Oral Answers to Questions

Karin Smyth Excerpts

Tuesday 23rd June 2020 Commons Chamber

[Matt Hancock]

Absolutely. When we set up the loneliness strategy in 2018, when I was the Culture Secretary, I had no idea that covid-19 would make it so vital. I very much hope that, in England at least, the measures the Prime Minister is due to set out very shortly might help in that regard. Covid has underlined the importance of loneliness as an issue that we must directly and actively tackle.

[Karin Smyth (Bristol South) (Lab)]

At the start of the crisis, as a former emergency planner for the NHS, I thought the Government would trust the local well-established emergency planning systems that were in place and they had my support. However, they have wasted time and money. My hon. Friend the Member for Leicester South (Jonathan Ashworth) is quite right to criticise the Government, because that has led to excess deaths and time lost. It is welcome that we are now supporting the local, but will the Secretary of State tell me why, when his friends at Deloitte have been set up to do the testing at Bristol airport, the complaints process is run through an NHS trust?

[Matt Hancock]

Because this is a big team effort by a combination of public and private sector partners. I pay tribute to Deloitte, without which the testing programme would not be possible. I pay tribute to all the pharmaceutical companies and I pay tribute to Amazon, which has delivered the home testing with remarkable success. Instead of trying to divide, we should unite and bring people together.

Coronavirus

Karin Smyth Excerpts

Monday 9th March 2020 Commons Chamber

[Matt Hancock]

This is a very important point. One thing we will be doing during this period is encouraging people who need to see their GP or to have an out-patient appointment for something that is not to do with coronavirus to do so via Telemedicine if it is both clinically and practically possible. That is even more important in rural areas, and absolutely critical for reducing the amount of infection through GPs.

[Karin Smyth (Bristol South) (Lab)]

Before I entered this place, I worked as an emergency planner for the NHS. I would like to pay tribute to my former colleagues and to say that I am pleased that the Secretary of State is following their expert advice. Most people will not go into hospital or go to their GPs; they will be supported in the community. Critically, they will be supported by the wider services of local government and the voluntary sector. Will the Secretary of State expand on what conversations he is having with his counterpart in the Ministry of Housing, Communities and Local Government to support the wider public health and social care provision of local government?

[Matt Hancock]

We have extensive work under way to provide exactly that support. It is also available through the Office for Civil Society, and through volunteers as well. It is very important that we offer the opportunity for people to volunteer in these difficult circumstances, but we have to do so in a way that the voluntary efforts can then plug in and add to the professional efforts that are, as the hon. Lady says, providing a great service to this country.

Health Inequalities

Karin Smyth Excerpts

Wednesday 4th March 2020 Commons Chamber

[Karin Smyth (Bristol South) (Lab)]

I agree with the hon. Member about the social determinants of health. Does she agree that, going back 10 or 15 years, to before 2010, the Labour Government appreciated those determinants and directed public policy to that end?

[Dr Whitford]

I do. I respect the work that Labour did, and child poverty was falling. Interestingly, the upturn in child poverty we have seen did not happen with the crash in 2008; it happened after the 2012 welfare changes. That is striking. The impact of Government policy has been austerity in every way and in every approach to individuals, families and communities. We have seen slow income growth for the vast majority of people over the last decade. There has been absolute inequality. The majority of the growth that there has been, has been at the top. The national living wage simply is not a living wage. More people are in insecure work—zero-hours contracts, the gig economy—and do not have protections. As the shadow Health Secretary mentioned, in all the discussion about covid-19, we have been trying to highlight that people on low pay and insecure contracts do not get sick pay, yet we will be asking them to stay at home for two weeks and self-isolate. In the meantime, the wealthiest people have actually trebled their wealth. So categorically we have not all been in it together over the last 10 years.

In addition, we have seen a restriction on public expenditure. The regressive welfare cuts of 2012 and 2016 have reduced support for families by 40%: the benefit cap, the benefits freeze, the two-child limit, the five-week wait for universal credit, which puts people in rent arrears and debt, personal independence payments, the bedroom tax. Eighty per cent. or more of these cuts have affected women directly because they tend to be lower paid, to be carers and to rely more on services. In the main, they are responsible for children. The disabled have also been particularly hard hit. We have not seen a cumulative impact assessment of female lone parents who are disabled and have three or more children. Some of them have had their income slashed.

There have been cuts to local government and services. Interestingly, the least deprived areas face 16% of cuts, while the most deprived on average had 31% cut from their local government budget. I have heard Labour Members talk about between 40% and 60% cuts in their local government budgets. There are changes in the pipeline to move £300 million from local authorities in the north to the south. I wonder if that will be reversed now that the Conservative party has won some seats in the north.

--- Later in debate ---

[Karin Smyth (Bristol South) (Lab)]

In 1980, the Black report told us that the

“causes of health inequalities are so deep rooted that only a major and wide-ranging programme of public expenditure is capable of altering the pattern.”

The report was, famously, whisked out on a bank holiday. It was massively rejected by the then new Thatcher Government as being unrealistic in its expenditure levels— typically short-sighted and we have borne the cost of that since.

The findings of the report and the consequent discussions about health inequalities, I discussed when I was at university, as quite a young person at that point. My lecturer, Professor Albert Weale, taught me a lot about health inequalities, which served me to want to seek a career in the NHS to make a difference. But the NHS contributes little if anything to reducing health inequalities, and many would argue that it in fact increases them: it makes them worse, with better-off patients finding access easier and being better able to navigate the systems—the sharp elbows. The inverse care law also applies: the best services are in the better-off areas. So I am always passionate about my career in and commitment to the NHS, but I have never deified it.

Progress was made in the last 40 years. In 1997 we, as the new Government, tried to tackle the social determinants of health, with healthy living centres, such as the one in my constituency in Knowle West, the new deal for communities, a focus on early years and families, smoking cessation, teenage pregnancies and sexual health services. We made a massive difference, but in 2011 the health inequality targets were removed. It is heartbreaking for me to see in my constituency the evidence-based work that we led in that Government destroyed by this Government, the shocking waste of human potential that has resulted, the huge personal and family and community loss, and the huge financial problem that that causes the Government in lost income and increased benefit payments.

