Healthcare Optimisation Plan: Kirklees

Justin Madders Excerpts

Tuesday 12th December 2017 Westminster Hall

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. I pay tribute to my hon. Friend the Member for Dewsbury (Paula Sherriff), who has been an assiduous campaigner on health issues since her election to this place. She has fought NHS downgrades in her area and, as a former member of the Select Committee on Health, forensically scrutinised the Government’s health policies. She has rightly gained a colossal reputation across the House for her committed campaigning. Today, she has turned her attention to another extremely important issue, which, as we heard, affects not only her constituents but millions of people up and down the country, and made a typically strong case.

My hon. Friend is right to categorise this as a dangerous time. Financial priorities are taking precedence over clinical judgments. Her CCG has been candid about the health optimisation programme being one of 21 cost-cutting measures that it is required to introduce. She highlighted the absurdity of that policy with the example of two patients who would be treated at the same hospital but live 9 miles apart: apparently, one would be entitled to surgery and the other would not. She is absolutely right that the decision about whether to operate should always be made by the consulting surgeon. I know that some people in the Government do not have a great deal of time for expert opinion, but that is a clear example of something on which there ought to be unanimity about the way ahead.

My hon. Friend gave examples of the questions that the CCG asked during the consultation on the health optimisation programme. As she said, nowhere was there a question about that very policy. As my hon. Friend the Member for York Central (Rachael Maskell) said, denying surgery is a draconian measure and an important matter. It was a real abdication of responsibility by the CCG not to ask that specific question but to couch it in general terms. What can the Minister do to ensure that the standard of consultation by CCGs is such that we can be assured that the resulting decisions are robust and supported by the public? What is the Government’s view on the consultation standard that is currently used throughout the country?

My hon. Friend the Member for York Central also said that the public and patients are being failed, and highlighted the fact that other CCGs use a different BMI level. Indeed, my CCG uses a different one again, which highlights the totally arbitrary nature of these policies. She was absolutely right to say that people need help to stop smoking and lose weight. Those are not easy things to do. Sadly, public health cuts have made assistance much more limited. She highlighted well how losing 10% of body weight can mean entirely different things to different people, depending on what their weight is to start with; how the system fails people by not supporting them to make healthy choices; and how people are failed again when it comes to referral. She also illustrated well how the capped expenditure process in her area undermines the very basis of the NHS. I totally agree that it is time for the Minister to step up to the plate and challenge the many inconsistencies that we have heard about.

The proponents of this scheme can dress it up however they like, but we should be very clear about what it is: rationing of treatment for financial reasons—no more, no less. As we know, we have a growing population with longer life expectancy, and medical advances continue. Those are of course welcome developments, but they increase demand across the board and in this area led to a 27.5% increase in finished admissions between 2006-07 and 2016-17. The NHS has made enormous efficiency improvements to cope with that demand at a time of financial restraint. I am sure that the Minister agrees and will join me in paying tribute to the hard work of NHS staff, who made those efficiency improvements possible. However, it is clear that we have reached the limit of what can be achieved through efficiency alone—in fact, we are now moving well beyond that point.

As my hon. Friend the Member for Dewsbury said, just this week Lord Kerslake resigned as chair of King’s College Hospital NHS Foundation Trust because, he said, the NHS is under-resourced and we “desperately need…a rethink” amid unrealistic demands for savings—the kind of unrealistic demands that lead to the nonsensical and counterproductive policies we have heard about. In the aftermath of the Budget, the national medical director, Sir Bruce Keogh, said that the failure to close the funding gap would

“force a debate about what the public can and can’t expect from the NHS.”

While that was an extraordinary comment for a public servant to make, it is also something of an understatement, as it is clear to everyone—we have heard it today—that CCGs are already debating those issues and deciding what treatments should be available. So far, however, the Government have refused to acknowledge the debate or even engage with it.

I will give some further examples of where rationing is already happening. In February this year, the CCG in West Kent implemented a policy to suspend all elective surgery until the end of the financial year in an attempt to save £3.2 million. More recently, Cambridgeshire and Peterborough CCG proposed a new policy requiring patients to wait a minimum of 12 weeks for surgery. While that decision was later reversed, it is a worrying example of the kind of policy we may see spreading across the country as the financial situation of the NHS continues to deteriorate. It is not just in surgery where such rationing applies: earlier this year, I responded to a debate in Westminster Hall on infertility treatment, and it was revealed that of 209 CCGs in England, just four follow in full the National Institute for Health and Care Excellence’s guidelines on IVF treatment.

The individual funding request process, once reserved for rare conditions, is routinely applied by CCGs for a range of treatments. In some areas, including east Berkshire, routine hip and knee replacements are now being considered only if an individual funding request is made. Analysis by The BMJ found that the number of individual funding requests has increased by 47% in the past four years. As my hon. Friend the Member for York Central said, that shifts the burden on to the patient to prove that they need treatment, which is not what the NHS is there for. The Minister may well say that these are matters for individual CCGs, but there has to come a point where the Government must take responsibility and accept that the rationing of treatments taking place on their watch can be traced back to central Government funding decisions.

