GP Services

Debate between Derek Twigg and Simon Burns

Thursday 5th February 2015 Commons Chamber

[Derek Twigg]

I cannot answer the hon. Lady’s question because I do not have those figures in front of me. I am sure that if she talks to the Royal College of General Practitioners or the BMA she will be able to find all those figures. I am sure she understands that I represent one of the most deprived urban constituencies in the country and so I am going to focus on that, as I am sure she would focus on her constituency.

Let me re-emphasise a point I made earlier: whoever forms the Government after 7 May, they will have to come forward with solutions to the mounting pressure on general practice and the NHS overall. There needs to be long-term, sustainable investment in GP services in order to attract, retain and expand the number of GPs. Retention is just as important as recruitment—a point made in the comments about GPs retiring early.

[Mr Simon Burns (Chelmsford) (Con)]

The hon. Gentleman raises an important issue. A significant amount of house building is going on and will be needed in the near future. Does he agree that to encourage people into general practice and to minimise the pressures, planning for any significant amounts of new housing should include health centres and facilities for GP practices, so as to make it easier for GP practices to be able to go to such places?

[Derek Twigg]

The right hon. Gentleman makes an important point. Clearly, if there is a large housing development or one that results in a large population increase in an area of the country, planning for that should include the need for proper GP services. Of course to do that we need more GPs—that is a crucial part of it. The other point to make, which other Members may want to raise in the debate, is that we also need good facilities and buildings, because unless we have those we are not going to attract as many people into general practice. Some facilities and buildings around the country, including some I have had in my constituency, are just not up to the job. Trying then to get new facilities or new buildings built, or passed through the NHS system, is remarkably difficult and takes years. I can give examples of that in my constituency. The right hon. Gentleman raises an important point, but we need to have more GPs to do what he suggests.

I am conscious that other Members wish to speak, but I want briefly to discuss the Government’s record. Like others, I believe strongly that the Government made a major mistake in embarking on a massive reorganisation of the NHS, despite saying that they would not do so, which according to different estimates has cost between £2 billion and £3 billion. Whatever my political differences, why do I think that was such a major mistake? Well, it distracted the health service at a time when it was under massive pressure, and used up crucial resources. The massive increase in financial pressure was also building.

As a result of the creation of the clinical commissioning groups, many GPs have had to spend more time away from their surgeries. Let me just add that the CCG in Halton works very well; it is very progressive and forward thinking. It is determined to try to improve health and has worked very well in partnership with the local borough council. But the health service was distracted by the change, which cost a lot of money and took away vital time and resources that should have been put into ensuring that we had the right number of GPs and the organisation that we needed.

This Government have not done nearly enough to prevent the shortage of GPs. We are still waiting to see whether their plans will add up and create the number of new GPs that we need. I was shocked by one revelation. I would have thought that if someone wanted to decide on the number of GPs that are needed, they would have to know how many vacancies there were, but when I tabled a parliamentary question recently, I found out that the Government no longer kept a record of GP vacancies. I then asked the House of Commons Library how that could be. It told me that the survey suspension coincided with a fundamental review of data returns, which was initiated by the present Government in September 2010 in response to a commitment in the White Paper, “Equity and Excellence: Liberating the NHS” to

“initiate a fundamental review of data returns, with the aim of culling returns of limited value.”

How such information on GP vacancies could be deemed as being of “limited value” is a mystery to me.

The Library has also told me that Health Education England’s work force plan indicates an estimated gap of around 3,000 full-time equivalent GPs between the number of staff in post and the forecast demand. I understand that the Government are saying that the supply and demand gap is expected to close by 2020 if an additional 3,100 new GP trainees can be found every year, but we have already heard about the problem of recruiting trainees to work in general practice.

Dr Maureen Baker, chair of the Royal College of General Practitioners, said that the threat was one element of a “shocking” wider crisis in front-line community care, with more than 1,000 GPs expected to leave the profession every year by 2022. The number of unfilled GP posts has nearly quadrupled in the past three years to 7.9% in 2013. The RCGP has estimated that we need some 8,000 more GPs in England, and 10,000 across the UK, by the end of the next Parliament in order to meet growing demand from patients.

The Government’s decision to get rid of NHS Direct and replace it with NHS 111 was short-sighted. Members do not have to take my word on that. They can just listen to the words of a GP in my constituency, who said:

“NHS 111 has been a complete disaster. Lay people/call centre staff working from a crib sheet/flow chart are creating huge demand in both primary care and A and E. Quite a bit of controversy about this in the last few days. They call for ambulances at the drop of a hat and seldom advise the patient to self-care. The callers not admitted are advised to see their GP within a few hours. The contact summaries are unintelligible.”

Those words are not mine but those of a GP: NHS 111 has caused some real concerns.

The Government have also cut GP training. The shortage of GPs is, without doubt, one reason why we are finding it harder to see a GP. It is also holding back the NHS from meeting the challenges of the future, such as providing better care outside hospital to support an ageing population. Of course the right hon. Member for Chelmsford (Mr Burns) will remember that that was one of the key reasons why the Government introduced the Bill they did.

My right hon. Friend the Member for Leigh (Andy Burnham) has stated that a future Government will raise something like £2.5 billion for a time to care fund from a mansion tax on properties worth more than £2 million, cracking down on tax avoidance and a new levy on tobacco firms. Such investment will enable a Labour Government, by the end of the next Parliament, to provide 20,000 more nurses and 8,000 more GPs to help people stay healthy outside hospital and to tackle GP access problems.

In 1997, only half of patients could see a GP within 48 hours. The previous Labour Government rescued the NHS after years of Tory neglect. By the time we left office, 98% of patients were being seen within four hours at A and E and the vast majority of patients—80%—could get a GP appointment within 48 hours.

One of the Prime Minister’s first acts was to scrap Labour’s guarantee of getting a GP appointment in 48 hours and to cut the funding for extended opening hours.

Vascular Services (Warrington)

Debate between Derek Twigg and Simon Burns

Monday 28th November 2011 Commons Chamber

[Mr Burns]

If my hon. Friend means by “piecemeal” that the decision is dealing only with a certain part of the country, then that is indeed the case. However, the review was carried out in the context of a wider geographical area in and around Merseyside, and in that respect it is achieving its aim of finding the most relevant service for the local communities. That is why the recommendation was to have two arterial centres located there.