The Treasury should be deeply concerned about the Marmot findings. The figures are stark; they continue to be stark. In report after report that I have read in my 30-odd years in the NHS and as an MP, we hear much about the north, but Bristol has neighbourhoods that are among the most deprived in the country, and the 10 most deprived neighbourhoods in Bristol are all in my constituency of Bristol South. Personal independence payment claims stand at 5,500, and those for carer’s allowance and live employment and support allowance at 4,907—all the highest in Bristol. One in 10 people of working age in Bristol South are not able to work because of health and disability reasons, and the joint strategic needs assessment also tells us that it is women who are bearing the brunt of this. Women in Bristol on average live in poor health for 22 years, which is higher than the England average. The health burden and the mortality and morbidity figures are equally stark, as Professor Marmot has highlighted.

In 40 years, we have learnt a lot, and if the Government are willing to use the learning we could have much better policy, but local government is key. Public health rooted in local authorities and using independent advice ought to be far more influential in issues around prioritising and resource allocation, overcoming the vested interests that are in the NHS.

Early intervention is key. The NHS does maternity and there is then a big gap until care of the elderly; local government has the interaction with children. The NHS focuses on individuals; local authorities focus on families and communities. NHS bodies are not co-terminus with local authorities. They have no grounding in community, but local authorities do. Resource allocation in the NHS is driven by payment by results. Local authorities are much better at aligning resources with local needs. The NHS is not directly accountable to electors, which would make it better understand communities and social care. Unless the Government support local government, everything else is platitudes.

Hospital Improvement Plans: VAT Rules

Karin Smyth Excerpts

Thursday 9th January 2020 Commons Chamber

[Karin Smyth (Bristol South) (Lab)]

It is a pleasure to see you in the Chair for this debate, Madam Deputy Speaker.

I am pleased to have been granted this debate at a significant time in Parliament, following this evening’s votes. I hope to shed some light on how complicated VAT rules, which have evolved over time in the NHS, are now creating incentives for trusts to behave contrary to the Government’s objectives, in particular those relating to capital investment and the implementation of the long-term plan.

I am pleased to see the Minister for Health here to answer the debate. My expertise in the finer aspects of taxation policy and its operation is fairly limited, and I do not believe that he is a tax expert either, but before I came to this place I spent most of my professional life as an NHS manager so I know a lot about planning and delivering health services, including new hospitals. The Minister has clear policy objectives as the Government work to implement the NHS plan, which is predicated on place-based commissioning and improved capital infrastructure. I believe that, as the Minister for Health, he has an obligation to support NHS leaders by providing greater clarity on how the rules operate. Indeed, the Office of Tax Simplification agrees with me that this is a problem, with its 2017 report recording frustration

“about a number of cases where the VAT position was unclear…with HMRC and government tendering departments having differing interpretations.”

It noted that

“VAT liabilities should be clearly outlined during the tendering process for public services and contracts.”

The Government also appear to agree, and the spring statement announced a policy paper, although it was vague on details. The announcement was for:

“A policy paper exploring a potential reform to VAT refund rules for central government, with the aim of reducing administrative burdens and improving public sector productivity.”

The 2019 OTS update noted that that spring statement had involved a commitment to

“a policy paper on VAT Simplification and the public sector”.

It is essential to raise this issue now, because as we move towards implementing the NHS plan we all need to understand exactly how the Government will allocate the necessary funding for hospital improvements and other infrastructure projects. The potential of VAT savings will increasingly become a major consideration for trusts up and down the country. Capital investment is always to be welcomed and it is long overdue. Whether we think we will have 40 or six new hospitals, my sympathies are with the finance directors and managers in trusts who are faced with the task of maximising these investments, and managing the competing interests of recruiting and retaining staff, developing integrated local health systems and securing local public trust in their plans. It is my belief that the underlying problem here is that the priorities of Her Majesty’s Revenue and Customs and the Department of Health and Social Care are not in alignment.

The problem manifests itself in a number of ways. First, a decade of underinvestment in our health service has led to NHS trusts desperately trying to recover whatever finances might be possible. Some of the VAT rules and debates go back decades. I hope the Minister does not rise to say that the last Labour Government used rules to involve the private sector and are responsible for some of this, and I respond by saying that it all started under Margaret Thatcher’s outsourcing, and we simply do not help anyone. I hope we can be more helpful than that. That was the last comment I had back, so I am just stemming that off at the pass.

The real explosion in this issue came from the direction of the coalition Government and the creation of contracted-out services regulations. The HMRC manual “VAT Government and Public Bodies”, from 2012, states:

“Government departments and health authorities have been encouraged to contract out services to the private sector which would have traditionally been performed in-house”—

over many decades.—

“It is recognised that many of these services would be subject to VAT and where they were acquired for 'non-business' purposes, the non-reclaimable VAT could act as a disincentive to contracting-out.”

That was then the policy of the Government. The manual continues:

“It was therefore decided to compensate government departments and health authorities by a direct refund mechanism, which is provided for in section 41(3) of the VAT Act 1994. Under this provision, the Treasury issues a Direction, commonly known as the 'Contracting Out Direction' which lists both the government departments and health authorities that are eligible to claim refunds of VAT, and the services on which VAT can be refunded.”

For lay people, myself included, that in essence means that under these regulations full VAT could be recovered on the cost of a managed service which provided premises that could be used for delivering healthcare. Of course, the private sector was pleased, as it meant it could now, as it saw it, compete on a level playing field with the public sector. But really we should view any tax breaks or loopholes with extreme suspicion, as they lead to reduced revenue for the Exchequer. There should always be a compelling public interest for any tax breaks or loopholes. After this direction and as austerity has bitten, more and more complex arrangements have been set up.

