NHS Long-term Plan

Karin Smyth Excerpts

Monday 7th January 2019 Commons Chamber

[Matt Hancock]

Yes, absolutely. My hon. Friend is a brilliant advocate for Torbay and for the English Riviera, and has made the case so strongly for his local hospital. I was delighted that we could recently find the funding to support the case that he and local clinicians have made, and I look forward to working with him to make it a reality.

[Karin Smyth (Bristol South) (Lab)]

Before coming to this place, I was a senior manager in Bristol’s primary care trust and then the CCG. I want to pay tribute to the NHS managers who have kept the ship afloat since the Lansley reforms. Today’s plan is clear in its commitment to triple integration and seeking to free commissioners from the barriers to integration in the 2012 procurement rules, but tomorrow the CCG in Bristol will embark on a huge re-procurement process for some community services for the next 10 years based on those old rules. In the light of his plan, will the Secretary of State intervene locally and support my call to pause that divisive community services re-procurement?

[Matt Hancock]

I will raise the hon. Lady’s point with NHS Improvement, which considers these things. Local provision of services should, rightly, be decided by local clinical priorities, but she makes a cogent point that I will raise with NHSI, and I will ask its chief executive, Ian Dalton, to write to her.

Oral Answers to Questions

Karin Smyth Excerpts

Tuesday 27th November 2018 Commons Chamber

[Stephen Hammond]

As my right hon. Friend the Secretary of State said earlier, we recognise the vital role that nurses play, and we are determined to support them. We are determined to have more nurses in training and more nurses treating patients. At the moment, a student on the loan system typically achieves 25% more in their pocket than they would have had on the bursary, but the Government recognise that there are still pressures, which is why we have the learning support fund, the exceptional hardship fund and support for mature students.

[Karin Smyth (Bristol South) (Lab)]

I talk to local employers who desperately want to support nursing apprenticeships as an alternative to the higher education route, but the uptake of apprenticeships is very disappointing. The levy can be used only for training costs, and trusts have been asked to plug the shortfall in funding for wider capacity building and to cover the 20% of time for which apprentices have to go to off-the-job training. Does the Department recognise this problem? What is being done to address it?

[Stephen Hammond]

The hon. Lady is right that the number of trusts that currently use the levy is not as high as it should be. We hope that all will do so. It continues to be a priority for us to broaden the routes into nursing. We will address in the long-term plan the specific matter about which the hon. Lady talks.

Budget Resolutions

Karin Smyth Excerpts

Tuesday 30th October 2018 Commons Chamber

[Matt Hancock]

The £20.5 billion is just for day-to-day running costs—the resource costs. Of course there is a capital budget, too, which includes £4 billion of taxpayers’ money. That goes towards ensuring that we can get the capital built. The critical point is that we have not only that £20.5 billion uplift in running costs but a capital budget. We will make further announcements on the allocation of the capital budget later in the autumn.

[Karin Smyth (Bristol South) (Lab)]

I am grateful to the Secretary of State for clarifying the £20.5 billion figure, which does not include training or capital. Of course, that contradicts the unhelpful briefing from Downing Street during the summer that it was something like £84 billion. Will he confirm that that £84 billion figure, which has been repeated in the media, is, as the Health Service Journal says, a fib, and that we are talking about £20.5 billion purely for resources in the NHS in England and Wales?

[Matt Hancock]

No. The £84 billion is the cash figure. The £20.5 billion is the real-terms increase by the end of the five years. If we add up all the extra money, we get £84 billion. It is there on page 36 of the Budget, if the hon. Lady wants to look. The biggest single cash increase comes next year, in 2019-20. It is all there in the Red Book.

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[Joan Ryan (Enfield North) (Lab)]

I thought I would start by picking out a few key points from the Office for Budget Responsibility report, which might have a slightly different emphasis from the points that the Chancellor would pick out. Let us start, on page 64, with household disposable income:

“Real household disposable income fell by 0.2 per cent in 2017”.

On page 65, the report says:

“We expect relatively weak growth in per capita real earnings and real disposable incomes… In 2019, real per capita disposable income growth is flat”.

On household saving and debt, on page 67, it says:

“We expect unsecured debt to rise steadily as a share of household disposable income”.