The hon. Member for Warrington North raised the issue of population, as she believes, I think, that there should be a third centre. The following point is based on advice from both the Vascular Society of Great Britain and Ireland and the local clinical advisory group. The population in the area under discussion in respect of this decision on services is 1.2 million, whereas the figures that would be required to have a third centre are 1.4 million for the vascular networks and 1.6 million for abdominal aortic aneurysm screening programmes. Therefore, the population currently under discussion is too small to warrant an extra centre. I hope she will accept that.

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

No, as there is not sufficient time.

On the proposals for consultation, I have been assured by NHS North West and the PCT cluster boards that an implementation steering group will ensure that the recommendations made in the impact assessment are taken forward. The final proposals will be subject to formal public consultation in 2012.

I appreciate that the hon. Lady and her constituents have concerns about the proposals for vascular services. However, I should stress that these proposals have been developed by the NHS in Cheshire and Merseyside based on advice by clinicians made in the light of best practice recommendations by the Vascular Society of Great Britain and Ireland. I therefore encourage her to take the opportunity to discuss the proposals with the Cheshire and Warrington and Wirral PCT cluster boards while they are being prepared for formal consultation, which will take place next year, as I mentioned earlier.

Question put and agreed to.

Private Finance Initiative Hospitals

Debate between Derek Twigg and Simon Burns

Wednesday 4th May 2011 Westminster Hall

[Mr Simon Burns]

I want to deal with this in detail when I come to my contribution. The hon. Gentleman said, “What man in his right mind would consider the private sector being used in the NHS for the management of an NHS hospital?”

[Derek Twigg]

This particular one.

[Mr Burns]

I am talking about the generality. I can answer the generality and will come to the specifics in my speech. The gentleman concerned, who accepted the principle in a generality, was the right hon. Member for Leigh (Andy Burnham), who was Secretary of State for Health before the election.

[Derek Twigg]

I am not sure that that is worthy of a reply. I am being specific. The Minister may remember—and the hon. Member for Broxtowe (Anna Soubry) sitting behind him will—that when the Health and Social Care Public Bill Committee discussed foundation trusts and insolvency, I made the point that it does not always follow that a hospital that gets into financial difficulties is badly run. That is the issue that the proposals in the Bill do not take into account. What was the logic behind the proposal for this specific hospital to have a private provider brought in to help manage it? That is a different point from the one that the Minister took.

I also want to make the point that the Government are placing NHS trusts under intense pressure through the policy of forcing foundation status within three years, coupled with the costs of reorganisation and the efficiency savings that trusts have been asked to find. That is leaving many NHS trusts in peril as they struggle to meet foundation trust status, or become foundation trusts with financial difficulties from day one. The Minister knows a number of hospitals are in financial difficulty. I do not know whether he has yet decided to put that list in the public domain.

The dangers are clear. St George’s hospital in Tooting, London, recently decided that it was too risky to push ahead with the Government’s preferred timetable for NHS trusts to become foundation trusts. Speaking after announcing a two-year delay to the plan to become a foundation trust, the board of the hospital said:

“The board recognises that if we put the organisation under pressure to become an FT during 2011-12 then this could impact on the quality and safety of the patient care that we provide.”

I wonder whether parallels can be drawn with the St Helens and Knowsley trust, as the board is not prepared to take the risk. Put simply, existing pressures on NHS trusts are too great to risk a massive reorganisation. Hospitals realise that, and so should the Government. It is important to understand that the pressures are great, and what is being asked behind the scenes at particular foundation trusts is important.

Now more than ever, the dangers of an FT or NHS trust experiencing financial difficulties are growing. Under the Tory-led Government’s plans for the NHS, a struggling FT will be faced with two options. One is insolvency in line with commercial insolvency procedures, and the other is the sort of takeover dictated by clause 113 of the Health and Social Care Bill, which the Committee discussed in some detail, or a takeover on unknown terms. The Minister refused to be drawn on giving an example of what hospitals might be in difficulty and what sort of takeover might be considered. I do not know whether he has changed his mind since then, because an example would help us with the detail of our deliberations.

Although the debate on PFIs and their appropriate use will continue, it is important to be clear on one issue. During our time in government, we supported the NHS. We undertook no step that would have endangered its position as a world class public health care system. In comparison, this Government’s policy on health care has been in turmoil from the very beginning. It is hated by the public and despised by the professionals, and we believe that that is dangerous for the NHS.

We need to know what plans the Government, the Secretary of State and the Prime Minister have for capital investment in the NHS. What will hospitals and NHS facilities have to do if they require large capital investment? Is it the case, as reported in the Financial Times last year, that the Secretary of State has ruled that they should no longer have access to public sector cash for big capital projects? Is that the Government’s current policy? Alternatively, will the Minister confirm that future investment in NHS capital projects will be determined solely by the market, as part of the Government’s plans to place the market at the centre of the NHS?

The Minister will expect me to remind him that he was forthright—it is not what the Secretary of State would have wished—in identifying the extent to which EU competition law will increasingly apply to the NHS. Just as importantly, we need to understand where the Government are going on PFI. Much has been said about what they are considering, but when will they publish their plans?

I remind the Minister that he is now in government. Whatever matters he raises this afternoon, he must realise that he needs to supply the answers to these difficult questions. There is great uncertainty within the NHS, which is not helped by the lack of policy detail on which course the Government intend to pursue. It is a crucial question for NHS services, and the answers need to be heard.

The Government should make no mistake about it that their massive reorganisation proposals are putting the future of the NHS as we know it in peril. They are causing massive uncertainty and distracting the professionals, and, as the Health and Social Care Bill impact assessment shows, it could have an impact on the safety and care of patients. The fact remains that opposition to the Health and Social Care Bill, which has been led by the Labour party, and the increasing rejection of the Government’s plans by medical professionals, health experts and patients groups alike have forced the Government to take this humiliating pause. If it is to be more than a simple political ruse to get through the local elections tomorrow, real and significant changes will need to be made to the Bill, including the crucial deletion of part 3, which has severe implications on the issues that we have been discussing today.

Labour left the NHS with record levels of public satisfaction, record low waiting lists and world class hospitals such as those at St Helens and Whiston. It is becoming increasingly clear that the NHS is moving backwards because of this Government’s cuts and broken promises. I have no doubt that that will inform the choice that people will make tomorrow at the ballot box.