Following the OTS 2017 report, I am sure many in the accounting departments across the public sector were relieved to hear last year's spring statement, when the then Chancellor announced a consultation on VAT in the public sector. This could mean a potential reform to VAT refund rules to reduce administration and improve public sector productivity. However, concerningly, the language of the spring statement, and the background to it, appear to suggest a widening of VAT refunds for those engaged in services—that, again, is reducing the amount of VAT paid by public sector contractors back to the Treasury. I am worried that the Treasury are going to make the situation worse.

My good colleague in the other place, Lord Hunt, followed up on the whereabouts of the review in October, when he asked for an update on the review’s progress. He was told by the Earl of Courtown to expect a policy paper for public consultation “in the coming months”. I know we have all been busy, but the world awaits and it would be helpful if the Minister provided the House with an update on that review, either tonight or in writing afterwards.

The area of VAT avoidance that has attracted a great deal of attention, and that myself and many colleagues—including my hon. Friend the Member for Blaydon (Liz Twist)—visited the Treasury to talk about last year, is the establishment of wholly owned companies in NHS trusts. Such companies can be seen up and down the country, from Northumberland to Yeovil. They vary greatly between those that try to remain part of the NHS and those that position themselves as separate corporate businesses only loosely connected to patients and the public. Most are set up to deliver a full range of facilities management services—including cleaning, catering, porters and security—and then charge the parent trust for this managed service on a private finance initiative-style unitary fee basis.

We have heard that, to avoid charges of tax avoidance, which created a degree of media discussion, the new arrangements are supposed to be better from a service-delivery point of view. Ostensibly, they are solving problems with estates and facilities management and how staff are managed, but there is no evidence of that. In every case, almost all the benefits, some of which are considerable financial benefits for the trust, appear to come from tax changes, not service improvements. Many of the schemes have resulted in thousands of NHS staff being taken out of the NHS and transferred against their will into wholly owned subsidiaries. This increases fragmentation, and there are examples of companies falling out with their parent trust. There are also arguments about which organisation is responsible for what and who pays.

Far worse is that in some cases the use of a separate company is used to undermine national agreements on terms and conditions. Around 50 such proposals have been progressed or are in the pipeline, and it is highly worrying that they were advanced in secret, without consultation with patients or the workforce involved. When freedom of information requests were made for access to the business cases that sought to justify the changes, trade unions and others were denied access, with claims that the information was commercial and confidential.

Just this week, The Pharmaceutical Journal reported that 34% of trusts had outsourced their pharmacy service to a commercial firm and 16% have created wholly owned subsidiaries. The practice is now widespread. Despite that, the recent examples at the Bradford Trust and the Frimley Health Trust have been vigorously opposed, particularly by Unison, and it appears that both proposed schemes have been stopped. That is good news for thousands of low-paid staff who wish to remain NHS employees.

Thanks to the considerable pressure put on NHS Improvement, trusts must now in effect ask for permission before they create a subsidiary company, although far from being a device to prevent the practice, the seeking of permission appears more like a scheme to embellish some badly written business cases so that the changes can go ahead with a veneer of justification. Under some pressure, that process is being reviewed.

Although in the short term it appears that individual trusts will gain through tax advantages offered by the wholly owned companies, other trusts will not, and it means less VAT for the Treasury. But the Treasury seems unconcerned about the lost income. The practice is not a strategic, collaborative or positive solution to the problems that trusts face, and it is not about better employment. The NHS has agreed national terms and conditions for a good reason: because overall it works. All these schemes try to undermine the national agreements and offer staff less favourable terms to save money.

Having two-tier workforces is not a good way to progress. A few years ago, I made that point successfully in my own area of Bristol. The North Bristol NHS Trust, which was at the time under considerable financial pressure, was considering adopting a wholly owned company but, following local discussions, including with Unison, it recognised that in the local, highly competitive market for staff, at a time when the trust needed to start to collaborate on service development, it needed not to outsource. The creation of a second and third-tier workforce made no sense operationally and gave the wrong messages to staff and the public about valuing the all-important workforce across the entire Bristol health economy, so the trust did not do it.

As I touched on in my opening remarks, the controversy over VAT and how it applies in the NHS is relevant to infrastructure investment, because the temptation for the trusts set to benefit from the new capital—I accept that there is new capital, and that is good—will be to avoid paying VAT to reduce significantly the direct ongoing costs. That is why it is so important that the Government give careful consideration to how the investment is going to be made.

I believe the choices made by the Government on this issue will reflect how well they understand both the importance of the NHS estate itself, as part of the health ecosystem, and the direction of the long-term plan. I cannot emphasise enough—and I do think hon. Members understand this—that capital is not a technical, dry subject, but is crucial to the delivery of quality healthcare. It is not a burden on the system. It is time for us all to show we understand that we need a joined-up strategy and proper investment.

The thing I kept at the forefront of my mind as an NHS manager, and do so now as a local representative, is that the health service is wholly funded by the taxpayer, and the public have a great attachment to people and place when engaging with healthcare. Buildings are so much more than a pile of bricks of which to sweat the assets, or empty vessels to lease for maximum return. Buildings really are a physical manifestation of local people’s love for and connection to their local health service. Local people are not over-concerned with how services are developed, but they do not expect their health service to behave in such a way as to constantly try to exploit tax loopholes or penalise staff.

For 15 years or so I have been a supporter of the concept of place-based commissioning, by which I mean local collaboration across the public sector, making good use of the publicly owned estate to deliver quality health services and maximising the value of the taxpayer’s pound. Place-based commissioning has been the direction of travel for some time. It was knocked off course by the Health and Social Care Act 2012, but there is hope of getting it back on track once the long-term plan is in place.

I understand that the setting up of a subsidiary might make sense in the short term for individual trusts, but it makes no sense for the wider health economy or the whole NHS. We must move from a competitive, short-term, market-driven approach at a micro level to a collaborative approach focused on overall gains. The logic of the VAT exploitation and WOCs practice is based on the old idea of trusts having autonomy, behaving like businesses and competing, but this is out of date and directly at odds with the NHS plan, which is built around place-based solutions like sustainability and transformation partnerships and integrated care schemes. On the contrary, the fundamental principle underpinning these initiatives and the Government’s own strategy is much greater collaboration across the system, which absolutely includes the use of buildings and any capital investment.

