GP Indemnity Costs: England

Debate between David Mowat and Julie Cooper

Wednesday 15th March 2017 Westminster Hall

[David Mowat]

I had forgotten to talk about MOD locums. My hon. Friend raised that issue, and I do not know the answer, but I will write to him and give him the information he needs, and he can talk to his wife about that. I was surprised by that example. I am sure that between the various parts of the Government, we can get an answer.

In the hour available to me, I will discuss in more detail the environment in which the NHS finds itself, the impact and the Government actions we are taking, but I will start with this: we all want access to justice. That is a fundamental of our country, and we should do or say nothing that causes people who have been badly treated to lose out. Lawyers have to be part of how they get access to justice, and that is right, but we also need to protect the viability of our NHS.

We are spending towards £2 billion a year in this area. That is £2 billion a year that we are not spending on nurses, doctors and the improvements we would all like to see. We often have debates about the level of NHS spend compared with other countries in Europe and different parts of the world, but one area in which we can say we are a leader in Europe is the amount of money we spend on litigation and all that goes with that. That is not because our NHS is less safe than other systems; it is to do with some of the points that were made earlier about the litigation culture that has built up. To an extent, that has been encouraged to build up because of our treatment of costs and some of those things. That spend of £1.5 billion to £2 billion has been increasing by something like 20% a year in the past three or four years. We cannot afford to continue to spend money in that way.

GPs are not the most expensive part of the system, but as my hon. Friend the Member for Cheltenham said, GPs typically have to spend £7,900 out of their own pocket on indemnity. That figure is increasing by 10% a year. Indemnity costs for GPs who do out-of-hours work are increasing by 20% a year, which has knock-on effects for the attractiveness of that work. As we discussed earlier, it also impacts on people in other ways, such as propensity not to become partners in GP practices.

What has made the acceleration in legal costs evident is not so much the major claims that everyone would agree need to be sorted out and dealt with—for example, babies who are damaged at birth and need to be looked after for their entire life—but the significant increase in the number of minor claims, which tend to have a higher proportion of associated legal costs. As I said, claims of around £10,000 would typically have legal costs in excess of three times the amount that the patient would receive. My hon. Friend the Member for Cheltenham said that many claims are successfully defended, and the fact is that 99% of all claims are settled out of court. There can be a tendency to settle minor claims for relatively small amounts—claims under £100,000—just because of the volume that are coming in and because it is cheaper to settle than fight to the end. All of that takes money out of our NHS.

We have talked a little bit about why this is happening. The life expectancy of people with complex needs is increasing, so if someone is damaged at birth, typically the awards they need go on for much longer than in the past. That is a good thing in terms of life expectancy, but it drives cost. There is a view that the best-quality care becomes more expensive. Technology is a part of that. We also have an environment in which, for whatever reason, there has been an explosion in small claims against the NHS, which particularly affects GPs, and there is a legal environment in which even unsuccessful claims or claims without merit can sometimes be rewarded. All of that is made worse, as we have heard, by the change to the discount rate made by the Lord Chancellor, which will come into effect next week on 20 March.

The time value of money essentially was 2.5% and is now going to be -0.75%. That will have a significant impact on all insurers in the private and public sectors. It particularly affects the health sector. The £59 billion reserve that the NHS has for central litigation costs will increase because of the change that has been made by something in excess of £5 billion or £6 billion. Those are significant and serious sums of money in the public purse. The Government’s position is that doctors will not have to pay as a consequence of the technical change in discount rate. We are working through how that will work in the central litigation authority and the three insurance companies that my hon. Friend the Member for Cheltenham mentioned. Nevertheless, the cost is significant in the context of all the other pressures on the health system.

A couple of Members talked about the fact that the issue affects not only doctors in primary care but pharmacists. Increasingly, clinical or prescribing pharmacists are working in primary care and they need indemnity, as do nurse practitioners. We need to remember that that is all part of the picture.

[Julie Cooper]

On that point, is the Minister prepared to acknowledge that professional indemnity is a significant burden for community pharmacists? That is something he might want to consider before going ahead with his funding cuts.

[David Mowat]

I will not be dragged into the issue of community pharmacists other than to say they are extremely valued and have a major part to play as we integrate them with the clinical pharmacists working in GP practices. I will simply say, since the hon. Lady has raised it, the Government are committed to getting community pharmacists to move into a much more service-oriented way of working. We will not do that by overpaying for prescribing or by acknowledging or encouraging clustering, which is what the reforms we have talked about will address.

So what are the Government doing? First and foremost, we need to continue the drive to improve standards and quality in the NHS. I made the point earlier that accidents happen and negligence takes place. When it happens, we need to learn from it and ensure that there is a duty of candour within the service. Doctors and nurses need to do what they can to make sure that the systems failure or breakdown that occurred does not happen again. To use a rather trite management consultancy-type phrase, the NHS needs to become a learning culture. It is true, however, that people need to learn from errors and continually try to improve standards. We need to avoid errors as much as possible, but at the same time we cannot have the medical profession being overly defensive, because that is not the right answer either.