--- Later in debate ---

[Mr Burns]

I do not share the hon. Gentleman’s blinkered view of what went on in the health service prior to May 1997. I am probably of a more generous spirit, in that I am prepared to pay tribute to the achievements of the last Labour Government, although it would be more difficult to discover those of the Wilson-Callaghan Government and before that the Wilson Government because of the chronic economic situation.

Unfortunately, the hon. Gentleman is not as generous of spirit; he seems to think that everything changed in May 1979 and did not improve again until May 1997, despite the fact that for every year between those dates we saw a real-terms increase in health spending. Indeed, health spending went up from just under £9 billion a year in 1979 to more than £39 billion in 1996-97, which at the time was an incredibly large sum, although due to inflation and other factors, it now seems far more modest. However, I am prepared to be more open-spirited and to acknowledge achievement when justified, but also to criticise when justified.

[Derek Twigg]

No one suggested that everything was renewed and changed under the previous Labour Government, but there was record investment and an unprecedented hospital building programme. How many hospitals did the Thatcher and Major Governments build?

[Mr Burns]

This is the point. Perhaps the hon. Gentleman is taking a punt on something with which he is not very familiar, but if he had been in the House in the mid-1990s, he would know beyond doubt that there were record levels of investment in the NHS. Even he said, looking at the report in front of him, that the Major Government used PFI, and there was considerable investment in infrastructure. He would probably argue—with some justification because one can always argue this—that there should have been more investment, but there was more. I shall give one example, but—

[Derek Twigg]

Give examples.

[Mr Burns]

I will. There are so many examples of old and dilapidated buildings or buildings that were past their sell-by dates that the Thatcher and the Major Governments knocked down and replaced through new investment. One example was the moving of the European-renowned burns and plastic surgery facility on a Billericay site in Essex, which wanted to expand to maintain its position at the forefront of providing highly specialist services and was moved to Broomfield. I remember a particularly happy day in February 1997 when, as a junior Health Minister, I accompanied the then Prime Minister to open it.

May I now get back to the point I was making to the hon. Member for St Helens North? However reasonable the hon. Member for Halton is trying to be, his hon. Friend was not quite so generous, suggesting that everything was appalling prior to 1997 and everything was magnificent after it. The hon. Member for Blackley and Broughton rather unfortunately brought the speech of the hon. Member for Halton to a bit of a halt by highlighting some of the perceived criticisms of the PFI system under the Blair and Brown Governments, but the hon. Member for Halton very neatly sidestepped the issue. He did not want his story of good news on investment in hospital buildings to be punctured, and neatly avoided it.

--- Later in debate ---

[Mr Burns]

To pick up the point made by the hon. Member for Blackley and Broughton, until October last year, I, too, for the 13 years of the previous Labour Government had a hospital in my constituency that was an old, Victorian workhouse, with ancillary wards that were improved Nissen huts. We could go round the country and find many buildings that needed improvement.

I am sure that Labour Members will accept that even the NHS is restricted in that it cannot have unlimited funding, there will be priorities for improvements and reinvestment, and not everything will be done all the time. The process is ongoing. To answer another point before I focus on St Helens, the hon. Member for Halton asked about what is happening to the capital spending settlement and programme. As I am sure he is aware, as an outcome of the spending review, the Government have a capital spending settlement up to 2014-15, and capital will continue to be used to provide investment for NHS development, as well as PFI.

[Derek Twigg]

How many hospitals?

[Mr Burns]

The hon. Gentleman wants me to list some more new hospitals. There is the Chelsea and Westminster hospital on Fulham road, which was a flagship hospital for the centre of London initiated by Baroness Bottomley, I believe. I could continue round the country, but I will not because my time is limited. I think that the hon. Member for St Helens North would prefer it if I spent more time discussing his local PFI project, because there is a lot to be said to clear his mind and reassure him, if only he has the open ears to listen; an open mind would help as well.

As the Government confirmed at the end of last year, where they can be clearly shown to represent good value for money, we remain committed to public-private partnerships, including those delivered via PFI. Such arrangements will continue to play an important role in delivering future NHS infrastructure. However, the Government also believe that not only have too many PFI schemes been undertaken, but some were too ambitious in their scope. The Treasury has now reviewed the value for money guidance for new schemes and looked at how operational schemes can be run more efficiently. We are clear that the focus should now be on releasing efficiencies at the many existing PFI schemes.

In January, the Treasury published new draft guidance, “Making Savings in Operational PFI Contracts”, which will help Departments and local authorities to identify opportunities to reduce the cost of operational PFI contracts. As part of that initiative, my noble Friend Lord Sassoon, the commercial secretary, launched four pilot projects to test the ideas raised in the Treasury’s draft guidance. The focus of the pilots is to find efficiency gains and savings within the PFI contract itself, allowing the quality of care for patients to remain the priority. The pilots should end by the end of this month. The lessons learned will be used to finalise the Treasury guidance and to improve other relevant PFI contracts, including the one at Whiston hospital. One essential element is that all NHS trusts will retain any savings made to reinvest in improving patient care.

The other important aspect of operational PFI schemes and their cost to local health economies is their effect on NHS trusts seeking NHS foundation trust status. The coalition Government have set a clear commitment for all remaining NHS trusts to achieve foundation trust status by April 2014. That policy will finally realise the ambition of the previous Labour Government. It is about ensuring high quality and sustainable NHS services by giving trusts the freedom to serve their patients to the very best of their ability, unhindered by top-down bureaucratic control.

An issue facing some NHS trusts in their move towards attaining FT status is the affordability of their PFI schemes, as hon. Members are aware from examples in their constituencies. We are tendering for an independent review to establish where PFI schemes may, in some organisations, be the root cause of problems that prevent them from becoming foundation trusts. St Helen’s and Knowsley NHS Trust is one such organisation, and will be considered as part of the scheme. In addition to the independent assessment, the Department and the NHS are developing solutions in a systematic and comprehensive way to manage the PFI schemes in the very small number of trusts where a local or regional solution cannot be found.

When the current management of St Helens and Knowsley NHS Trust signed their PFI agreement in 2006, with the agreement of the then Secretary of State for Health, Patricia Hewitt, and other Ministers, local PCTs agreed to make up the shortfall between the revenue generated by the hospital through the national tariff and other means and the cost of the unitary payment—the annual PFI charge, which was some £20.3 million. Unfortunately, that decision built a deep lack of sustainability into the trust’s finances—a lack of sustainability that the trust, the strategic health authority and the Department are now working extremely hard to rectify. To that end, the trust’s board and the strategic health authority, NHS North West, are developing a tripartite formal agreement, or TFA, to be agreed with the Department of Health, which will support the work to achieve foundation trust status.