Another example of what those running the health service are trying to grapple with is GP commissioning and the new primary care networks. One of my last jobs before coming to this place was running a GP commissioning group, so I understand how difficult it is to get practices to work together and align their businesses. Last summer the NHS published a document called “The Primary Care Network Contract DES and VAT”, referring to the way in which the health service funds these proposals. The document sought to give guidance about VAT in the new primary care networks. The author goes to some pains to set out over several pages what NHS England “expects” will be the best approach—and then comes the following caveat:

“Although we anticipate the VAT treatment to follow the above analysis it is not straightforward. Practices should note that HM Revenue & Customs has not agreed the position described in this document and that they are the authority responsible for agreeing, administering and collecting VAT.”

If the Government and NHS England are publishing guidance on how to set up these new organisations without really knowing how HMRC is going to treat them, how on earth can we expect people in the frontline to develop good services?

Let me mention another issue, which is local to my constituents and which I have been working on for some time: GP employment status. For the last five years, HMRC has been reviewing the employment status of GPs who provide NHS out-of-hours services, which are now called integrated urgent care services. During this period, demand for GP services has risen and the need identified by NHS England for a substantial—that is, 5,000-plus—increase in the number of GPs has not yet been met with wholetime equivalent resourcing. Based on arrangements in place since the formation of the NHS, GPs have continued to work on a self-employed basis, and this remains the desired option for many of them. This has been the subject of some political debate over a number of years, but it is the position as people understand it.

BrisDoc is a local GP organisation based in my constituency that provides urgent care services to the NHS. It has been faced with five years of uncertainty regarding its workforce because HMRC does not accept the legitimacy of independent GPs working on a self-employed basis, even though this correctly reflects the way services are contracted based on professional and legal advice. How they are funded is a separate debate, but if HMRC changed GPs’ status, it would increase the risk that GPs would not be willing to work and would increase the cost to the NHS. Both of these have a negative impact on NHS services, reducing GP capacity at a time when we need more, and costing more, which will ultimately lead to a greater cost for the Treasury.

The priority has to be on patient safety and care, and the provider, BrisDoc, has continued to fight for this focus in order to maintain the best possible level of GP availability. However, HMRC states that its focus is simply on “employment status” and not any wider implications of any change, whereas NHS England indicates that it cannot get involved with determining employment status for GPs, who are an essential part of the NHS workforce. This leaves BrisDoc vulnerable to financial and workforce loss while doing everything possible to maintain the service. Its plea, and my plea on behalf of my constituents, is this: can the overall strategy for the GP workforce be reviewed to ensure that the key priorities and objectives are aligned with regard to any change in employment status? It is unacceptable nonsense for it to spend five years between the two Government Departments. Will the Minister be willing to meet me and BrisDoc to better understand the problem?

I hope that I have impressed on the Minister not only the preposterous nature of this VAT problem but how critical it is that we sort this loophole out now through proper consultation with the NHS and an urgent publication of the VAT review. Finance directors in particular need the support to make decisions that align with the strategic vision of the long-term plan, not that are at odds with it. To do this, the guidance from HMRC and the policies of the Department of Health and Social Care must be joined up. If the Government are, as they have indicated, supportive of the strategic direction of the NHS plan, then this must mean supporting local health economies to flourish through the collaborative partnerships integral to STPs and integrated care systems. They simply cannot work if trusts, and other delivery partners, are in competition with each other.

After a decade of fairly imprudent underinvestment and failing policy, we really are at a crossroads, and we need to get this right. If we can level the playing field for all trusts through proper funding, and consistent, sensible VAT rules that do not divert time and effort from the objectives of the trusts to serve their local patient population, we could have every reason to be positive about the potential of local place-based commissioning for success.

Health Infrastructure Plan

Karin Smyth Excerpts

Monday 30th September 2019 Commons Chamber

[Edward Argar]

My right hon. Friend makes an important point. This money will be hugely important to doing exactly what she says: investing in our NHS buildings for the long term, so reducing the reliance on expensive capital repairs.

With this plan, we are also looking to deliver a step change in how we deal with capital in the NHS, which is also hugely important. Instead of stop-start investment, we are looking for a rolling programme of investment to make sure we get those facilities up to standard in order to reduce the day-to-day spend on repairs. I will happily talk to my right hon. Friend about what we can do to ensure that we go through due process as swiftly as possible so that her hospital trust can get on with it.

[Karin Smyth (Bristol South) (Lab)]

I worked on many business cases for capital projects during my long NHS career. These projects are important to local people, but local people across the country were misled over the weekend. This is a proposal to give permission to think about building a hospital; they are not new hospitals. The Government’s own response to the Naylor report said that sustainability and transformation partnerships are the chosen means of planning and delivering capital projects, so how were STPs consulted about which projects to progress?

[Edward Argar]

The hon. Lady, as she says, comes to this with a wealth of experience. The bids were put forward by individual trusts working with their STPs, and in the context of the STPs that have been developed. There is a synthesis and a read across to ensure that, in this announcement, we have picked the trusts that put together the most compelling bids in order to deliver value for money and improvements where they are needed.

Decriminalisation of Abortion

Karin Smyth Excerpts

Tuesday 23rd July 2019 Commons Chamber

[Jackie Doyle-Price]

The specific offences to which the hon. Lady refers are a matter for the Home Office. The Government’s position is that they should not be repealed for England and Wales at this point. I absolutely understand the issue she raises with regard to the most vulnerable, and she and I have had discussions on that basis, but that is also a reason why simple repeal is not necessarily the best tool. To have a safe regime in place is also to protect exactly the people she identified. As I have said, from a personal perspective I do not think that the current law is in any way satisfactory, and I hope that in future we can have sensible discussions about how we might modernise it.

