Primary Care: Tottenham

David Lammy Excerpts

Wednesday 16th December 2015 Westminster Hall

[Mr David Lammy (Tottenham) (Lab)]

I beg to move,

That this House has considered primary care in Tottenham.

I am grateful, Sir Roger, for the opportunity to introduce the debate. It is now 67 years since my party introduced the national health service. At that time, living to 100 would have been a newsworthy event, but today more than half the children being born in our country can expect to reach that age. This is clearly a sign of great progress and the quality of our healthcare system. However, that progress has not been the same across the board. There remain in this country huge discrepancies and a postcode lottery that determines the quality of healthcare people can expect to receive. I am particularly worried that the life expectancy of many children in Tottenham is nowhere near the national average.

The current situation paints a worrying picture. Today, average life expectancy for a male in this country stands at more than 80 years, but in my constituency, in the wealthiest city in one of the richest countries in the world, a male can expect to reach an average age of just 74. That is some five years lower than the national average, lower than Cuba where the average wage is £15 a month, and lower than Slovenia, Colombia, Bosnia and Peru. Perhaps most worrying, it is more than eight years lower than the life expectancy of men just a couple of miles away in Crouch End, in a wealthier part of the London borough of Haringey. That is a troubling and stark difference within the same London borough, and the same is true for women.

Primary care is the first point of contact in the healthcare system. In this country, that usually means GPs. They are the very frontline of our health services, the entry point for all our healthcare needs and the means by which we access a whole array of treatments. Primary care is, therefore, the linchpin of our healthcare system. In fact, it accounts for 90% of patients’ interaction with the NHS. Because of that, NHS England’s five-year forward view stated that in future a much higher proportion of its budget would be spent on GP services.

Both this Government and their coalition predecessor claimed to understand the importance of primary care, and to some extent matched their words with funding. For example, £550 million was earmarked in March 2015 to improve GP access, to modernise facilities and to provide better care outside hospitals. Then in May 2015, the Prime Minister announced the “seven-day NHS”, proudly stating that by next April 18 million patients will be able to see a GP in the mornings, evenings and at weekends, with everyone being able to do so by 2020. One would therefore be forgiven for thinking that primary care provision on an average weekday is securely in place, given the £8 billion of extra funding earmarked in a time of austerity to provide additional services outside the current working week. That may be true in some areas of our country, but it is not true in mine.

Recent research paints a stark picture of primary care in Tottenham. The data come not from NHS England or from the Department of Health, which does not seem to be monitoring the situation adequately, but from a small local organisation, Healthwatch Haringey. With no extra funding or support, it went out and listened to local people about the problems they were facing in accessing primary care, and it found something quite disturbing. Some 86% of the patients at one GP surgery were either unhappy or very unhappy with their surgery. That surgery is ranked in the bottom 10 practices in England, with 41% of patients reporting they were unable to get an appointment.

That is apposite because, on Monday this week, Rob Clarke in my constituency tried to access his surgery, Bridge House surgery, with his three-year-old. He tried repeatedly for many hours and was ultimately told to go to A&E. That is not what we want in Britain, where A&E is always overrun, and it was appropriate in that circumstance for the child to be treated at the GP surgery.

Across Tottenham, there are currently 1,300 too few appointments a week, which equates to 52,000 appointments a year fewer than the NHS benchmark. In just one ward of my constituency—Tottenham Hale—there is a shortfall of 18,000 GP appointments a year. Tottenham Hale is undergoing significant regeneration and now has several large blocks of apartments, a sizeable retail park, 500 more properties under construction and a further 1,900 planned for the medium term. It is one of the Mayor of London’s designated housing zones, but despite the influx of thousands of new residents, no new GP surgery was planned. It was only when the desperate need was pointed out by Healthwatch that NHS England’s task and finish group eventually arrived to complete a planning exercise. I note that a final decision on a new surgery will be made on Friday 18 December.