Every trust is required to produce a TFA, setting out how it plans to progress to FT status by 2014, the challenges that it faces and how it plans to overcome them. In the case of the St Helens and Knowsley trust, the TFA is still in draft form and is very much a work in progress. Beyond what was leaked to the Liverpool Echo and to the hon. Member for St Helens North, I have not seen the draft and while discussions are ongoing it would be inappropriate for me to do so and I will not see it. Therefore, it would also be inappropriate at this stage to publish the documents.

--- Later in debate ---

[Mr Burns]

Because it was a first draft document, drawn up between officials in the Department of Health, the SHA and the trust, and I do not think that at that stage it was appropriate for me to see it. Also, I suppose that if one is being totally candid, which often gets me into trouble when the hon. Member for Halton or particularly the hon. Member for Leicester West (Liz Kendall) are around, it does make it slightly easier for me because I can say, “In all honesty, I have not seen it.”

I will now make some progress, because I think that what I am about to say may answer some of the questions put by the hon. Member for St Helens North and it may well help the right hon. Member for Knowsley, too. If it does not and I have time to do so, I will give way then.

The TFA process should be completed soon, with the final approved version hopefully being published some time in June or July. I can confirm—if the hon. Member for St Helens North would like to listen to me, because I think that he will find what I am about to say particularly interesting, as he has expressed a degree of confusion about the issue—is that one of the options under review is not, I repeat not, to somehow “privatise” the NHS. As I said to the hon. Gentleman during Health questions last week, this Government will never privatise the NHS and we have no intention of doing so at the St Helens and Knowsley trust.

Perhaps it would be a help if I took a moment to explain the process through which the trust, like all trusts in a similar position, is progressing towards becoming an FT. First, the trust, along with local health authorities, will attempt to find a local solution to whatever financial issues there may be. If a simple local solution cannot be found from within its own resources, then a more radical solution may be necessary, such as merging with another trust and examining whether services need to be reconfigured. On that point, it may be of some consolation to Opposition Members that the benefits of a merger with another trust are that it reduces the percentage of the unitary payment of the PFI in relation to income, which helps with the financial situation, and for other FTs in a merger it increases the income base and economies of scale become possible, which again potentially helps with the finances of a trust.

If the problems cannot be resolved in that way, we would work to a national solution, which is being developed by the Department and which will be agreed with the Treasury. If there is no foreseeable solution, a final option would be to consider tendering the management of the trust. Under that option, management teams from within the NHS, from a social enterprise or from the private sector would put forward their ideas on how to find a way forward for the trust.

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

May I just continue, because this is rather important?

While that option is a very long way down the line of potential solutions, it is only what is currently being done at Hinchingbrooke hospital in Huntingdon, in the constituency of the Under-Secretary of State for Justice, my hon. Friend the Member for Huntingdon (Mr Djanogly). The decision on that hospital was taken by the previous Labour Government, when the right hon. Member for Leigh (Andy Burnham) was the Secretary of State for Health. So it is not a new option dreamt up by the present Government since coming into office. We are simply taking an option that is already on the table and that was there when we came into power, which the previous Secretary of State for Health—a Labour Secretary of State for Health—was prepared to accept.

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

Just one minute. I must say that at the time, during the discussions about what should happen to Hinchingbrooke hospital and about the use of the option that the right hon. Member for Leigh agreed to, nobody said that that was privatising the hospital, because it was not. If—and it is a big if—that solution were to be considered the right way to solve the problems at the St Helens and Knowsley trust, that would not be privatisation either.

[Derek Twigg]

With respect to the right hon. Gentleman, we are not comparing like with like.

[Mr Burns]

We are.

[Derek Twigg]

We have a double-excellent hospital at St Helens and Knowsley; it has excellent financial management and excellent services. It meets all the standards. I put the question back to the Minister. On that basis, why is the Department—whether we call it the SHA or not, it is part of the Department and it has responsibility to the Secretary of State—

[Mr Burns]

It is not part of the Department.

[Derek Twigg]

Well, I understand the SHA discussed this as an option with the hospital. I want the Minister to ask my question. Did the hospital voluntarily reject the third option of a private sector provider coming in to manage or run the hospital? Did it refuse that option and also say that it would not accept the cuts being asked of it by the SHA as that would put patient safety at risk? Is that correct or not? If he does not know, will he find out?

[Mr Burns]

I can advise the hon. Gentleman that it is not correct. That is the advice—

[Derek Twigg]

indicated dissent.

[Mr Burns]

The hon. Gentleman could at least have the decency to listen to what I am saying first. The advice that I have been given is that that is not correct.

[Derek Twigg]

What is not correct?

[Mr Burns]

That the trust rejected consideration, or the possible consideration, of that option, because—[Interruption.] What I want to do is to put it in context. As I said in my comments earlier, that is very much a last possible solution if the other solutions are not able to be worked out.

[Mr Burns]

Let me just finish. If I have been given the wrong information, and I do not believe that I have been, the hon. Member for Halton will be the first person to find out, because I would hate to mislead him.

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

No. I have answered the hon. Gentleman. He said, “Did the trust reject the proposal because they found it unacceptable and they thought it wasn’t in the best interests of patients and patient safety?” That is what I—

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

All right, I will give way for the last time.

--- Later in debate ---

[Derek Twigg]

I understand that the SHA, not the hospital trust, suggested as a third option having the private provider, on the basis that the hospital—I understand that it was approved by the board—would not accept what was on offer because of the cuts that it would have to make and it was concerned about patient safety. It therefore would not accept voluntarily an option to have a private sector provider come in. The question is whether that option was proposed by the SHA and whether the trust, because of concerns about patient safety, rejected it on that basis, on a voluntary basis. I make that point very clearly.

[Mr Burns]

Right. I repeat the answer that I gave to the hon. Gentleman before. My understanding is no, that is not correct.

Oral Answers to Questions

Debate between Derek Twigg and Simon Burns

Tuesday 25th January 2011 Commons Chamber

[Mr Burns]

I am grateful to my hon. Friend in view of the considerable interest he takes and work he does in this field of health care. Let me reassure him that we have guaranteed the funding for next year, so it can work itself out to a successful conclusion thereafter through the cancer networks in the commissioning plans.