[Karin Smyth (Bristol South) (Lab)]

In my role as a member of the British-Irish Parliamentary Assembly, the committee on which I serve, which is chaired by the noble Lord Dubs, has for the past two years been looking at abortion policy across the whole of Ireland and Britain. Our report should have been available already, but there was some disagreement as to its final content. We will be updating it, hopefully for publishing in October. It would be helpful to discuss that report with the Government. As well as online medication, we have found other particularly concerning issues: we need to remember that there are no borders for healthcare for women across these islands, and there are no borders for how women across these islands will continue to support each other. We want to see more equality. Of real concern are the often very traumatic cases of late terminations. The workforce across our islands are not skilled—there are not enough of them and there are not enough good-quality skills. Does the Minister agree that the Government should at least look into those points regarding workforce?

[Jackie Doyle-Price]

Yes, absolutely. I would be delighted to meet the hon. Lady about her report. That there is difficulty in getting agreement comes as no surprise to me but, given the intentions of the people behind it, having that discussion would be useful. Yes, I have heard concerns expressed about skills levels, in particular to perform late-stage terminations, which are incredibly dangerous, as she is aware. I will endeavour to take that forward with the relevant bodies.

Adult Community Services

Karin Smyth Excerpts

Wednesday 26th June 2019 Westminster Hall

[Karin Smyth (Bristol South) (Lab)]

I beg to move,

That this House has considered re-procurement of adult community services by Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group.

It is a pleasure to serve under your chairmanship, Mr Gapes. I am pleased that this important subject has been selected for debate. Although they cannot be present, my hon. Friends the Members for Bristol West (Thangam Debbonaire), for Bristol East (Kerry McCarthy) and for Bristol North West (Darren Jones) fully support my comments. This is an important issue for the people of Bristol South, and it is a local example of the debate on the legacy of the Health and Social Care Act 2012 and of the invidious position that local managers are being put in to understand the procurement rules.

Hon. Members know that I speak frequently about accountability and the opaque way in which many parts of the NHS operate. We seem to have lost sight of the fact that, however individual bodies are constituted, our health services are public services that are paid for by taxpayers—our constituents. I have also repeatedly said that if we keep asking people to pay more for our health services, they must have a greater say in the way that those services are run, particularly when they are being changed.

I have spoken before of my concern about the attitude of my local clinical commissioning group in Bristol, North Somerset and South Gloucestershire to the openness and transparency of its work, especially on the reprocurement of adult community services. The lengths to which the CCG, supported by NHS Improvement, has gone to hide, cover up and obfuscate are nothing short of a scandal. Most infuriatingly, the whole protracted cloak-and-dagger exercise has been entirely unnecessary, because a far less onerous and costly approach could have been used instead. The reprocurement is the wrong approach at the wrong time to developing community services, and runs counter to the direction of travel being set, in theory, by the new NHS 10-year plan.

Before I review the shortcomings of the reprocurement in greater detail, I will remind hon. Members why it matters. Away from the jargon, acronyms, terse letters and confidentiality agreements, thousands of people across Bristol, North Somerset and South Gloucestershire simply want to know what is happening to their local health services.

My constituent Clive got in touch just over a year ago to tell me about the great work being done at the Healthy Together leg clinic at the Withywood Centre, which provides intervention and treatment for the leg ulcers of patients in south Bristol. It is exactly the sort of joined-up, innovative and integrated community provision that Ministers tell us they want to see—a true partnership between Bristol Community Health, local GP practices and Age UK in Bristol, which come together across different sites to deliver gold-standard patient care that promotes faster and longer-lasting wound healing. The clinic also provides a social setting where patients feel more supported and are encouraged to feel more in control of their condition. There is time for people to care.

The service has transformed countless lives in my constituency and has been nominated for a national award. As I saw first hand when I visited the clinic earlier this month, it is an exemplar of the sort of collaborative provision that the new adult community services contract could and should expand on. Such collaboration takes years to yield results and very much responds to the local needs of the particular community.

The people who are providing the service, however, do not know for how long they will be able to continue, because the CCG will not tell them. The patients do not know for how long they will be able to access that life-changing service, because the CCG will not tell them. As the local MP, I cannot lobby, engage or reassure people, despite asking repeatedly for a peek behind the self-imposed reprocurement iron curtain, because—hon. Members will have guessed it—the CCG will not tell me.

Interestingly, another consequence of the process, which I do not have time to really go into, is the destabilising impact on the voluntary sector. Age UK will have to wait, cap in hand, to see which successful bidder secures the primary contract and how it then decides to sub-contract the provision. The same goes for all voluntary organisations involved in this sort of service provision. It would be bad enough if the Healthy Together clinic were a one-off —the only service caught up in a closed-shop procurement mess—but it is not. In truth, every adult community service is in the same position, which is simply not good enough.

Despite a year of making speeches in this place, asking questions of Ministers, doing time-consuming research and making countless phone calls to offices, neither the CCG locally nor NHS Improvement nationally will engage with me beyond continually asserting that they had no choice but to go down this route. That is a prime example of what the Health and Social Care Committee referred to in its recent report, which said that the

“problems stem not only from the procurement rules themselves, but also from people’s interpretation of these rules and their difficulty in understanding what is permissible within the rules.”

In place of answers, I am forced to restate the litany of my constituents’ questions and concerns that have essentially gone unanswered. First, there is a fundamental lack of clarity surrounding the reprocurement and an abject failure to link it to any broader NHS strategies. I am not the only one who is concerned about the process. I have been spoken to privately by many consultants, nurses, and other staff throughout the healthcare system; I am grateful to them for contacting me.

At no point has the CCG properly defined a needs assessment in the request for proposals. Moreover, at no point has it made the business case for change—the most basic starting point for any such process. Staggeringly, there is no service baseline, so we do not know what services exist. By extension, there are no defined outcomes, so bidders are being asked to make proposals. That is not what commissioning is meant to be about.

Although Ministers continue to trumpet the importance of the sustainability and transformation plans, there is no sense of alignment with those plans, the NHS long-term plan or the emerging integrated care systems. Similarly absent is any indication of integration with local councils on social care or public health, which we all acknowledge are the key issues facing our constituents.