To turn to the matter at hand in Kirklees, when responding to these debates on behalf of the Opposition I have never failed to be impressed by the euphemistic names for schemes that no doubt are dreamed up by handsomely paid consultants but actually limit patient access. I have to say that the use of the term “health optimisation programme” to describe a system that could delay treatments for a year, leaving patients in chronic pain, is well placed to win my 2017 award for worst use of NHS management-speak. In Kirklees, as we have heard, about one in four people will be affected by the new restrictions based on weight, while 14% of the population are smokers. As the Royal College of Surgeons has pointed out, while obesity leads to poorer health outcomes, its relationship with post-operative success is less clear, and there is a lack of evidence that rapid weight loss before surgery makes much difference. It goes on to point out that there is evidence of a lower risk of post-operative cardiac and respiratory complications among obese patients.

It is clear that this policy, which will leave patients in unnecessary pain and discomfort for a prolonged period, is not motivated by medical considerations or necessity. Indeed, in many cases, patients are actually prevented from losing weight effectively as a result of the debilitating condition that they are seeking treatment to correct in the first place. Given that that goes against NICE guidance, will the Minister explain why CCGs are being permitted to pursue a course of action that causes so much discomfort and has no clear clinical benefit? As my hon. Friend said, we all want levels of smoking and obesity to be reduced, but leaving people in excruciating pain for months on end is simply not the right way to do it. If the Minister disagrees, I ask him to point out even one piece of evidence that suggests that denying access to surgery helps patients to improve their behaviour.

We all know that the best way to see sustained improvements in smoking cessation and obesity reduction is though well funded, consistent public health policies, which is why it is very disappointing that the Government chose to cut significant funds from public health budgets, a move that the King’s Fund described as

“the falsest of false economies.”

In 2015, Kirklees lost £1.6 million of public health funding, which could have been used to tackle the issues we have been discussing in a much more positive way.

Concern has also been expressed about the use of BMI as a measure. As we have heard, it is a particularly crude and unsophisticated way of estimating excess body fat by simply comparing weight and height. We gave the example of a professional rugby league player, I believe, who has a BMI of over 30. It is clear to anyone that if my BMI were to be in any way elevated, that would be as a result of body-building rather than any consumption of alcohol. As the Minister will know—I say this with the greatest of respect to him—there are people far healthier than either of us who happen to have a higher BMI. Will he therefore advise whether the Government support the use of such a crude measure to determine whether someone is allowed to undergo surgery?

Of all the inequities of this scheme I have referred to, the greatest is the fact that it applies to children aged just 5 and over. Is the Minister really prepared to stand by while children in primary school, who have no say over their own diet, are being left in pain while they wait for operations, or does he agree that they would be infinitely more likely to improve their fitness if they were not suffering from a medical condition in the first place?

Just as public health cuts are a false economy, as my hon. Friend the Member for Dewsbury said, delaying treatment will cost far more than it saves in the long term. There is a clear risk of patients developing complications if their treatment is delayed. A National Audit Office report on the costs of clinical negligence highlighted that 39% of claims are related to failures or delays in diagnosis or treatment of a condition, and it stated that that is likely to

“increase if waiting times are longer”

and treatment is arbitrarily rationed. I know the Government are committed to reducing the cost of clinical negligence in the NHS, but this policy seems to run counter to such intentions.

These episodes of localised rationing are becoming far too commonplace and creating a postcode lottery for patients. It is a lottery that patients did not ask to enter and one that leaves them suffering in pain. If we are truly to have a national health service, I hope that the Minister will reflect on what has been said today and take meaningful steps to end this unnecessary, unfair and counterproductive rationing of treatments.

--- Later in debate ---

[Mr Dunne]

I will come on to that. The short answer is that I agree that the relevant clinicians should make those decisions.

Going back to where the CCGs are in this process, as I said earlier, they have not yet introduced the proposal. They have been working with the local population and with Healthwatch Kirklees, and have held a number of engagement events with local authorities and interested stakeholders to try to understand the reaction of those parties to the proposal. An engagement event was conducted in March and April of this year, and one with Kirklees Council in August and September of this year.

The CCGs have listened and responded to some of the points made. They have made several changes to their original proposals, including exempting children from the programme. They also recognise the limitations—amusingly identified by hon. Members in their contributions—of using BMI as a measure of body weight. Therefore, for example, people with high muscle mass should be excluded from the BMI calculation for the reasons that were well explained earlier in the debate.

The CCGs are including safeguards in the proposals, and they intend that, in exceptional circumstances, normal individual funding request processes will continue to apply. Hon. Members have criticised that as imposing an undue obligation on the individual to seek that route to secure treatment. That is effectively an appeal mechanism that applies across the NHS and is a well-worn and well-understood path for clinicians to support individual funding requests for patients where needed, which we should continue.