[Derek Twigg (Halton) (Lab)]

Under Labour, hospital waiting times were at a record low and satisfaction with the NHS in its current form was at a record high. Over the last few months, however—no matter how much the Secretary of State does not like it—we have seen more and more operations cancelled or postponed at our hospitals. A number of nurses in my constituency have written to tell me that they are short staffed. One of them pointed out that

“those who have left are not being replaced”.

Is that not the true picture of what is going on in the NHS at the moment? If the Minister is confident in his Secretary of State’s plans for the NHS, will he guarantee that under those plans, hospital waiting times will not rise—or is he going to duck the question like the Prime Minister did last week?

[Mr Burns]

Under these reforms, by concentrating on raising quality and outcomes, we will give improved quality health care for patients. What I can guarantee is that under these reforms, when implemented, people will not only get improved quality treatment but will see times based on clinical decisions rather than being distorted by political processes.

Health (CSR)

Debate between Derek Twigg and Simon Burns

Thursday 11th November 2010 Westminster Hall

[Mr Simon Burns]

Old Labour.

[Derek Twigg]

No, not all old Labour at all. There has been a mix of Labour: young, old, new—some a bit younger than others. My hon. Friend the Member for Easington made some very important points about this being the worst settlement since the 1950s, and he raised the point about rising to the challenge of the financial settlements and the impact on social care. We heard many important points from my right hon. Friend the Member for Rother Valley (Mr Barron) who, along with my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), is probably the most experienced person in the Chamber, given his knowledge of the health service and his involvement in it over the years. One of those points was what the Nuffield Trust said about this being a real-terms cut, once the £1 billion that is being transferred from the NHS is taken out—I shall come back to that later. My right hon. Friend also made an important point about how the Government have used a Health Committee report to support their policies. His point was very clear, and he also raised the important issue of commissioning for GPs.

My hon. Friend the Member for Newport West (Paul Flynn) made a very important point about NICE and drugs companies with reference to funding and influence. My hon. Friend the Member for West Lancashire (Rosie Cooper) has great experience in the health service. She is a near neighbour, and our areas successfully share the excellent women’s hospital in Liverpool. She made a number of powerful and important points about the reorganisation and cost pressures, and their effects on patient care. She also talked about Ministers not listening—[Interruption.] I know that the Minister has listened to what has been said in the Chamber, but Ministers’ listening will also be an important aspect of the reorganisation.

My right hon. Friend the Member for Tottenham (Mr Lammy) made a powerful speech. I think he said that because he had believed what was in the Conservative and Liberal Democrat manifestos, he was somewhat disappointed—[Interruption.] Perhaps I got that wrong, but he made the point that what was said before the election and in the manifestos is not now being delivered.

[Derek Twigg]

I always carry a copy of the coalition’s programme for government—it is a fascinating read and, I must say, comforting at times.

My right hon. Friend the Member for Tottenham made some important points about mortality, the different life expectancy rates in his constituency, and the impact of the 28% cut on local government services, to which I shall return later in my speech.

[Mr Simon Burns]

I advise the shadow Minister to take the analysis of the right hon. Member for Tottenham (Mr Lammy) of the impact of the so-called figures that he used with a pinch of salt, because he also said that when he was as a Health Minister in 2001, he remembered the PCTs beginning to bed down. That was rather confusing, because of course the PCTs were not established until 2002.

[Derek Twigg]

The hon. Gentleman should have listened much more carefully to what my right hon. Friend the Member for Tottenham said. He made a lot of good points, including one about GPs being put under pressure by the reorganisation due to the fact that some of them do not have the skills that it will require. That was a very powerful point, because many GPs are either opposed to or very uncertain about the Government’s proposed reorganisation.

My hon. Friend the Member for Gateshead (Ian Mearns) made a very impassioned speech about his own experience, his local health service, of which he has great knowledge, and the consequences of the Government’s actions for A and E and maternity units. He also made an important point about the great uncertainty in the health service as a result of the reorganisation—not just financially, but in all aspects of the service.

It is worth reiterating that we have had some successes in the health service, although many of them were achieved in recent years by the Labour Government rather than during the Conservatives’ 18 years in government. Back in 1997, I was regularly contacted by constituents who had to wait between 18 months and two years to have an operation. We have now got that time down to 18 weeks or fewer, and two to three weeks for cataracts. I set out that information because the Government will be measured on such things, although I am not sure whether they will be “outcomes”, “horizons” or “milestones”. A million more operations have been carried out each year since 1997, and there is now rapid access to chest complaint clinics. A large part of the NHS estate dates from before 1948, but we now have more than 100 new hospital building schemes and more than 90 NHS walk-in centres.

We have not achieved those gains for patients without sustained, deliberate and targeted investment. The combination of reform and investment that Labour undertook when in it was power has brought about tangible results for patients: heart disease deaths are down by more than a quarter; cancer mortality rates are down by more than a tenth; and breast cancer and male lung cancer death rates have been cut faster than anywhere else in the world. Under the cancer target, patients now see a cancer specialist within two weeks, which saves many lives. We made real investment and real change, and real people’s lives were made better. Let us see how the coalition intends to honour some of Labour’s guarantees. It has scrapped the right to cancer test results within one week of referral.

[Mr Burns]

Will the hon. Gentleman please explain in rational terms how something that was never in place can be scrapped?

[Derek Twigg]

As I said, that was one of our guarantees, and the Government have not taken forward those guarantees. They have gone against what we said, which was welcomed by many patients and organisations. Free prescriptions for vulnerable patients with long-term conditions have been scrapped and, in this Parliament, some 8,000 new psychological therapists have been scrapped.

--- Later in debate ---

[Mr Burns]

The shadow Minister is a reasonable and intelligent individual, so he knows that we did not scrap that target because it was never in place. All that happened was that the previous Prime Minister, at his party conference just over a year ago, made public an aspiration that was totally unfunded and totally untried against any clinical guarantee for quality.

[Derek Twigg]

The Minister should realise that he cannot meet what we proposed. I notice that he intervenes on that point, but not to congratulate us on the many improvements that we made in the NHS over the years. I look forward to hearing what he says about those improvements in his speech.