Secondly, there are concerns about the chosen procurement process, because any number of much less onerous and costly approaches were possible. As ever, however, accurately assessing the process is near impossible because of the vice-like secrecy that the CCG has used throughout. What is certain is that we do not know how much it is costing the CCG or the bidders, which include the current not-for-profit community service providers. That means that we do not know how much it is costing us, the taxpayers.

I worked in the national health service for many years, and I have some experience of procurement in the organisation, but I have struggled to understand properly the process through which the procurement has been undertaken. To illustrate, the CCG’s description of the chosen process, in its own words from its own document—bear with me, Mr Gapes, because I did not write it—says:

“The procurement is being undertaken using a process developed by the CCG which has similarities to a competitive process with negotiation. For the avoidance of doubt, the CCG is not running the process strictly in accordance with any specific procedure set out in the Regulations so reserves the right to depart from that form of procedure at any point. This Request for Proposals sets out the procurement process the CCG plans to use for this particular Contract. The inclusion of particular stages, the use of terminology and any other indication shall not be taken to mean that the CCG intends to hold itself bound by the full scope of the Regulations.”

What does that mean? I think it means that the process is as clear as mud, carried out behind a wall of secrecy, but with a disclaimer that enables the CCG to do what it wants without our knowledge. Although we cannot access the process details, what we know does not bode well.

There are myriad loose ends and errors throughout the process. Taken together, they form a significant body of concerning issues. Of course, I would never have known about them—most people do not—if I had not scoured 300 pages of detail and 100 clarification questions asked by bidders. In fairness, I doubt the CCG was expecting anybody outside the process, including the local MP, to do so, but I read them all because I like detail and I think it is important to know what is going on. A lot of the gaps and oversights concerned me.

There seem to have been incorrect working assessments about bed numbers at South Bristol Community Hospital; gaps relating to workforce numbers and staff who have been TUPE-ed; and a number of misunderstandings and examples of where the CCG lacked knowledge about current contracts, rental payments and void space. There is also missing information about assets, and the bidders were apparently expected to carry out the due diligence. That not only places a huge burden on providers, but runs the risk that the entire process will collapse if it is not carried out correctly, as has happened elsewhere. It is worth highlighting that the National Audit Office investigation into the collapse of the UnitingCare Partnership contract in Cambridgeshire and Peterborough found that bidders

“faced significant difficulties in pricing their bids accurately due to limitations in the available data”.

The evidence I have seen in the documentation suggests that that is now happening.

We should all be very worried about that, because failed procurements in Staffordshire for cancer services and end-of-life care, and in Cambridge and Peterborough, had similar procurement processes to the one chosen by Bristol, North Somerset and South Gloucestershire CCG. In each case, there was a secretive process, a complex procurement methodology and a failure to engage. Together, they cost taxpayers millions, and they all failed. Instead of learning lessons, NHS Improvement and the CCG seem intent on repeating the mistakes.

[Darren Jones (Bristol North West) (Lab)]

I congratulate my hon. Friend on securing this important debate. Does she agree that the complexity of the procurement process and the difficulty that she—an expert in this area—is experiencing means that patients who rely on these services and workers in not-for-profit organisations, who deserve to know what the process means and what the outcomes will be for them, find it impossible to take part as important stakeholders?

[Karin Smyth]

Absolutely—I completely agree. That is why I will continue to speak up on behalf of my constituents; I know I have my hon. Friend’s support.

Predictably, I would like to finish where I began, on the issue of secrecy and a lack of transparency. As I have highlighted, this absurd behind-closed-doors approach has bedevilled the reprocurement from the off. If this is such a great change to community services, why are we not trumpeting it? Reprocurement was first referred to in governing body papers in May 2018, but other than that there has been virtually nothing. There was no official announcement, no media blitz, no news stories or television news clips, no leaflets in local GP surgeries or South Bristol Community Hospital to enable local people to have their say on the plans—nothing. Although there has been talk of consultation, it seems that only 20 people from south Bristol took part. In fairness, there were some nods to engagement, and surveys were completed by 196 people. There was an engagement planning workshop with patients, carers and the voluntary sector, but because it is a contracting process, they were asked to sign a confidentiality agreement.

There is no evidence that even that limited feedback has been listened to or acted on. The workshop was merely an illustration to bidders of what stakeholders might want to identify when community services are planned and delivered. Tellingly, in documents from January, the CCG stipulated:

“Formal public consultation is not required as part of the procurement as no ‘significant variation’ to services is planned at this stage”.

Why is it being done if there is no significant variation to services?

All the documentation—approximately 300 pages in total—is hidden behind a portal, including more confidentiality agreements. The whole process appears so desperate to avoid the merest hint of engagement that it screams, “We’ve got something to hide!” It is utterly self-defeating, and serves no one well—not patients, bidders, the CCG or the community at large.

The CCG says that it is seeking a consistent service across all three areas and both acute trusts. Two of the CCGs and one of the trusts have been in deficit for years, and at various times in the past few years they have been on NHS Improvement’s naughty step. The deficits are now being shared across the whole community. The jam is being spread more thinly and differently from how it was spread before. The process is being embarked on to help spread the already struggling and inadequate level of service more thinly. Those service providers are spending money that should be spent on services on a process that I believe will inevitably reduce community services in Bristol.

I have great respect for the Minister, but I have no confidence that the Government will be able to make any difference to the local position. I hope that she takes note of the variability in how the rules are interpreted locally, as the Health and Social Care Committee noted in its response to the legislative proposals for the NHS long-term plan. Other commentators are saying the same. I hope the Minister will reflect on this local example. Will she explain directly or through her officials why, when I wrote to the Secretary of State about this originally, I got a reply from NHS Improvement? NHS Improvement is the provider regulator; this is a commissioning issue.

I believe that the Government should rapidly respond to the proposals to remove the requirement for competition under the section 75 regulations. There is no reason to wait; they need to get on with it. This saga shows that the lack of investment in NHS services remains a problem. Why not just build capacity rather than go through these expensive tendering processes with providers outside the NHS? I actually support the place-based approach to service provision in the NHS plan, but I object to the fact that this reprocurement goes counter to that plan.