On household net lending and balance sheets, on page 70, it says:

“the ratio of household debt to income has risen steadily since the start of 2016…we expect the ratio of household debt to income to continue to rise steadily…with the ratio reaching just under 150 per cent by the start of 2024.”

On business investment and stockbuilding, on page 72, the report says:

“The latest data suggests business investment fell in both the first two quarters of this year…we expect a modest rise in business investment as a share of real GDP over the forecast period—less than would be typical at this stage of an economic cycle.”

On UK exports as a share of GDP, on page 77, it says:

“In August, the Government announced an ambition to increase the UK’s exports to 35% of GDP, but has not specified the date by which it believes that this can be achieved. The Government’s previous aspiration was to increase exports to £1 trillion by 2020—our forecast suggests that this will be missed by £320 billion. The Government is not on course to meet its current ambition in our forecast”.

On risks and uncertainties, on page 81, the report says:

“The outlook for productivity growth remains hugely uncertain.”

On page 83, it says:

“the probability of a cyclical downturn occurring sometime over our forecast horizon is…high”.

On assumptions regarding the UK’s exit from the EU, it says:

“we still have no meaningful basis for predicting a precise outcome upon which we could then condition our forecast.”

On page 91, it says:

“Real GDP Growth has been revised down in 2018”.

Now, the Chancellor, of course, would and did choose to cherry-pick a different set of headlines yesterday, but I think this is a more balanced picture than that presented by him.

I can assure the Chancellor of two things in relation to this Budget. First, the people of Enfield are sick and tired of austerity. Secondly, we have no confidence that the Government’s programme of austerity is coming to an end. The Government’s £1 billion cut to the Metropolitan police budget since 2010 has resulted in 230 police officers and police community support officers being removed from the streets of Enfield. Over the same period, violent crime has surged locally by 85%. Where was the Chancellor’s announcement to reverse those cuts, put more bobbies on the beat and help create safer neighbourhoods?

How can the Government have the cheek to say austerity is over, when they are still planning cuts of £1.3 billion to councils next year? By 2020, the Government will have slashed funding to Enfield Council by 60% in just a decade.

There is a better example in this Budget of the Government’s misguided priorities. The Chancellor announced more funding for potholes than for our schools. Pothole funding is welcome, but surely education should be a higher priority. Does the future of our children not matter? This is a slap in the face for many schools in my constituency, which are having serious problems paying for basic items such as pens and paper, let alone retaining and recruiting teachers.

Austerity is not coming to an end, and nor, as the Chancellor asserted, is the “economy working for everyone”. This year, we have seen household debt rise to its highest level on record. Over-indebtedness in Enfield is higher than the London and national averages, and we have more than 14,000 residents in real financial difficulty. One in three workers living locally does not earn a living wage, and the average worker is £800 a year worse off than they were a decade ago.

The Government’s abject failure to address the housing crisis means local families are struggling to cope with soaring rents and a lack of affordable homes, with our borough having the highest eviction rate and the second highest level of homelessness acceptances in the capital.

The last Labour Government lifted 1 million children out of poverty, but child poverty rates under the Conservatives are getting worse, not better. Some 34,000 children in Enfield are now living below the poverty line. This is a shameful record for the Government, and a record that could deteriorate still further as a result of their disastrous universal credit roll-out.

[Karin Smyth]

My right hon. Friend is making an excellent speech. Does she agree that the failure to say anything considerable in the Budget about early years support and education and Sure Start centres yesterday represented a glaring omission, and addressing those issues would have helped families in constituencies such as Bristol South and Enfield North?

[Joan Ryan]

My friend is absolutely right. In fact, in Enfield, we now see a real problem, as we do in many other parts of the country, with children not being ready for school at the age of five. This has a significant impact on their achievement throughout their school careers and on their future.

North Enfield Foodbank has said that food bank usage continues to increase, with Enfield having the fourth highest rate of food bank usage in London last year. The main reason for that increase is delays in the payment of benefits and changes to them.

The Chancellor said that the Government were

“delivering on the British people’s priorities, supporting our public services”—[Official Report, 29 October 2018; Vol. 648, c. 668.]

There is no public service or institution more important in our country than the national health service. Huge pressure has been placed on doctors’ surgeries. Well over half the residents who replied to my GP services survey said they had difficulty getting an appointment to see a doctor, and we know that, going forward, Enfield is short of 84 GPs to serve our growing population.