My hon. Friend the Member for Cheltenham discussed what we have done so far in the “General Practice Forward View” to protect GPs from the rising costs of indemnity. Some £30 million a year is being paid out for the year just gone. There is a clear commitment in the forward view. The increases in indemnity costs, which are not a consequence of GP actions or failures or whatever, will be indemnified by the Government. I repeat that again today. I have already made the point about specialist nurses and pharmacists.

We are trying to make progress on the law and address the level of costs awarded in some cases. The 12-week consultation on fixed recoverable costs began on 30 January this year. In the case of smaller claims, proposals include a cap on solicitors’ fees and on the hourly rate for expert witnesses and locums. It is also proposed that both sides share a single joint expert witness, because it is not always sensible to have two expert witnesses arguing with each other: it is possible to do that in a more effective way. The direct aim of the consultation is to reduce the ratio of the amount of money that the patient gets to the amount of money that the lawyer gets, particularly in the lower-value cases. The Government look forward to the results of the consultation and we hope we can move forward.

Another aim—this applies less to GPs, but is also very important—is to do what we can to keep cases out of court altogether by means of the rapid resolution and redress scheme. I have talked a little about maternity cases, but because of the level of the costs and the complexity of the case it can take many years for payments to start being made. That is not right because, from a justice point of view, the baby or the baby’s family needs the money more quickly. It can sometimes takes nine, 10 or 11 years until the legal side is sorted out, and that is not just.

We began a consultation on the rapid resolution and redress scheme in October last year. The scheme tries to keep the whole thing out of court by attempting through mediation and working together to come up with a sensible and fair solution much quicker so that the 11 and 10-year court cases are avoided. We will try and make progress on that. We have not talked about tort reform. The Government are not currently working on that in respect of indemnity, although that was implied in some of the remarks that my hon. Friend the Member for Cheltenham made.

I will finish where I began. Indemnity is a very important area for the NHS. We are spending towards £2 billion a year. That cost is accelerating and will potentially undermine the level of care that we can give. We need to do what we can to moderate costs.

Pharmacies and Integrated Healthcare: England

Debate between David Mowat and Julie Cooper

Wednesday 11th January 2017 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Bailey. I congratulate my hon. Friend the Member for St Albans (Mrs Main) on leading the charge on what we all agree is an important subject. We have heard some very useful speeches, although I would make the point in passing that the subject is apparently so important to the Opposition that there have been no speeches from their Back Benchers on any aspect of the reforms during the last hour and a half.

My hon. Friend used an important word in introducing the debate: integration. I will talk about that, because if we are to fulfil the potential of the sector, which we need to do, it needs to be integrated. We have heard other important words too. We have heard about “pharmacy first” and also the phrase “wellbeing hub”, which I think sums up where we want to be in time. I will try to address many of the points made in all parts of the Chamber, but I will also set out what the Government are planning. When we boil it down, however, there is a huge amount of agreement about where we need to get to and the direction of travel. We also heard about Scotland, which is not perfect—the Murray review made some points about IT integration in Scotland, which is not yet working as well as it might—but as I have said in the past, I think we have things to learn from Scotland.

Everyone in the Chamber, Government or Opposition, can agree on three things. First, we need to move funding and the profession from a model based principally on dispensing to one based much more on services. Of course it is true that, to an extent, we are already going in that direction, but the funding model is not facilitating that, and it needs to. The Government must address that and take it forward.

Secondly, we all agree that services are a good thing per se, but that they are better if integrated with the primary care pathway much more than has been the case historically, and that is about working much more closely with GPs. I do not agree that employing more clinical pharmacists in GP practices is a “red herring”; it is part of how we bring the professions together, although I accept historically there have been difficulties doing that.

The third thing we all agree on—this must apply to the Opposition as well—is that we need to get value for money for the £2.8 billion that we spend on dispensing around £8 billion-worth of drugs. It is right to look at doing that as efficiently and effectively as possible. For example, the existing funding model encourages clusters to develop. I note that the establishment payment in Scotland is £1,700 per annum—I think I heard that right—while ours is £25,000, which has encouraged clustering, so that NHS money is not being spent on frontline services.

It is worth reminding the House that none of the efficiency changes that we announced before Christmas represents a cut of money going back to Treasury; the money is being reallocated to other areas of the NHS. The impact analysis talks in some detail about how money can potentially be spent more efficiently. In parallel with that, we need to make progress on services. I completely agree with that, and I will talk about the pharmacy integration fund and the Murray report, an important piece of work which my hon. Friend the Member for St Albans talked about and which will inform our policy.