At the very least, on behalf of local people, I would like the Minister to support my calls to see the proposals before contracts are signed for the next 10 years. We need a local plan and collaboration with the local authority that meets our health and social needs. I want a guarantee that people in south Bristol will not be worse off. Currently, no one can give me that.

Government Mandate for the NHS

Karin Smyth Excerpts

Thursday 25th April 2019 Commons Chamber

[Stephen Hammond]

The hon. Lady knows that the House and her Committee will have the fullest opportunity to scrutinise the document as and when it is published. She also knows that there is a commitment to publish it soon. She also rightly points out that it will deliver on the need to ensure that health and social care are integrated.

[Karin Smyth (Bristol South) (Lab)]

For most of my professional life, I was an NHS planner. I assure the Minister that the great expectation and anticipation of NHS planners for planning guidance in the mandate is very real. They are public servants who expect to be held accountable and do what the Government ask them to do. It is unacceptable to leave them in the dark. It is an insult to patients—taxpayers who pay for services and expect to know what they can receive locally. The delay is inexcusable.

The Minister says he has a plan and the Government say they have the money, so why cannot they publish it? What are they trying to hide?

[Stephen Hammond]

The Government are not trying to hide anything. The hon. Lady is right that it is an important document, and it is important therefore that we get it absolutely correct. I refer her to what the chief executive of NHS England said yesterday. He said:

“We have an agreed direction in the long-term plan…We have the budget set for the next year, and we have the NHS annual planning process…wrapped up…2019-20 is…a transition year…stepping into the new five-year long-term plan.”

The chief executive of the NHS thinks that the process is working acceptably.

Integrated Care Regulations

Karin Smyth Excerpts

Monday 18th March 2019 Commons Chamber

[Jonathan Ashworth]

The hon. Lady makes an interesting point. She is correct in as much as there is not currently a long queue of companies lining up to take control of whole health systems, but that could change if some new form of Transatlantic Trade and Investment Partnership is brought in by a post-Brexit deal. A number of these companies are becoming increasingly litigious in the courts, which is why Virgin Care took the NHS in Surrey to court. However, even if a private provider is not gifted a whole contract, which is the point that the hon. Lady is making, there is nothing to prevent it from buddying up with NHS bodies in joint ventures as a way of exercising influence over the way in which local health systems are configured. There is already evidence of private sector involvement in the establishment of the integrated care system, with Centene UK—an offshoot of an American health insurer—working with Capita in the Nottingham ICS.

[Karin Smyth (Bristol South) (Lab)]

Earlier in his remarks, my hon. Friend talked about confidence for people locally in what is happening in the NHS. Further to the point made by the hon. Member for Totnes (Dr Wollaston), only in February NHS England itself issued its case for primary legislative changes in which it says, with regard to these proposals, that it wants to

“start a broad process of engagement with the NHS, its partner organisations and those with an interest in how our health service operates.”

That will hopefully involve patients and the public. In Bristol, we embarked on a 10-year contract for community services on the day after the NHS plan was invoked without consultation with local people, an assessment of basic health needs or alignment with the rest of the situation. The problem is that we have yet another change that people locally do not have confidence in. It really is time for the Government to come forward with a cohesive change for the future.

[Jonathan Ashworth]

That is absolutely right. Notwithstanding the sincere views of the Select Committee, there is a lack of confidence out in the country about the way in which these commercial contracting arrangements work. We are seeing that in Bristol, as my hon. Friend so eloquently outlined. Despite the blasé attitude of the Secretary of State in the Select Committee, this is the same Secretary of State who has sat back and done nothing while a PET-CT cancer scanning contract in Oxford is privatised, leading to a fragmented service putting patient safety at risk.

Community Hospitals

Karin Smyth Excerpts

Tuesday 12th March 2019 Commons Chamber

[Fiona Bruce]

My hon. Friend has made one of my points for me. None of the major hospitals in east Cheshire lie within my constituency, although it is reasonably large, so my constituents must travel some distance to use their services.

I have mentioned the four-hour GP appointments on Saturdays and Sundays. They are always full, and are meeting a very clear local need. The convenience of such services cannot be overstated. During my visit, an elderly gentleman, clearly frail, arrived asking for directions to the X-ray department. I watched as he was directed to it immediately. He was seen, and he departed. All that happened within what seemed to me to be about three minutes flat.

The value of such local services for a population like mine, which contains a higher than average number of older residents, cannot be overstated. They are particularly appreciated by those who are less mobile owing to age or infirmity, or for whom a lack of convenient public transport facilities would make travel to the larger hospitals outside my constituency very difficult, if not impossible. Moreover, 9,000 fewer out-patient appointments across east Cheshire must reduce congestion.

The trust informs me that the Congleton Hospital site also has space for use by other NHS organisations, including providers of mental health and health visiting services. As local health partners and providers increasingly work together in support of their local communities’ health and wellbeing, Congleton Hospital, located as it is almost in the centre of the town, is ideally placed to become an even more strategic community health hub for additional services.

[Karin Smyth (Bristol South) (Lab)]

The hon. Lady is making a powerful speech on behalf of community hospitals. South Bristol Community Hospital was opened only in 2012, after 60 years of campaigning by local people. As three providers run different services in it and as it is a LIFT building, no one is really responsible for making it work. Does the hon. Lady agree that the health service must bear in mind that such hospitals are developed and fundamentally loved by their communities, and that those communities should have the ultimate say in what goes into them?

[Fiona Bruce]

The hon. Lady is absolutely right. Indeed, members of the community in Congleton are speaking out about the importance to them of their community hospital. I shall say more about that shortly.

On behalf of my constituents, I am pressing Ministers to consider resourcing Congleton Hospital as a community hub going forward. It has a very special place in local people’s hearts, as I have said, not least because of the manner in which it was funded many decades ago by local people’s contributions from wage packet deductions. It was founded in 1924 by public subscription as a memorial to those locally who gave their lives in the first world war, hence its full name: Congleton War Memorial Hospital. I spoke at greater length about this here in this place in 2014, when I raised concerns about the future sustainability of the hospital, so this is by no means a new issue. Indeed, in 1962 when there was a suggestion that the hospital be closed, it resulted in a mass meeting in the town hall with an overflow of some 2,000 residents, presided over by the then mayor leading to a petition of 24,000 signatures. Plans were quickly dropped. More recently, the £20 billion additional funding announced by the Prime Minister for investment in the NHS surely offers an opportunity for the future of the hospital to be secured, or even augmented as a community hub for the long term.