Returning to mental health, the Department of Health website says:

“Policy around mental health is developing…Mental health policy cannot be devised and implemented by any single government department or the NHS alone – it requires collaboration across central government, local government and the independent sector.”

We knew that already, did we not? However, the coalition has cut those 8,000 therapists. Of course the financial climate is difficult, and whomever was in government would have difficult choices and decisions to make, but the Prime Minister and the coalition have, again, broken their promises on health, which I want to explore, particularly with reference to the CSR.

For all the coalition’s boasts of ring-fencing the total NHS budget, the negligible 0.1% increase in NHS spending over the CSR period is low by historical standards, as we have heard. The King’s Fund has been cited, but let me give another quote from it:

“the NHS has averaged real terms increases of 4% a year since it was established and 7% since the turn of the century. The only similar period of near-zero real terms growth was in the early 1950s”—

I think that the Minister agrees. Spending in the NHS has increased from 6.6% of gross domestic product in 1996-97 to 8.7% in 2009-10.

The Minister might be interested to hear that the Royal College of Midwives has said:

“there are fears that a funding increase of 0.1% a year could be swallowed up by a rise in drugs, an ageing population, the cost of reorganisations and inflation.”

While we are on the subject of midwives, will the coalition deliver on the pre-election pledge to increase substantially the number of midwives, or will that be another broken promise?

Perhaps the Minister will want to respond to my next point. The CSR also announced that £1 billion will be transferred from the NHS budget to local councils for spending on social care. He will argue that that is designed to improve working relationships between the NHS and local social services departments, to improve health and to reduce costs on the NHS, such as by helping older people to stay healthy and independent in their homes. Of course, that is a good thing. However, the Government cannot have it both ways and double count. This is a real-terms change in NHS funding over the next four years. When we consider the net funding for social care support, there is a reduction of 0.5%, which is a real-terms cut.

[Mr Simon Burns]

indicated dissent.

--- Later in debate ---

[Derek Twigg]

The Nuffield Trust actually supports that point of view. This is a broken promise. Will the Minister confirm that not all the additional money for social services announced in the CSR is ring-fenced?

[Mr Burns]

I want to respond to the point that the shadow Minister made about the Nuffield Trust. He said that we were giving £1 billion to local authorities for social care, but we are not giving—[Interruption] I think that he did say that, but if he did not, we will wait for my speech.

[Derek Twigg]

Let me make it clear that £1 billion is being taken out of the NHS budget. Is that correct?

[Mr Burns]

Carry on.

[Derek Twigg]

Therefore that is a real-terms cut of 0.5%.

[Mr Burns]

indicated dissent.

[Derek Twigg]

I am asking the Minister to intervene. Has £1 billion been taken out of the NHS budget for social care?

[Mr Burns]

I will be careful because of the context in which the shadow Minister is trying to put the matter. We have made no secret of what we have done. Because of the lack of funding for social care and the demand for it, which we inherited, we have decided that we will use £1 billion out of the capital budget on social care and, at the same time, local authorities, through the revenue support grant, will provide another £1 billion. There will be £2 billion of extra money: £1 billion from the health service, which the health service will spend, and £1 billion through the RSG.

[Derek Twigg]

I am not sure about that, although I am always happy for the Minister to intervene. Will he confirm, just for the record, that £1 billion has been taken out of the NHS budget?

[Mr Burns]

indicated dissent.

[Derek Twigg]

I will carry on and we will take this up later during the Minister’s speech.

Will the Minister make clear whether the money has been ring-fenced? What what will be the impact on local services of the 28% cut in councils’ budgets over the next four years, which was announced as part of the CSR? We must not forget the increase in VAT to 20% from January, which several of my colleagues mentioned, which will do little to enhance the NHS’s spending power. It is little wonder that the King’s Fund feels it necessary to warn:

“slashing budgets and cutting services should not be the answer to the financial challenge facing the NHS.”

I cannot allow the Government to get away with another disastrous decision for the NHS and it will be interesting to see what the Minister has to say about this.

The NHS has accumulated £1.8 billion of capital and £3.7 billion of revenue underspend. It would normally be allowed to keep that money to reinvest in patient care or to help deal with future overspends, but the CSR has abolished end-of-year flexibility. Perhaps the Minister would like to deny that or tell me that we have got it wrong.

What estimate has the Minister made of the number of job losses and redundancies in the NHS that will occur as a result of the CSR? What will be the impact on waiting times in the spending review period? What is his estimate of the number of nurses who will be employed in the NHS at the end of the spending period? What measures has he implemented to deal with winter pressures? How many specialist nursing posts will be left vacant at the end of this financial year? I have many other questions. We do not have time to go into them now, but I shall be tabling a lot of written questions for the Minister to answer.

We now move on to another broken promise in the context of the CSR, which has been the subject of a fair bit of comment. An ideologically inspired, top-down reorganisation of the NHS has been proposed. It has been put forward in defiance of the coalition agreement. The approach is untested and threatens the viability of the NHS. I remind hon. and right hon. Members that the coalition agreement says:

“we will stop top-down reorganisations of the NHS”—

another broken promise. Here is a straight question for the Minister: why, as many believe, did his party hide their plans for such a massive reorganisation from the public? Why did it make no mention of the scale of the proposed changes in its manifesto or election campaign? This is the biggest reorganisation in NHS history. The King’s Fund estimates the actual cost at some £3 billion, and that is at a time when the NHS can ill afford it. The British Medical Association has stated:

“these proposals risk undermining the stability and long-term future of the NHS”.

What is the Minister’s latest estimate of the financial cost of the reorganisation, and will he publish the rationale underpinning the assumption for those costs?

The coalition talks about reducing waste, but the 45% cuts in strategic health authorities and primary care trust management will save just £850 million of the £15 billion to £20 billion of efficiencies that are required. I could not agree more with the words of my right hon. Friend the Member for Wentworth and Dearne (John Healey):

“This reorganisation is untested and unnecessary. It is high cost and high risk. At this time when finances are tight, all efforts should be bent to making sound efficiencies and improve patient care. We are in favour of giving clinicians greater responsibility and patients a greater say in their healthcare. NHS experts, professional bodies and patient groups say ‘slow down’, because this big reorganisation is a big risk for the NHS.”

Trade unions such as Unison, the RCN and Unite, who represent many who work in the NHS, have raised genuine concerns, but we do not believe that the Secretary of State is listening to what is being said.

