitals released a couple of years ago, it was noticeable that there was 3.6 times more consultant cover for acutely ill people on a Wednesday than on a Saturday, even though 3.6 times more people were not acutely ill on a Saturday. The comparison is roughly drawn, but it points to a mismatch between rostered staff and peak patient flows. Most hospital managers would not only accept that point, but offer it to you.

All that suggests that somehow no seven-day NHS working is going on at the moment. As the shadow Minister and other hon. Members have said, however, some hospitals are already delivering an exceptional seven-day service—sometimes at no extra cost at all, and sometimes with only a minimal cost increase. What is most noticeable is that care quality has improved. In some cases that is now measurable, which is very exciting, and we can see reductions in mortality attributed to changes to staff working patterns. The staff, when asked, “What difference has this made to your lives?” point, as the key difference, to the fact that this was led by enthusiastic members of the staff themselves. There we have a pointer as to where we need to go: we need to get staff buy-in at the beginning. When the change is done well, it gives staff far greater control over their working life, which has led in a couple of hospitals to appreciable improvements in staff satisfaction.

Those settings have achieved the trick that we want to see throughout the NHS, which is for contract reform to empower and help staff to deliver care with the professionalism that I and everyone in this Chamber know that they wish to, while delivering better, higher quality care and decreased mortality—all within tight spending constraints, despite the increases to the cash budget that the Government have pledged to the NHS. If we can achieve that, we will have done something very special: we will have dealt with the lack of a link that has existed for too long between patient quality and care, and restrictive contracts that do not reflect how many staff want to work, and certainly do not reflect how patients admit themselves to hospital.

There is one final thing that I would like to add—in fact, it is the penultimate thing, because I must answer the point made by the hon. Member for Warrington North about staff. She is right to say that, of course, seven-day services will, in some disciplines, have an effect on the staff numbers that might or might not be required. That is part of the plan being developed by NHS England, in close association with Health Education England. We are recruiting close to record numbers of nurses, doctors and consultants, and we are doing so in many of the diagnostic specialties as well.

However, this is a question of not just staff numbers, as the hon. Lady recognises, but much smarter rostering and rota-ing, so that we use staff and their time as effectively as they would like us to. It is also a question of the productive use of staff time. She rightly pointed to the bureaucracy that ties people down. In some hospitals—some quite near her constituency—that bureaucracy has been reduced to a very minimum, as a result of which staff have patient contact time of an order of magnitude different from that in hospitals just 50 or 60 miles away. If we can bring all levels of staff exposure to patients—the patients they want to care for, for the maximum period of time—up to the best level in the NHS, we will already have the productivity gains in the workforce that will make possible not just seven-day working but a whole series of other improvements in care quality.

My final point about the opportunity that contract reform gives us was touched on by the hon. Member for Ealing Central and Acton (Dr Huq), who spoke about whistleblowing. It is an important point. When people attack the Secretary of State they should remember that he brought in freedom to speak up and the duty of candour, is bringing whistleblowing champions into the NHS, and has acted on some of the most difficult recommendations of the Francis report. It is this Secretary of State who said for the first time, “If you are employed by the NHS and feel that care is not being delivered in a way that is good for patients, we will prize your voice and listen to you above those who might stop you being heard.”

That kind of message to the system is new. It is so radical that I think many still do not quite believe it could be true, but I hope that the instigation, at some considerable cost, of whistleblowing champions, along with the framework for whistleblowing and the independent national officer, demonstrates to Members and the outside workforce that we are deadly serious about listening to staff, no matter where they work or who manages them, to make sure that we improve patient care wherever possible. We know that improving staff’s experience in their working lives is a crucial part of that.

Although this was not mentioned in the debate, I am conscious that far too many staff in the NHS suffer bullying and harassment. The numbers are almost unheard of in any other walk of life, including the Army and the police. NHS workers unfortunately can expect abuse from members of the public and bullying within management chains to a degree that is unique in the public sector and close to being so across the entire workforce. That is an historical problem that has led to the very high levels of staff sickness that the NHS has carried for decades. It will not be an easy problem to crack, but I have to tell Members that I and the Secretary of State are absolutely committed to doing something about it. NHS staff go to their place of work because they care about patients and about their vocation, but too often can get pushed back by poor management, abusive patients and poor performance management processes, and often feel belittled in what they are doing. If we can do something about their working conditions and improve their working lives, that will be very important, not just for staff but for patients. If we can improve the working practices and the working lives of the 1.3 million people devoted to our nation’s healthcare, we will do so much to help them produce even better care for the patients they serve.

I hope that Members on both sides of the House have come to a broad understanding that the changes anticipated by the contract reform are necessary. It is certainly true that we must take account of the data and listen carefully to the arguments of everyone involved in the provision of NHS services seven days a week, to make sure that changes are made as collaboratively as possible, so long as collaboration is made possible by all parties. We must also bind ourselves to the promise that we should all reflect correctly the words of politicians on both sides of the House, lest their misconstruction cause worry and fear in the outside world. In all that, we must ensure that the changes we make improve the quality of patient care and reduce the excess rate of mortality, which I know everyone, including all Members, would like to come down when and if possible.

Question put and agreed to.

Resolved,

That this House has considered the e-petition relating to contracts and conditions in the NHS.