Clinical Commissioning: North Durham

David Mowat Excerpts

Wednesday 23rd November 2016 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship today, Mr Davies. I, too, congratulate the hon. Member for City of Durham (Dr Blackman-Woods) on obtaining the debate, and I congratulate the other hon. Members who spoke too. It is good to have a chance to discuss the matter and weigh up the pros and cons of what is being done.

The context is the CCG in the hon. Lady’s area, which consists of 31 GP practices. It has been rated as a good CCG by the Care Quality Commission. Its treatment referral time is above the national standard, at 92% within 18 weeks. I want to talk first about the policy area, and then about the specifics of the decision to employ About Health in North Tyneside and North Durham.

The first thing to say about the policy is that referral management is not a new area. In 2007, something like 70% of primary care trusts had a type of referral management system in place. The intention is fairly clear: when a GP is making a referral, it will be absolutely obvious in many cases that it needs to happen. In many other cases it will be clear that a referral is not needed. There will also, frankly, be a grey area in the middle—that will happen in any profession.

[Dr Blackman-Woods]

Will the Minister focus on this specific referral system, under which, we understand, all referrals to specialists from GP practices in the CCG area are subject to private company screening and there is also a target to send back at least 50% of all referrals made?

[David Mowat]

I was explaining the purpose of the policy and the fact that this referral mechanism was used widely in 2007. A King’s Fund report from 2010 sets out the pros and cons of using referral management—I suggest the hon. Lady reads it.

These things are not new. They are a mechanism by which a consultant, or a GP with a specialist interest in the area of what is being referred—there are six areas of referral in this CCG, as the hon. Lady said—has two to three days to either accept that the referral goes on to the secondary system, or to contact the GP and have a discussion about what the best alternative pathway might be. There is an appeals process if the GP does not agree with that decision.

The hon. Lady asked where else such referral management was being done across the NHS in England. It was introduced in 2007, as I said, and it is being done very commonly. It is being done in Bromley, Cambridge, Peterborough, Imperial in London, and Southampton. I saw a similar system in Tower Hamlets to the one working in her area—indeed, the GP was very proud of the way they reacted, with an email referral system, when there was every possibility of things not going ahead.

This is not rationing. It is completely wrong to say that. It was brought in by the CCG, which is GP-led. If the GPs in the CCG do not agree with it, they have the mechanism to replace the chairman of the CCG.

[Mr Kevan Jones]

I understand what the Minister is saying, but what about the patient? Where does the patient come into this? If I go to my GP and he says I need a referral, that is between me and my GP. If it was not for my hon. Friend the Member for City of Durham (Dr Blackman-Woods) or the BBC raising this, none of my constituents—or myself and my hon. Friend, who are patients of the CCG—would have known about it. Will the Minister please answer the point about the patients?

[David Mowat]

The point I was in the middle of making—which I will finish making—is that if the GPs in the CCG have difficulty with the scheme, they have the mechanism to replace the CCG chairman and therefore to not go ahead with the scheme, so the GPs in his area are presumably content with it.

[Mr Jones]

The patients are not being consulted.

[David Mowat]

The fact is that the GPs vote for the head of the CCG who has put the scheme into place. On the patient issue, which is a fair one, if the patient expresses a preference to go to a secondary or an acute hospital and have an appointment, which could typically be six to eight weeks away, of course that is part of the process, and of course the referral management schemes will take that into account.

[Mr Jones]

I am sorry, that is not the case. In North Durham, patients have not been told about it. If I went to a GP who said I needed a referral, I would not be told that. What the Minister is saying is in complete contrast to what he told me during a debate on coeliac disease a few weeks ago, in which he condemned CCGs for not consulting people before awarding contracts.

[David Mowat]

We are moving around a little bit here, but I will come to the point about consultation. The GP that the hon. Gentleman refers to is a part of a CCG that has made the decision to extend the North Tyneside pilot to North Durham. All I am saying is that those GPs are part of the CCG and that presumably the CCG is doing this because it believes the clinical out-turns are right. We have a locally driven system. I will make some progress on the benefits of this for patients.

[Julie Cooper]

Will the Minister give way?