We all agree not only on those three things, but on others. For example, there is a big benefit in diverting activity away from GPs. Various reports have been produced by the sector itself, and the Government accept that up to 30% or 40% of GP appointments could possibly be handled by pharmacists. That is a massive number. If we can achieve that, it will be of great benefit to us all. More can be done in pharmacies, such as medicine reviews and medicine optimisation, let alone how they can help us with the public health agenda, which we have not covered in particular today. A lot could be done with smoking cessation, obesity and sexual health programmes.

[Julie Cooper]

The Minister is contradicting himself. Pharmacists are already planning to reduce the hours that they are available to provide these services—the very services that he tells us he values and wants to see more of. Does he accept that if he persists with the cuts, there will be less of them? Some pharmacies will close, while others will reduce services, and are already planning to cut opening hours and reduce staff.

[David Mowat]

What we are not reducing is the amount of money available for services, as opposed to dispensing. Some pharmacies use part of their dispensing money to provide services on a discretionary and ad hoc basis, but I make this point again: overpaying for dispensing is not a good vehicle for getting more and better services.

I want to talk about some of what is already happening. We have heard about flu jabs this morning—I, too, had a flu jab at a pharmacy—and at the end of last year, we had had more flu jabs in pharmacies by October than we had in all of the previous year. The money available for that and similar service-based allocations has not been affected by the changes we announced. The community pharmacy sector has received £10 million for flu jabs up to the end of October. We want to see more of that happening, and that direction of travel is important.

A number of hon. Members made the point, which I agree with, that the public need to understand that pharmacies represent an important first port of call—it should not always be GPs. The Government can do more to make that clear. When I was preparing for this debate last night, I saw a television advert from NHS England for its “Stay well this winter” campaign. The campaign is running TV and newspaper adverts, and its theme is for people to visit their pharmacy as soon as they feel unwell. The people running the campaign have told us they think the advertising campaign has generated about 1.2 million additional pharmacy visits that would not have happened otherwise. That was a good challenge and we need to do more of that.

We also need to go further with services. There are two approaches. I recommend that anyone interested in this subject—as everyone present clearly is—reads the Murray review, which was produced by the King’s Fund. NHS England commissioned the review to inform it and us on how to spend the integration fund, the budget available to drive services more deeply into the system. I will talk about some aspects of that and about some announcements that I made in October as part of the package we are discussing.

One of the announcements was about urgent or repeat prescriptions. At the moment, NHS 111 gets about 200,000 phone calls a year asking for a further prescription, and those callers are told to see an out-of-hours GP to issue a prescription, which in due course goes to the pharmacy. We are changing that so that people will be directed to a pharmacy immediately. That is a stream of revenue for the pharmacy, which will provide both a consultation, for which it will be paid, and then the drug or prescription, as necessary.

My hon. Friend the Member for St Albans asked whether that scheme would somehow affect a good local scheme in her area. There is no reason why that should be the case. The new scheme is supplementary to anything that might have been commissioned already. It sounds as if her scheme was commissioned by the CCG, and that is good, although it takes us to the fact that things are patchy—different CCGs do different things in different areas, which I will come to. However, that is an example of where we need to be.

Another example is the minor ailments scheme. As I have said, 30% to 40% of GP appointments could be dealt with in pharmacies. Parts of England already have minor ailments schemes, but the service is very patchy and it need not be. It is true that different CCGs and indeed different GPs have different attitudes to such schemes, but NHS England has made a commitment that by March 2018 it will have encouraged all CCGs to be commissioning minor ailment schemes in pharmacies across their patch.

[David Mowat]

Yes. Throughout the country, the number is far more than £5 million—

[Julie Cooper]

Will the Minister give way?

[David Mowat]

If I may answer the previous intervention, I will certainly give way again. I have talked about medicine optimisation and pharmacies doing reviews, in particular in people’s homes, for example, and they are part of that solution. Pharmacists in GP surgeries are part of the solution too, and a way of achieving that—as I said earlier, I do not agree that that is an irrelevancy.

[Julie Cooper]

I thank the Minister for giving way. A highly trained pharmacist, who often has a trusted relationship with his patients in the community, is better placed than any other health professional to lead on saving money on wasted drugs. Patients quite often say in a close conversation when they collect their prescription, “Actually, I’ve not been taking that,” but they quite often do not say that to their GP. The pharmacist will then take it upon themselves to say either, “Actually, do you realise you should be taking this?” or, “Let’s speak to your GP and, effectively, avoid waste.” The pharmacist is best placed to do that.

[David Mowat]

I completely agree. Pharmacists have a big role to play in saving money, and medicines optimisation is very important in that. NHS England has established an integration fund, which will provide £42 million—a significant amount, even in the context of the rebalancing that has occurred—of seed money between now and the end of the next financial year to address just those sorts of things and take that work further.

