Healthcare Optimisation Plan: Kirklees

Debate between Justin Madders and Philip Dunne

Tuesday 12th December 2017 Westminster Hall

[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.

Oral Answers to Questions

Debate between Justin Madders and Philip Dunne

Tuesday 14th November 2017 Commons Chamber

[Mr Dunne]

As I said to the hon. Member for Keighley (John Grogan), the trust, which would consolidate subsidiaries in its accounts, would publish the accounts of subsidiaries as part of its consolidated accounts each year.

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

On Sunday, the Secretary of State said that

“good public services are the moral purpose of a strong capitalist economy”,

yet trusts are so strapped for cash that they are creating private companies to get around VAT laws. Not only does this take money away from the Exchequer, meaning that other parts of the NHS are effectively subsidising these trusts, but it also removes vital protections for staff, who will find that they no longer work for our national health service. Be in no doubt: this is another step down the road of privatisation. Will the Minister set out, therefore, what protections are in place to prevent any of these companies from being sold off in the future to the highest bidder?

[Mr Dunne]

I am afraid that the hon. Gentleman, for whom I have considerable respect, is trying, yet again, the tired old approach of weaponising the NHS by alleging privatisation—seeing privatisation fairies where there are not any. This is about responding to the review of Lord Carter—one of his hon. Friends in the other place, I remind him—of driving efficiency through the NHS, which I know he supports, and about finding the right structures to allow, for example, the back offices of different NHS bodies in an area to be combined. That requires a structure, and a number of foundation trusts are setting up subsidiaries to provide those services to each other.