Our treasured national health service has been fractured by this Government and their coalition predecessor, but even with the best will in the world and even when clear need is established, nothing can be achieved quickly. I want to press the Minister on how fast we can and need to move in the circumstances I am outlining. It will have taken over a year for a decision to be made and, if that decision is positive, nearly 18 months for the surgery to finally open. During that period—I put this starkly—people are dying as a result of not being able to get an appointment, and children are being born unregistered. They are the truly dispossessed in our city. Will the Minister look closely at the issue and do all in his power to make the process as swift as possible?

The issues surrounding primary care in Tottenham relate not just to the number of GP places, but to quality and accessibility. According to NHS England, three quarters of GP buildings there do not meet legal compliance, and there are not enough consulting rooms. Some of the facilities in use in the fifth largest economy in the world are shocking. Healthwatch found that 20% of young mothers were not registered with a GP at all.

The consequences of not being able to obtain a GP appointment are stark: more avoidable deaths from cancer, worse life chances for children, and a lack of antenatal and postnatal care when women and, of course, their infant children are at their most vulnerable. My constituency is where Victoria Climbié and Baby P met their tragic end. The ability to obtain an appointment is important if we want to safeguard children. If people cannot do so, it raises serious concerns for mothers and their unborn children, and has led to the grave situation of three unregistered births in my constituency, one of which was of a disabled child whose mother gave birth at home with no one to help her.

Furthermore, Healthwatch discovered clear health inequalities between the west and the east of the Haringey borough, where my constituency is located.

[Catherine West (Hornsey and Wood Green) (Lab)]

My right hon. Friend is making an excellent speech with some good points about the disparity between those who live well and live long lives in the London borough of Haringey and those who do not. Does he accept that it is not solely Tottenham where there is a lack of primary health care? Parts of my constituency—for example, Noel Park—have similar problems with provision of basic, high-quality primary healthcare. Will he give that some consideration?

[Mr Lammy]

My hon. Friend is absolutely right. Her constituency includes Wood Green, and there are pockets of deprivation across Crouch End and Muswell Hill. She is absolutely right to make that point. In a way, this debate stands in both our names, because the crisis affects the borough of Haringey. It is not a coincidence that life expectancy of a male in the far west of the borough and the east correlates with the statistics that I have given, especially when so many mothers of infants are unable to register children in the constituency.

None of us should accept the situation. It is the sort of thing we associate with parts of urban America where there is no universal health provision. In the UK, we have a proud history of our national health service with its own constitution, which states clearly that people have the right to access NHS services. I fear that that is not the reality for many of my constituents.

These issues are not a reflection on the doctors in Tottenham, the vast majority of whom do an excellent job on behalf of the local community. I have recently met, for example, Dr Muhammed Akunjee of West Green surgery and Dr John Rohan of Lawrence House surgery, and I am very grateful for the work that they and their colleagues do in the constituency. As usual, the problems arise much higher up the chain of command. However hard GPs in Tottenham work, there are simply not enough of them and not enough facilities to serve our growing community. That leads me to wonder what it will take for the Government to address the crisis.

We know that there is a well documented link between poverty and ill health; we know that social conditions such as unemployment, overcrowding and inadequate housing make illness more likely; and we know that deprivation increases health problems and therefore pressures on the health system. Given that, I ask the Minister why one of the poorest constituencies in the UK receives significantly less health funding than wealthier areas nearby. Given the greater pressures, it should be receiving more. It is clear that the way to alleviate the GP crisis in Tottenham is to attract new GPs to the area and to retain the ones we already have. However, it is impossible to do that, because despite the huge workload, the urgent pressures and the ceaseless demand, GPs in my constituency are paid significantly less than those in wealthier areas just a few miles away.

For example, a GP in Holborn and St Pancras, the 126th most deprived constituency in the UK, receives £154.64 per registered patient, whereas their counterparts in Bethnal Green and Bow, the 36th most deprived community, receive less—£144.48 per patient. Despite the huge pressures on GPs operating in Tottenham, the 23rd most deprived constituency in the whole country, they receive only £124.94 per patient. That is a full 20% less than in Holborn and St Pancras. Clearly there are fundamental problems with the Carr-Hill formula, which is used to calculate GP funding. There are also real concerns about the impact that withdrawing minimum practice income guarantee payments has had on GP practices in deprived areas such as my constituency. I urge the Minister to look at what he can do to incentivise new GPs to come to areas such as mine.