The Government’s chronic underfunding of our national health service since 2010 means that North Middlesex Hospital, like so many other hospitals across the country, is operating with a substantial financial deficit. NHS England is trying to deal with a deepening staff crisis, while hospitals are trying to recruit doctors and nurses. This is an impossible situation. We cannot square this circle. On public health, which warranted no mention whatever, we in Enfield are facing another £1 million cut by 2020, and everybody knows the link between poverty and health.

The Government have failed to address eight years of devastating cuts to our communities, and they are failing to deliver on the priorities of the British people. Austerity is not coming to an end. Yesterday’s Budget proves it. There is no hope here that I can take to the people of Enfield from this Conservative Government. I will not be supporting this Budget.

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[Debbie Abrahams (Oldham East and Saddleworth) (Lab)]

I should like to highlight some of the facts and figures that the Chancellor missed yesterday before I move on to discuss some of the taxation and public spending measures. First, a record 8 million working people are now living in poverty. There are also 4 million children living in poverty, two thirds of whom are in working families. That number is going in the wrong direction. There are also 4 million sick and disabled people living in poverty—twice the number of non-disabled people. Our life expectancy is flatlining, and for women it is actually going backwards, but what do this Government do? They increase the state pension age. We also know that infant mortality has increased for the first time in 100 years, and that four in 1,000 babies will not reach their first birthday, compared with 2.8 per 1,000 in Europe.

Many epidemiologists have linked this reversal of the generations of health improvement with the austerity that this Government have wrought on the country as a whole and on people on the lowest incomes in particular. Resolution Foundation analysis published today and yesterday’s Budget book show that people on the lowest incomes will be hit disproportionately hard. The Government have not reduced inequalities. Have Ministers assessed the Budget’s impact on life expectancy? Will it continue to flatline, will it get worse or will it increase? I doubt they are able to say it is on the road to recovery.

On tax, I am pleased that small businesses, particularly those on the high street, will have their business rates reduced—that has been a particular issue for a number of my constituents—but what will that mean for councils’ revenue, and how will they be recompensed? My council has lost nearly half its budget from central Government. The digital services tax sounds great, but the OBR says it will affect around 30 tech giants, which will pay about £15 million each. How will that address the fundamental issue that, for example, in 2016, Google paid £36.4 million in corporation tax on declared UK sales of £1 billion, whereas according to its US accounts those sales were £6 billion?

On public spending, the Chancellor confirmed that the NHS would be given much-needed cash. That is welcome, but a range of think-tanks, from the King’s Fund to the Nuffield Trust, say it actually needs £30 billion by 2020. Again, the additional £2 billion for mental health crisis is welcome, but what about emphasising prevention? What about assessing the Government’s own policies on sanctions, work capability assessments and the personal independence payment process, which make the mental health of many claimants worse?

The £1 billion for social care is important, but it does not address the £2.5 billion funding gap since 2010 and does not help the 1.2 million people who need care but cannot get it. I worry that after the publication of the social care Green Paper, which is being consulted on, a new funding regime involving a social care insurance scheme will be announced. That would have disastrous implications for the NHS, as we see closer integration between the NHS and social care.

I could go on about the derisory figures for education and the fact that my local police force and our emergency services will receive nothing substantial, but I want to talk about homelessness, which is rising but was not mentioned in the Budget. We see rough sleepers on our streets in towns and cities up and down the country, but we hear nothing about the families who live in temporary accommodation or people who sofa-surf, as they are not deemed as having priority need for housing. That is the Government’s biggest shame. It epitomises their neglect of too many citizens and reflects not just their failure to ensure that enough houses are built for us all, with social and affordable homes as part of the mix, but their ill-thought-out social security policies, such as universal credit.

Universal credit has been a disaster from start to finish, and it has now been revealed to be driving homelessness. One shelter says UC is the reason why a third of its residents are in it. UC tenants of the housing association First Choice Homes in Oldham are in more than £2.5 million of rent arrears. Research suggests that nearly one in five people in Oldham struggles to pay a social rent. UC is part of that problem. Policy in Practice estimates that the changes to UC announced in the Budget will not have a significant effect. It says 345,000 more households will still be worse off and 29,000 will be no better off. Disabled people will still be worse off. People in employment will see some improvements, but self-employed people will see none at all.