As part of these changes, there is danger of fragmentation, of more of a postcode lottery and of doctors’ time being diverted from their main role of looking after their patients. We need to know the extent and nature of future private sector involvement in running the health service. How and to whom will organisations be accountable? How can we deal with current overspends in organisations, which my right hon. Friend the Member for Tottenham mentioned?

Will the Secretary of State and the Chancellor listen to the appeal of patient groups, Royal Colleges practitioners and other health staff, or is he bent on setting his face against the view from the coal face—from the same professionals whom his party’s manifesto says we should trust to deliver services?

I want to mention another important issue: the proposed stealth cuts to the funding of specialist children’s hospitals, which will affect the hospitals that treat some of the most severely ill children in the country. The Prime Minister promised that the health budget would be “protected”. In an interview with Andrew Marr on 2 May 2010, he said that he

“would not accept cuts to the NHS”.

It is unarguable that specialist children’s services are the front line, so even that is not being protected. This is another promise broken by the Prime Minister.

The Secretary of State is not being straight on this matter. During oral questions on 2 November, he told my right hon. Friend the Member for Holborn and St Pancras that the hospital that my right hon. Friend asked about would face a 2% cut under the proposed tariff changes. That is bad enough, but it is contradicted by the trust’s own assessment of those changes, which suggests that they will bring about much larger cuts. Will the Minister set out—I ask him this carefully—what the situation is and how much funding the hospitals will lose?

I will give a couple of examples of the figures that we have received from the hospitals involved. Great Ormond Street hospital, which is in the constituency of my right hon. Friend the Member for Holborn and St Pancras, will face a cut of £16.3 million. In Birmingham, the cut will be £12.8 million, and at Alder Hey hospital, on the doorstep of my constituency, it will be £12.9 million. Will the Minister confirm what the funding cuts will be and how much those hospitals will lose? What figures have the hospitals provided to the Department in their assessments of the cuts? Will he make public any assessment that has been sent to his officials about the impact of the tariff changes?

I do not feel that Liberal Democrat or Conservative Members have realised the true extent of what the coalition Government are doing to the health service and the impact that it will have on their constituencies. Perhaps they are not in the Chamber because they find the measures difficult to support. As the impact of the health cuts becomes clearer, I believe that hon. Members will become more worried and will seek answers to the broken promises of the Prime Minister and the Secretary of State.

There have been broken promises on NHS funding to protect front-line services, and broken promises about structural change. Hon. Members might ask why the Secretary of State is forcing the NHS into a major reorganisation that costs valuable time and resources at a time that the King’s Fund and the NHS Confederation have called the biggest financial challenge of its life. I assure the Minister and the Secretary of State that we will hold the coalition Government to account for what they have said and what they will do.

--- Later in debate ---

[Mr Burns]

I will briefly answer that now; I was going to come to it later. The figure that has been bandied around by shadow Ministers, Labour Back Benchers and so on is £3 billion. The Department does not recognise that figure. We recognise the figure that the previous Secretary of State for Health, the right hon. Member for Leigh, put in this year’s Budget, which is 1.7%. He put that in specifically for reorganisational purposes under a Labour Government. That is the only figure—[Interruption.] That is the only figure that we recognise.

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

Once, then I will make progress.

[Derek Twigg]

The Minister is using a figure that was in the Budget for reorganisation. I assume that that reorganisation is not the reorganisation that his Government are proposing, so have he, the Department and his officials made any assessment of the cost of their reorganisation? That cannot in any way be linked to a figure that was laid down by the previous Government; it is bizarre if it is. If they have made such an assessment, what is the rationale for it and will he publish it?

[Mr Burns]

I am saying that the previous Secretary of State had built in to this year’s Budget a £1.7 billion figure for reorganisational purposes and we recognise that amount of money as money that can or could be used for reorganisational purposes. On the question of the full figures, we will publish in due course our response to the consultation process on the White Paper and the documents that flowed from that White Paper. Also, we will respond on any decisions that we have taken emanating from that consultation process. We will also publish the Bill, which will flesh out more of the details where details need fleshing out.

As a number of hon. Members mentioned, there are parts of the Bill where we are not prescriptive and we are not dictating, down to the last dotting of an i and crossing of a t, what has to happen. That will be down to local decisions. That will then put us in a position—

[Derek Twigg]

Will the Minister give way?

[Mr Burns]

No. That will then put us in a position to move forward on the implementation and funding the costs of those changes. I shall now move on to deal with the rest of the issue. This year, before we spend a single—

--- Later in debate ---

[Mr Burns]

The hon. Member for Newport West (Paul Flynn) probably is not aware, because this is a new form of debate following the setting up of the Backbench Business Committee, that I am not winding up the debate, even if I am speaking last. I am making a speech on the Government’s position on the subject that we are debating, and I will certainly—on occasions, where appropriate—refer to and answer hon. Members’ questions, although I have to say to the hon. Gentleman that I probably will not answer any of his questions because he was not taking part in the same debate that is on shown on the annunciator. He was having a general roam-about on NICE and pharmaceuticals, rather than speaking on the spending review and health.

[Derek Twigg]

That is very unkind.

[Mr Burns]

No, it is not. It is a fact, and the hon. Gentleman knows it.

As I said before the intervention and the point of order, just as important as reducing the deficit is protecting and improving the nation’s health. That is why I am proud that we have kept our pledge to protect the NHS budget. More than that, it will receive an increase of 0.4% over the next four years. In this difficult financial climate, that demonstrates the Government’s determination to provide the best care and the best outcomes for patients.

This year, the NHS budget is £103.8 billion. That will rise to £114.4 billion by 2014-15. No matter how anyone looks at that, it is obvious that it is a real-terms increase. A number of people who have sent in briefings for this debate and who have commented on the spending review have echoed the view that I have just outlined. It is a self-evident fact that it is a real-terms increase, however much Opposition Members prefer to say that it is not. The facts do not bear out that criticism.

[Derek Twigg]

What about social care?

[Mr Burns]

The shadow Minister must be patient; I will come to social care.

The Department’s capital budget will be sufficient to ensure that key schemes that have already been agreed are continued and that the NHS estate is properly maintained. The NHS capital budget will pay for, among other things, publicly funded projects at North Cumbria University Hospitals NHS Trust, Pennine Acute Hospitals NHS Trust, and Epsom and St Helier University Hospitals NHS Trust.