The Murray review, which was commissioned by Dr Ridge, the chief pharmaceutical officer at NHS England, and published in December, sets out in some detail what we believe the direction of travel should be. Someone asked earlier when the Government will respond to that review. I expect NHS England to respond this month—if I may put that on the record in that way. NHS England will respond, not me, but there is not a lot in the review that is controversial. There are a lot of very good points, many of them about IT integration and the care record. I agree completely that some of the progress we need to make with services involves the ability to both read and write to the summary care record. That will be part of where we have to get to. Frankly, technology is an area in which the NHS could improve. That is true in Scotland—it is true everywhere. I will not spend a lot of time talking about what we need to do, but we could facilitate an awful lot of progress on integration between pharmacy and primary care, and primary care and secondary care, if we had stronger technological and IT solutions.

Colleagues have talked about the need to have more pharmacy involvement in medicines optimisation, and care homes are part of that. Pharmacists could do an awful lot with a more structured approach to care homes. One strand of work that has come out of the integration fund is a care homes taskforce, which is chaired jointly by the Royal Pharmaceutical Society and NHS England and is setting out a direction of travel for doing the sorts of things we have talked about, such as medicines optimisation, in a more structured way in care homes right across the country. There are more than 50,000 qualified pharmacists across our country. There are also 23,000 qualified pharmacy technicians, who are part of this too. The pharmacist profession is not as short as some, and it can and needs to do more to make progress in this area.

One part of the Government’s approach to this whole area that has been mentioned and I do not think enough is made of is the GP forward view. Everyone understands how much pressure GPs are under. There are something like 400 clinical pharmacists working in GP practices. We have committed and budgeted £112 million to increase that to 2,000 clinical pharmacists, many of them dispensing pharmacists. Parts of the community pharmacy network, which we have heard a little about, regard that as potentially in conflict with what they do. I think that is wrong. It is not in conflict; it is a way of breaking down the barriers that I accept there have occasionally been between CCGs and GPs and the pharmacy profession. Those are not in anyone’s interests, and we need to get over them.

Oral Answers to Questions

Debate between David Mowat and Julie Cooper

Tuesday 20th December 2016 Commons Chamber

[David Mowat]

I have mentioned on previous occasions that Scotland has, in some respects, gone further and faster than we have in England so far on community pharmacies. The £300 million that we have set aside in the integration fund for the rest of this Parliament is going to be used to do just the things that the hon. Gentleman has mentioned, in terms of minor ailments and repeat prescriptions. We are determined to make that happen.

[Julie Cooper (Burnley) (Lab)]

Over the festive period, in every town and city in the UK, community pharmacies will be open to dispense emergency prescriptions, and to provide specialist services and professional advice. Does the Minister appreciate that service, which not only helps the public, but takes pressure off other parts of the NHS? Will he join me in thanking community pharmacies and their staff for the work they do? Will he commit to reconsider budget cuts that will lead to a reduction of this valuable service, and instead meet the Royal Pharmaceutical Society and the National Pharmacy Association to discuss extending the role of community pharmacies, to deliver savings for the NHS?

[David Mowat]

I have met the royal college of pharmacies on a number of occasions, and indeed it has worked with us on the Murray review, which is an essential road map that sets out how we are going to move the community pharmacy network away from a remuneration model based just on dispensing and on to services as well. I agree with the hon. Lady that the 11,000 community pharmacies across the country all provide excellent services, and we expect that to continue.

Clinical Commissioning: North Durham

Debate between David Mowat and Julie Cooper

Wednesday 23rd November 2016 Westminster Hall

[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.

Oral Answers to Questions

Debate between David Mowat and Julie Cooper

Tuesday 11th October 2016 Commons Chamber

[David Mowat]

The STP process is locally led, not led from the centre, but I would expect clinical judgments of the type mentioned to be made if they could be confirmed on the basis of scientific and trial-based evidence.

[Julie Cooper (Burnley) (Lab)]

Central to the aim of the five year forward plan for the NHS is a sustainable health service in which all patients receive the right care at the right time in the right place. With that in mind, can the Minister tell me what action he is taking to address the problem of delayed hospital discharges, which have risen by 20% so far this year? That amounts to an additional 926 people every day condemned to stay in hospital longer than is medically necessary.

[David Mowat]

First, may I welcome the hon. Lady to her post and wish her luck in the new job? There has been an increase in delayed discharges in England over the past year. Only a part of that increase is due to difficulties in the integration between social care and the NHS—a large part of it comes from within the NHS itself—but it is not uniform across local authorities. Indeed, many local authorities are improving in this regard. What is very clear is that those making the most progress the most quickly are those that have gone furthest in integrating social care and healthcare.