[Karin Smyth]

My hon. Friend is a well-known expert in this area, which she has spoken up about many times. Does she agree that the Government’s inability to look at people in the round—particularly at their mental ill health, their disability, their poverty and their lack of access to work—drives some of the problems she highlights, including those with universal credit?

[Debbie Abrahams]

My hon. Friend hits the nail on the head. The human misery caused by such an inhumane policy cannot be underestimated.

L contacted my office recently after her UC was suddenly stopped because her son, B, has severe learning difficulties and L, who is the main carer, did not realise that he would have to make a separate claim once he had reached his 19th birthday. When the money stopped, L had nothing—she did not know why it had stopped and nobody contacted her. It was an absolute disaster for her, and she said:

“At times I just want to end it all…it’s just so hard and I get no support or respite.”

L is a candidate for the new mental health crisis fund that the Government have set out—a product of their universal credit policy. On top of this, the investment in UC does not offset other cuts to social security, with welfare spending set to fall in the next couple of years.

Most worrying are the cuts affecting disabled people, which have not been addressed in the Budget. In fact, according to the OBR, disabled people will be worse off. As the United Nations said last year, this Government are presiding over a “human catastrophe”. The Equality and Human Rights Commission estimates that families with a disabled adult and a disabled child will have lost 13% of their income—£5,500 a year—by 2022. This is on top of colossal cuts across other Departments. What about their help from the Chancellor? What about their bright future?

We have done a lot—the former Labour Government did a huge amount to improve life expectancy, and to lift disabled people and children out of poverty—but we need to do more. The inequalities in our society are getting worse, not better. These inequalities are socially reproduced, so they can be changed, and that should give us all hope. But political will is needed to tackle them, and I am afraid that this Government just do not have it in them.

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[Karin Smyth (Bristol South) (Lab)]

It is an absolute pleasure to follow my hon. Friend the Member for Kingston upon Hull West and Hessle (Emma Hardy), who made an excellent speech.

We have had the usual smoke and mirrors about the real money that is going into the NHS through this Budget, but I think that everybody outside the Chamber agrees that it is not enough to meet the increase in demand that we all know about. Equally as concerning, however, is the fact that the percentage of the NHS budget that will be part of public spending over the forthcoming years will rise to roughly one third of overall spending. That says an awful lot about what we are not spending money on, as well as what we are spending.

Sometime soon, we will have the 10-year plan. The taxpayers, whom the Secretary of State was so concerned about earlier, will have absolutely no say in that plan, the priorities or how the resources are allocated. It is a completely missed opportunity to treat the public as grown-ups in the debate about health funding so that they are clear about the cost of health services, the extent of spending and the quality that money can buy, and understand what they are prepared to pay for.

Let me speak briefly about VAT. Page 50 of the Red Book refers to some tinkering around the edges of VAT, but the Government make no mention of closing the loophole that has been exploited by some NHS trusts. I visited a Treasury Minister recently to talk about wholly owned companies saving VAT. The Treasury seems unconcerned about the loss of income from VAT on wholly owned companies, and the Department of Health and Social Care seems totally unconcerned about the competing fragmentation of our services. It would be really good if both Departments had a chat with each other, decided what the policy should be and sorted it out.

I want to concentrate now on the Budget. Bristol is a city of high employment, and also a city with high rates of ill health and disability. The greatest inequalities are in my constituency, with people living on average for 19 years in ill health. The Marmot review on health inequalities estimated that between £36 billion and £40 billion are lost in taxes, welfare payments and costs to the NHS through health inequalities. This is a huge opportunity for us to do better.

I want to touch on universal credit and social care. Some 5,900 of my constituents currently claim employment and support allowance and the Government intend, at some point, to migrate them on to universal credit. In successfully claiming ESA, my constituents have been subject to the work capability assessment. Many have been initially refused, but then have successfully appealed that decision on one or more occasion. They will have proved to the Department for Work and Pensions that their long-term disability or ill health means that they cannot work and need financial support. There is still no recognition or understanding that these constituents will never work again. They do not need incentives or sanctions to work. The DWP agrees that they cannot work, but universal credit offers them no benefit, only a loss of income. Surely it is time to halt the migration of anyone currently claiming ESA and allow new claimants with an illness or disability to claim that benefit. We need a proper rethink about how we support those who most need our help.