If the GP situation in my constituency is to improve, GPs in Tottenham must be paid at least the same as their colleagues working nearby. That is an urgent need, given that one third of GPs in the borough are over 60 and therefore due to retire. Things could get considerably worse before they get better. Clearly, younger GPs are being attracted to work in other London boroughs because of the price differential.

It was this Government who wanted the NHS run on market principles, yet they have failed to grasp the obvious problem that for a GP to set up a business in Tottenham, he has to do more work, in worse facilities, for lower pay. Any 12-year-old fan of “The Apprentice” knows that that is not the way to run a successful business. It clearly demonstrates the inherent problem with trying to force a market on the health service, yet we are stuck with this Government’s NHS market framework, so I ask the Minister this: will market rules be applied so that GPs are given proper incentives to set up practices in Tottenham? Also, will he ask the chief executive of NHS England to finally take an interest? I am not clear whether it is Simon Stevens I should talk to or his London lead, but I would quite like the London lead at least to come down to the constituency for herself. I would have thought, given the work that Healthwatch has done, that she would have sought to do that.

I understand that following Healthwatch’s report, NHS England has started to take the problems in Haringey seriously and has produced a detailed 10-year capacity plan, which sets out how many full-time GPs and clinical and treatment rooms are required. Growth is predicted in four key areas: Green Lanes, Northumberland Park, Tottenham Hale and Noel Park, which is in the constituency of my hon. Friend the Member for Hornsey and Wood Green (Catherine West). Three of the four areas are exclusively within my constituency. NHS England has identified a need for five extra GPs in the Green Lanes area, six in Northumberland Park, 16 in Tottenham Hale and eight in Noel Park over the next 10 years. That is 35 extra full-time GPs, 27 of whom are needed exclusively on my side of the borough.

There are a few questions that I want to ask. Does the Minister agree that it is unacceptable that 20% of my constituents in Tottenham Hale do not have access to a GP? Is he concerned that the gaping holes in primary care provision in Tottenham have contributed to the fact that the average life expectancy of a man in Tottenham is just 74—below that of Cuba? Will he explain how, within the NHS market framework, he will attract more than 27 GPs to my constituency, where, despite the far higher workload, GPs are paid significantly less than those in leafy areas just a few miles away?

Will the Minister give me his word that there will be a transparent process to increase the funding per patient in Tottenham by 20%, so that it is brought up to the level of its far wealthier neighbour, Camden? Does he agree that it is disgraceful that the Government have committed themselves to providing a “seven-day NHS”, with weekend GP appointments for 18 million patients, many of whom are in the richest areas of the country, whereas in my constituency 20% of new mothers and their infant children have no access to a GP at all? I look forward to hearing what the Minister, the Government and NHS England, which I hope is paying attention, have to say.

[The Minister for Community and Social Care (Alistair Burt)]

It is a great pleasure to serve under your chairmanship, Sir Roger. I congratulate the right hon. Member for Tottenham (Mr Lammy) on securing the debate and thank him for his great courtesy in sending me and my officials a copy of his speech, which will enable me to address in my remarks some of his questions. I appreciate that.

I have some knowledge of the area. I was a member of Haringey Council between 1982 and 1984. I represented Archway ward at that time, and I was on the governing body of a school in Tottenham, so I have some feel for the area and I am grateful to it for giving me a start. I sat on benches opposite the right hon. Member for Islington North (Jeremy Corbyn). I think I am now the only Member of Parliament who served on the council with him, so we have a long-standing relationship and friendship. My time in Haringey taught me that it was an outer London borough with inner-London characteristics. I saw at that time colleagues on the Labour-run council wrestling with very difficult issues and problems and I have never forgotten that.