Notwithstanding the real-terms increase in funding, we always knew that the NHS was facing challenging times. That is self-evident and we have never sought to hide behind it; everyone recognises it. As a number of hon. Members said, that challenge is due to an ageing population, expensive treatments, and health care and social care costs rising substantially every year. That is why the NHS and social care need to do more with their resources and make every penny count. In health, we are asking the NHS to secure, as a number of hon. Members said, up to £20 billion of efficiency savings over the next four years through the QIPP—quality, innovation, productivity and prevention—programme.

In addition, every penny of those savings will be reinvested in front-line services, enabling us to meet the costs of increased demand for care. The savings will come from cutting administration costs across the system by a third, as well as from other efficiencies throughout the NHS. Frequently, better care can save money. It is cheaper, as well as better for people, to get the right care first time, rather than the inappropriate or insufficiently relevant care that is involved when people have to go back to be provided with extra care—an expensive way to provide care and not an experience that patients should have.

--- Later in debate ---

[Mr Burns]

I cannot see how much more I can say, because my answer seemed fairly conclusive.

[Derek Twigg]

rose—

[Mr Burns]

Does the hon. Gentleman want to intervene about social care, which I want to move on to?

[Derek Twigg]

No, it is on the specific point that has just been made.

--- Later in debate ---

[Mr Burns]

On the issue of social care, it is accepted by all parties that we need to be more efficient. There have been historic problems in the funding of social care and we found that, given the mounting pressures and the economic situation when we came to power, there was a serious problem that needed to be addressed so as to provide support in the forthcoming year and thereafter for some of the most frail and vulnerable members of society.

We believe, as I am sure the hon. Member for Halton does, that re-ablement services can restore someone’s independence. They have a crucial role to play, where appropriate. Around half of those who go through re-ablement require no immediate care package afterwards. The NHS is investing £70 million this year, £150 million in 2011-12 and £300 million a year for the rest of this Parliament in better re-ablement services. That will have a significant impact on improving the lives of many people.

Telecare, too, can help keep people safe and feeling more confident in their own homes, reducing their reliance on formal home care services. These are not isolated cases. There are similar remarkable stories across the country.

Re-ablement can make a real difference, provided that the authorities act seamlessly and quickly to ensure the equipment and anything else needed to assist someone to return home, avoiding a stay in a hospital, care home or any other non-domestic environment.

[Derek Twigg]

We will pursue the issue about specialist children’s hospitals, but I will now concentrate on the issue of the £1 billion that the NHS has set aside for, or put into, social care. No one argues that putting more money into social care is not a good thing, but we want to ensure that there is no double counting. The Minister confirms that £1 billion has been set aside, but will some of that money, or all of it, be used to fund the social care side of those services provided by local authorities?

[Mr Burns]

If I may, I shall start on that point in my own way, as I want to give the setting for the whole social care thing. I know that the hon. Gentleman and the right hon. Member for Wentworth and Dearne (John Healey) have shown considerable interest in the matter.

The shadow Minister accepts that the NHS does not stand alone. It is only one part of this country’s care system; another essential service is social care, which helps hundreds of thousands of people to live as independently as possible. As I said earlier, when the Government were elected, we found a huge hole in funding for social care. That affects some of the most frail and vulnerable, and we believe that it is imperative to do something immediately to make up some of the shortfall. As the shadow Minister will know, the Department of Health has always funded social care—not all of it, but part of it—and local authorities have funded the other part. In some areas, there is a means test under the National Assistance Act 1948, so there are possibly three funding streams. I hope that I carry the shadow Minister with me.

To redress the funding gap in social care, the NHS will transfer up to £1 billion from the health capital budget to the health revenue budget by 2014-15. That will be spent by the health service on measures that support social care as well as health. That will include a specific allocation for re-ablement services to help people regain confidence and independence following discharge from hospital. We believe that this will help hundreds of thousands of people to live as independently as possible. To the person who uses both services, it makes no sense that health and care should be separate. I hope that I have given the shadow Minister sufficient explanation.

[Derek Twigg]

rose—

[Mr Burns]

If I carry on for another minute, the hon. Gentleman may not need to intervene.

As well as the extra £1 billion that the Department of Health is making available for NHS social care, additional grant funding—again, rising to £1 billion by 2014-15—will be made available for social care through the revenue support grant. By 2014-15, the total additional funding for social care will amount to £2 billion, half from the NHS and half in grant funding. That will be allocated in addition to the Department’s existing social care grants, which will rise in line with inflation. In total, therefore, grant funding from the Department of Health for social care will reach £2.4 billion by 2014-15. I hope that that explains the situation for the shadow Minister.

[Derek Twigg]

I want to be clear about it, so I put the question again. How much of the £1 billion that is being taken from the NHS budget will be spent on services that council and local authority social services provide?

[Mr Burns]

The £1 billion will come from the NHS capital fund and be transferred to the NHS resources fund. It will then be spent by the NHS on re-ablement and other sorts of help and care for which the NHS is responsible. The NHS is responsible for the social care element of the assistance required by those in need. [Interruption.] So that the shadow Minister understands, on top of that, £1 billion will be coming from local government through the RSG.

[Derek Twigg]

It is in here.

[Mr Burns]

The shadow Minister says that it is in the document, as if it has suddenly occurred to him, but I am going through it slowly so that he gets it. Some of the letters that we have received are not quite right.

Oral Answers to Questions

Debate between Derek Twigg and Simon Burns

Tuesday 29th June 2010 Commons Chamber

[Derek Twigg (Halton) (Lab)]

2. What assessment he has made of the effects on NHS waiting times of NHS targets in the last 10 years.

[The Minister of State, Department of Health (Mr Simon Burns)]

Targets focused the NHS on bringing down waiting times, but also put process above clinical judgment and patient choice. Changing the way in which we manage waiting times will empower both patients and clinicians. NHS targets have dictated clinical priorities and harmed patient care. Focusing on long waits has meant less progress on reducing average waits than could otherwise have been achieved.

[Derek Twigg]

I noticed that in his answer the Minister did not say that any assessments had taken place. How many representations has he received from clinicians, people working in the NHS and the public demanding the removal of the 18-week target, for instance? Targeting is about making people better and getting them seen more quickly, so is not the real reason for dropping targets the fact that the Minister wants to undermine the NHS again?