[David Mowat]

I will make some progress; I have taken a lot of interventions.

The benefits to patients are that a consultant will review their case within two or three days of a GP referral and a decision will be made on the appropriate pathway. That is why the King’s Fund recommended these sorts of systems in 2010—in terms of patient out-turns—and that is why it is of benefit to patients.

One example that the hon. Member for City of Durham talked about was a skin case that resulted in cancer. That is a very serious situation, and if it happened in the way that she says, it should be investigated. Another example is when a patient with acne was referred to a dermatologist at a hospital. The referral system said, “Why have we not tried a cream for this first?” That process was put into place two or three days later, as opposed to having an eight-week wait for a specialist appoint. That is of benefit to the patient.

[Julie Cooper]

Will the Minister give way?

[David Mowat]

I have given way a lot; I want to make some progress.

That is also of benefit to GPs, because they can quickly validate decisions on the best pathway for those grey areas that may or may not require a referral with a consultant who knows more than them about that particular discipline. Of course, it is of benefit to the providers because it takes away something like 20% of unnecessary outpatient appointments. Indeed, one of the providers for the scheme in North Tyneside has asked for it to be extended to an additional discipline, because they feel that some of the referrals they receive are unnecessary and that the referral management system—in the way we have been doing it in the NHS for the past decade—is a mechanism for preventing that.

[Dr Blackman-Woods]

The only information that North Tyneside CCG has put into the public domain is how much money it has saved through this system. It has not made an assessment of clinical outcomes for patients at all.

[David Mowat]

I am going to talk about the About Health situation and the people who have been awarded the contract in North Durham. It is a one-year pilot that builds on the one-year scheme in North Tyneside. I think it started last month; it covers six disciplines and it does not cover urgent referrals, in particular cancer. All the national requirements for referral-to-treatment times still count in exactly the same way. The local CCG performed a risk analysis before it decided to take the scheme forward and build on what happened in North Tyneside, and the scheme is monitored.

I have been told that a very important feature is that there is a clear GP appeals process. If they are not happy with a decision that has been taken, that process can happen very quickly.

[Mr Kevan Jones]

What about the patients?

[David Mowat]

The GP represents the patients in the health system; that is the fact of the matter. If there are out-turns that are detrimental to patients, as the hon. Member for City of Durham implied, that is a serious situation and should be investigated.

About Health is CQC-regulated—with all that goes with that—in exactly the same way as a GP practice. It is staffed by NHS consultants and GPs with a particular interest. As I said, there is a two or three-day turnaround, and they have to have the same indemnity cover as everybody else. Part of what the CCG is doing is to save money—that is true. Inappropriate outpatient appointments mean that more people than necessary are working. If that can be reduced, there is a cost saving to the national health service. It is about optimising pathways.

[Mr Jones]

Will the Minister give way?

[David Mowat]

I will make a little bit more progress and let the hon. Gentleman in later.

This is about stopping inappropriate treatment; it is absolutely not about rationing. If it was about rationing, the whole referral management system would not have been first introduced by the last Labour Government. I think it is incredible that that point has not come across more strongly.

One of the concerns is that About Health is a private company. It is a private organisation that has won the contract, and the local CCG made that decision. Fair questions were asked about the confidentiality of patient records, in terms of them going across a boundary to a private company. My first point, which is an obvious one, is that GP practices are all private companies. Every partner that works in a GP practice works in a private company, in the same way that the GPs who work for About Health are working for a private company. However, all the requirements around patient confidentiality that About Health needs to make sure are in place apply in exactly the same way as they do in every other part of the national health service.

[Mr Jones]

The point about that is that I, as a patient, have not given permission for that. The way this has been done—with no consultation, which the Minister says is wrong—means that no one knows what is actually happening.

[David Mowat]

I was going to come to the point about consultation—I do not have a great deal of time left now. It is right to say there was no consultation on this, and that is because this is an administrative process change. There is no service change—

[Mr Jones]

That is absolute nonsense.

[Geraint Davies (in the Chair)]

Order.

[David Mowat]

We are clearly not going to agree on this point, but there is no service change in what is being done.

Motion lapsed (Standing Order No. 10(6)).