I will tackle some of the issues that the right hon. Member for Tottenham raised. I do not follow all his argument. Yes, there is some element of market principles in the NHS, but I think Mr Blair had something to do with that as well as us. If the right hon. Gentleman would really like to reorganise the national health service completely, I am keen to hear the proposals from those on the Labour Front Bench in relation to that. The structure that we have is one we will have for some time. It does not stop the work being done but enhances the localisation of making sure that the right things are done.

The right hon. Gentleman is right on poverty and inequality. The tragedy of the United Kingdom is that this is not a short-term issue. If we laid a map of poverty in Victorian Britain over a map of the United Kingdom today, we would find remarkable similarities between the two. The issue that all Governments wrestle with is that Government in, Government out, and socialism in or liberal capitalism in, we still have not cracked all the issues of inequality that we want to crack, and everyone has given it a lot of effort. We have to do better and we have to try different things. That is at the heart of some of the different things that the Government have been trying in health service reform. It is a process that will go on, but none of the issues that the right hon. Gentleman mentioned—length of life and inequality issues—has arisen in the past six years. They are long-standing issues that go back many years, which is why it is always essential to work at new initiatives and look for things that are different, to try to make a difference.

The right hon. Gentleman raised very straightforward and serious issues. All of us in the Chamber pay tribute to those who work in front-line services—the primary care staff. GPs are the first point of contact. Of course, it is not just GPs, but nurses, physiotherapists, occupational therapists, pharmacists and many other healthcare professionals who play a part in delivering high-quality care to patients in practices and in the community every day through the NHS.

In relation to the right hon. Gentleman’s constituency, he quoted extensively from the report by Healthwatch Haringey. Healthwatch nationally is actually funded and part-supported by Government. It is part of the monitoring process that the Government use. I understand that the report “GP Access in Tottenham Hale”, published in September 2014, highlighted a number of serious issues around accessing GP services in that part of his constituency. I thank Healthwatch and all associated with it for all the work that they do.

I am aware that access to GP services is a long-standing issue for local people. I am also aware that many local practices are single handed, and that some premises are not suited to the needs of primary care in 2015. Haringey clinical commissioning group has developed a primary care strategy to address just the sorts of issues that we have heard about this afternoon. That strategy focuses on encouraging practices to work together to run services more effectively, funding initiatives for practices to improve their appointment and triage systems, and encouraging a mix of professionals to work together as part of local networks: for example, welfare advisers, nurseries and healthcare assistants.

A number of practical steps to improve primary care locally have already been taken. In north-east Haringey, a shared call centre has been set up so that staff can respond to patients more quickly. In the south-east of the borough, GPs have worked together to provide telephone consultations for patients between 6.30 pm and 8 pm. In central and western areas of Haringey, Saturday clinics have been established. I understand that the CCG plans to have Saturday clinics and evening appointments available across the whole of Haringey in the new year. The CCG has funded two part-time practice managers to support practices that are struggling to meet access demands, and it is working to increase the number of practice nurses in Haringey through a recruitment programme to enable nurses from other settings to transfer into primary care.

On the important matter of GP premises, I am advised that the CCG and the local council have worked with NHS England to develop a strategic premises plan. The right hon. Gentleman is correct in saying that those have not been adequate, and he is right—as was Healthwatch—to draw attention to that. The premises plan was completed in July 2015. It highlights a shortfall in GP provision and in premises capacity in Haringey. The shortfall was particularly noted in Tottenham Hale and, to a lesser extent, in Northumberland Park. The plan makes a number of recommendations for short and medium-term action.

To date, NHS England London has appointed a local provider of temporary services for up to 6,000 patients in Tottenham Hale. It has also, together with Haringey CCG, sought national approval to use capital funding from NHS England’s primary care transformation fund to purchase the temporary premises. It has done so because capital funding is seen as representing best value and minimising annual revenue costs. As the right hon. Gentleman said, NHS England London and Haringey CCG hope to obtain approval for capital funding of the premises on 18 December, which is Friday of this week. However, I understand that, in the event of NHS England not agreeing to provide funds from the primary care transformation fund, the purchase of the premises will still be secured by means of revenue funding. NHS England will continue to work with Haringey CCG to find a permanent site for the practice in Tottenham Hale.