Both the hon. Member for Dewsbury and the hon. Member for York Central used the expression “lives at risk”. I would gently say that there is absolutely no intention that policies such as this should lead to lives being at risk. They are about trying to put individuals in a position where their own circumstances would lead to better outcomes from the proposed surgery. The hon. Ladies have called for evidence supporting the proposition —it was raised by the hon. Member for York Central when we met at the end of last month. I have asked for that evidence. A number of research papers support the propositions made by the CCG, in particular on the question whether obesity at the time of surgery is associated with a wide range of problems. Sustaining weight loss is the key. Rapid weight loss followed by rapid weight gain clearly do not help the patient, but the evidence from the research papers provided to me is that maintained weight loss or cessation of smoking undoubtedly and clearly have clinical benefits for the patient. There is evidence to support that.

I will come back to the point raised earlier on by the hon. Member for Dewsbury and the hon. Member for York Central, but I absolutely recognise that the clinician primarily responsible for the care, whether that is the GP or the secondary clinician, should have discretion to ensure that a referral is made, should a non-referral of a patient or a delayed procedure outweigh any benefits from a period of improving health and reducing risk factors prior to a routine operation. We will encourage the CCGs to ensure that that is in their final proposals, once those are made.

[Justin Madders]

The Minister says he will encourage CCGs to listen to clinical advice when making referrals. Is there any mechanism by which he will actually ensure that that happens?

[Mr Dunne]

As the hon. Gentleman knows, CCGs are subject to appraisal and are accountable to NHS England, which is accountable to Ministers. It is not for Ministers to direct individual CCGs as to how they should enact their policies, but there is a route through which we can provide some encouragement to NHS England to ensure that these policies reflect its national position. That is what we will do.

On where the process is, in October the two CCGs presented details of the proposed plans to Kirklees Council’s health and social care scrutiny committee. The committee requested that the CCGs undertake a further six weeks of engagements, especially with hard-to-reach communities in the area of the hon. Member for Dewsbury. The CCGs have assured me that they are committed to that further engagement with the local community to ensure that the plan is fit for purpose, so there is a continuing opportunity to reflect on the revised iteration of the proposals. I am also advised that the CCGs have not yet made firm decisions on the plans. Instead, as a result of the engagement with local stakeholders, they are considering four options, and variations on the four options, for implementing the proposed plan, including not proceeding with the programme, which remains on the table.

Those options include: first, a phased approach, beginning with applying the programme initially only to patients who smoke and subsequently rolling it out further to obese patients if appropriate; secondly, only implementing the plan for smokers; thirdly, introducing health optimisation periods across clinical thresholds and pathways, in line with NICE guidance; or fourthly, moving away from implementation of the plan as previously defined and focusing on a strengthened education campaign to reinforce the benefits to patients of stopping smoking and losing weight. Those options remain on the table and there will be a further period of engagement. A decision on which option will be taken forward is due to be made by the CCGs in January, and further engagement on the implementation of the recommended approach will then take place later in the new year.

I said earlier that the plan is not a blanket ban on treatment. Instead, the intention is to encourage patients who are obese or who smoke to lose weight and/or quit smoking. There is evidence that that will have benefits, in terms of both surgical outcomes, as I have said, as well as reduced risk for general medical conditions, and there are clearly also benefits to patients’ general health in the long term. Hon. Members can be assured that the CCGs are providing support to the patients on weight loss and smoking cessation, and have agreed to invest £133,000 a year in such services to account for any health optimisation-related increase in uptake.

The hon. Member for Dewsbury asked how we will assure that the plan is in accordance with national guidelines. As she would expect, NHS England has been closely reviewing this and similar proposals where they have been made to ensure that there is robust supporting clinical evidence and appropriate safeguards. The Government expect NHS England to ensure that the responsible CCG is not breaching its statutory responsibility to provide services that meet the needs of the local population. I can confirm to hon. Members that NHS England has had ongoing discussions with both CCGs about the health optimisation plan and will continue to do so to ensure that it works in the best interest of patients. That is the right approach, in terms of both protecting patients and both encouraging the population to put themselves in a condition to maximise the benefits from surgical procedures, without allowing CCGs to introduce an inappropriate blanket ban.

NHS England carries out regular assurance of CCGs and holds them to account through the CCG improvement and assessment framework to ensure that they are fulfilling their statutory requirements, and NHS England can and will intervene if a CCG is failing to discharge its key responsibilities. NHS England’s regional teams also have regular discussions with CCGs about their commissioning activities and plans.

It is important in a debate like this, in which there are allegations of there being a postcode lottery, that we recognise that it is down to clinicians at a local level, through their CCG bodies, to make decisions that affect their local population, rather than, as has happened in the past, central diktat from Whitehall. Those may lead to perverse consequences and a less relevant healthcare capacity and treatments for patients on the ground.