I have been in continuing dialogue for some months now with—and have met, together with local councillors—John Wilbraham, chief executive of the local NHS trust responsible for the management of the hospital, the East Cheshire NHS Trust. I am grateful to Mr Wilbraham for that open dialogue. We spoke again recently when he confirmed that, in his words, the sustainability of the site is on the agenda for the transformation programme to be discussed by the trust shortly. So also on the agenda is the future of the minor injuries unit, which is, as I have mentioned, causing particular concern to residents, as the trust is aware from recent public demonstrations which involved people from right across the community and political divides, including me and Congleton town mayor Suzie Akers Smith, who was in full mayoral regalia and chain.

I am grateful that Mr. Wilbraham has agreed to meet a cross-party group in the town shortly to discuss the hospital’s future further and look forward to that meeting. In the meantime, for the record I note that in his most recent letter to me of late December 2018 he confirmed, and I welcome this, that

“the Trust has no plans to change the service provision at the Congleton Hospital site and this remains the case. I continue to discuss with health and social care partners about the service offer from the hospital site and I understand the desire of you and the local population to maintain the facility. We await the publication of the NHS 10-Year Plan in early 2019 which provides the basis for the local health partners, including the town’s GPs, to set out its plans for the next 5-10 years. I am certain this will provide the opportunity to be clear on future service provision across the local health economy including Congleton.”

I am optimistic that both Mr. Wilbraham, as its chief executive, and the trust itself have listening ears. We need only witness the furore that arose in Congleton three years ago when there was a suggestion that car-parking charges be introduced at the hospital. The trust clearly registered the indignation of local residents, not least through a petition I presented here in Parliament at that time. That they could be asked to pay to park at their own hospital—a hospital they and their forebears had paid for by both wage packet deduction and subsequent fundraising and donations over the decades—aroused considerable consternation. The trust subsequently discounted the suggestion of car park charges outright; it listened to local people’s concerns.

I was pleased to note the chief executive’s reconfirmation of this in his most recent letter to me, with the words:

“I note the suggestion of car parking charges being introduced to supplement the income for the hospital site but this is not something the Board will be considering.”

Now that the 10-year plan has been published, and in the light of the Secretary of State’s indication of his support for community hospitals, I am today asking the Minister what more can be done to ensure that vital services provided by community hospitals in the heart of our local communities, like Congleton, are not swallowed up by larger hospitals at a distance. What the Congleton community seeks is reassurance that the future of Congleton hospital is put on a firm, clear and sustainable footing going forward, so that the periodic recurring concerns over the years about its future can be fully and finally put to rest.

--- Later in debate ---

[Caroline Dinenage]

The hon. Gentleman makes an incredibly strong point. I often stand at the Dispatch Box—usually during Adjournment debates—having listened to hon. Members talk about CCG decisions that they feel may not be in the best interests of their local area, but it is up to local areas to decide. The whole point of devolving money and decision making down to CCGs is that we trust them to be able to make the best decisions in the best interests of local communities to deliver services that best meet needs and priorities. If the hon. Gentleman feels that that is not happening and if he has had the opportunity to discuss that with his CCG, it could be a good idea to take the matter up with NHS England.

CCG funding allocations are decided by an independent committee, which advises NHS England on how to target health funding in line with a funding allocation formula. This objective method of allocation supports equal opportunity of access and reduces health inequalities. That way, the decision of where taxpayers’ money goes is decided in an independent and impartial manner.

As my hon. Friend the Member for Congleton will be aware, it is down to the CCG—in this case Eastern Cheshire CCG—to decide how it spends its allocation and to determine which services are the right ones for the local community it serves. One would hope that CCGs have the necessary clinical knowledge and local expertise to make informed decisions on how to spend taxpayers’ money. To support the long-term planning of services, NHS England has already informed all CCGs about how much funding they can expect to receive between 2019-20 and 2023-24. My hon. Friend may be interested to know that Eastern Cheshire CCG’s funding will increase from £270.2 million to £311.6 million over that period—a substantial increase. I hope that she will agree that that information gives CCGs the stability to plan appropriately and establish their services for the long term.

[Karin Smyth]

I do not disagree with much of the thrust of what the Minister is saying, because CCGs—I used to work for one—do spend taxpayers’ money. She will often have heard hon. Members say that there is no link between the accountability for that money, the work that we do as Members of Parliament and the decisions that are made by CCGs. The new NHS plan looks like it may want to do something about that, but will the Government send a message to NHS England and the CCGs that local democratic accountability must somehow start to be built into the CCG decision-making process?

[Caroline Dinenage]

The hon. Lady makes an interesting point, and it is one with which I have a certain sympathy. When NHS England comes up with the implementation plan for the long-term plan, I hope it will include suggestions as to how such issues might be addressed.

It is important to remember that the NHS is close to all our hearts. Fundamentally, it belongs to the people of this country. It is founded on a common set of principles and values that bind together the communities and people it serves. For that reason, it is welcome to hear my hon. Friend the Member for Congleton talk so highly of the open and honest relationship between her local NHS and the residents of Congleton. The examples she gave of the decision-making process for introducing car parking charges highlights how local people in Congleton are being listened to and, if I might say so, it says a lot for the people of Congleton. It takes a lot for the people of Congleton to demonstrate, but this shows that they do so effectively when they decide to take such action.

I commend my hon. Friend for the role she has played in the work to protect her local hospital and for all her activities in that direction. I also commend her for her ongoing efforts in forging constructive relationships, which are so important. These open conversations between health systems and the people they serve will, ultimately, allow us to continue building a sustainable future for the NHS.

Question put and agreed to.