The new GP practice in Hale Village is due to open in the new year. It will start with a zero list and will have the capacity to register up to 7,000 new patients. That development has been welcomed by Healthwatch Haringey as representing a positive outcome for local residents. NHS England has also asked CCGs to set out an overarching estates strategy to ensure that estates resources are used across all of health and social care. As part of that work, Haringey CCG is looking closely at how else it can help to ensure that GP local premises are fit to meet current and future primary care needs, particularly in the light of the regeneration in Tottenham that the right hon. Gentleman mentioned and projected population growth in the area.

The right hon. Gentleman made clear his concerns about the levels of primary care funding in areas of relative deprivation. The national formula is currently under review, and the possibility of giving greater weight to deprivation is one factor being considered. I can reassure him about GPs’ salaries, however. GPs are not paid differential salaries in different areas. The capitation is different, because capitation covers things other than GPs’ salaries, but clearly it could not work if GPs in one area were deliberately paid less than those in another. That is not at the heart of the problem. When it comes to capitation and things that are considered in the national formula, deprivation is being considered as an issue to be looked at further.

Getting more people into primary care is really important. The Secretary of State set out in June details of a new deal for general practice, in line with the five-year forward view, recognising the pressures that GPs are under. We are training, and plan to train, more GPs. In the last Parliament, we increased the number of GPs working and training in the NHS by some 1,700, which is a 5% increase, but we still need more. That is why we have announced plans to increase the primary and community care workforce by at least 10,000 by 2020. That figure includes an estimated 5,000 more doctors working in general practice. That will be a 14% increase in the overall number of GPs working and training in the NHS.

We have established some work to try to reduce the level of workload. Having visited a number of practices in urban deprived areas and others, I can say that there is very much a sense in some practices that GPs are worn down, that they are on a treadmill and that they are worried about bringing new people in. In others, however, sometimes not very far away, GPs are trying something different. They are working with the Prime Minister’s challenge fund pilots or the vanguard sites on different ways of providing their services. Such work can often be the trigger for more doctors being interested in coming into work.

There is a different side to the pressures on GPs. I am clear that, in practices that are very much under pressure, by reducing bureaucracy and working with them to provide support, we can lift them up from their present difficulties. The transformation fund of £1 billion that will be used to improve premises over the next few years will also make a difference, and it will ensure that premises are fit for purpose when it comes to what we want from primary care in future.

If we are to address the health inequalities that the right hon. Gentleman rightly mentioned at the beginning of his speech, it will be essential for that work to be carried out in the most deprived parts of the country, as in any other. It has been interesting to visit those pilots and look at what has been done. The reorganisation of resources in primary care and the establishment of more contacts with those who provide allied health professional services—relieving some of the pressure on GPs—can have a marked impact, as can the closer integration between the NHS and local authority services in the same area.

We are all trying to lever up standards and deal with the inequalities, as the right hon. Gentleman has mentioned. There are plans, proposals, new initiatives and new ideas, and some of those are demonstrated in London. I hope some of the practices involved, particularly the new ones, will take those opportunities to do something different where they are and try to meet the challenges that they face.

To conclude, as well as the investment in primary care that I have detailed, a number of approaches are making a difference to access to GP services: longer opening hours, to increase the sense of access; better use of telecare and health apps, which are really working and beginning to have an impact on populations that are much more used than some others to using such things; and more innovative ways to access services by video call, email or telephone. Schemes are integrating services in order to offer a single point of contact to co-ordinate patient services across health and social care. Some 2,500 practices have taken part in the access fund schemes, covering more than 18 million patients, so a third of the country will have benefited from improved access to primary care by March 2016. We want to continue to roll out such initiatives to 2020, investing in primary care and making sure that investment is made in the areas where most work is needed. It is clear from what the right hon. Gentleman said that Haringey is right up there.

[Mr Lammy]

Can the Minister get NHS England to take a greater interest, at leadership level, in Tottenham?

[Alistair Burt]

I will ask exactly that. I do not doubt that it is doing that already. Clearly, the right hon. Gentleman needs to be reassured, and we shall do so.