The problem on social care is well documented. We know how many people are losing support, but it is still a silent misery for thousands of families, because until someone goes into the system, they do not understand how bad it is. The King’s Fund said that public awareness of the system is very poor and that

“As long as the public view the issue from behind a veil of ignorance, it is easier for national politicians to trade on…rivals’ proposals”.

I do not want to trade on fear and misinformation; I want us to set a path for what we need. I would like the Budget to have helped, but it has not. The language needs to change. Spending on social care is not a drain, a time bomb, a burden or a threat to assets. It is an investment in people and in our future. Every business, every public service and every family is struggling to cope with social care, and investing in it is an infrastructure issue. It is essential to our prosperity.

The cycle of ill health, disability and poverty is well known, as is the problem of low productivity, and poor educational attainment does not help. Last month, one of my colleges came up with the Love Our Colleges campaign to talk about underfunding in further education and the need to bridge the skills gap. College funding has been cut by 30% since 2009 at the same time as costs have increased dramatically, including for pensions. At the same time, however, the number of adult courses has dropped by 62% and the number of health and social care courses by 68%. How can that be a priority when there is that level of disinvestment? This is a huge problem in Bristol South because we do not send youngsters to higher education—further education is the driver of prosperity for our people.

As I highlighted earlier, also not mentioned was the OECD report on early years education. There was nothing in the Budget about this, despite evidence that early years education is a driver of prosperity. Nursery schools, which are under the control of local authorities, were forgotten even in the Chancellor’s miserly throwaway comment. He has not given them anything. They do not even get the pittance he threw away in the Budget.

Finally, I want to say something about our police services. Some 75% of recorded incidents are currently non-crime and include missing persons reports and issues relating to people experiencing mental health crises, all of which are highly resource intensive. I am currently on the parliamentary police force scheme and spending a lot of time with our police force, so I have seen this at first hand. The police funding formula has not been updated for a decade and does not reflect current demand. The police and crime commissioner has been clear about this. In Avon and Somerset, we have a very good system for analysing demand and the associated resource needs, but we are still not getting the money, even though we have proved we need the resource.

In conclusion, the Government are ignoring all the data and evidence, and not linking up their policies in order to deliver the improved productivity that this country needs and which will drive prosperity for all our constituents.

Social Care Funding

Karin Smyth Excerpts

Wednesday 17th October 2018 Commons Chamber

[Liz Kendall (Leicester West) (Lab)]

This year is the 70th anniversary of the NHS. It is also the 70th anniversary of our social care system, but that has received far too little attention to date. It is not getting any of the national celebrations—the birthday cakes and cards—and certainly none of the £20 billion birthday present that the NHS received from the Prime Minister.

Yet social care is more important than ever before. A quarter of older people now need help with daily living—getting up, washed, dressed and fed. More adults with physical and learning disabilities need substantial packages of support. There are 1 million paid care workers and 6.5 million unpaid carers. Yet despite the fact that this touches so many people’s lives and that there is an increasing demand, we have no sense from the Government of the reality of the situation. There has been a 10% cut in real terms in social care spending, with 400,000 fewer people getting any kind of help and support. A third of carers have to give up their job or reduce their hours to look after their loved ones, and a quarter of the paid care workforce leaves every single year. There is nothing from Government Front Benchers—no sense of the urgency of the challenge we are facing.

We cannot solve this problem without substantial extra funding. The Health Foundation says that we need £6 billion just to maintain the current inadequate system. It is not good enough.

Over the last 20 years, we have had 12 Green and White Papers and five independent commissions, but we have not solved this problem, and we need to understand why. Most people think that they are not going to end up needing this support. When they end up needing it, they do not realise that many of them will have to pay. They think the current system is unfair, but when radical proposals have been put forward for how to fund the system, they believe that those are unfair too.

This issue has been a political football. Labour was accused of imposing a death tax, and the Tories were accused of imposing a dementia tax—but it is not the politicians who suffer; it is the people who use the services and their carers. We cannot go on like this any longer.

I believe that one of the reasons this issue has not been solved is that much of it is about low-paid women who work in people’s homes and care homes invisibly. Caring is not valued, and we have to change that.

[Karin Smyth (Bristol South) (Lab)]

My hon. Friend is making an excellent speech and she is an expert in this area. She is right; the language we have heard today is all about the challenges and the costs. This is an infrastructure issue, and it needs to be treated as such. Because women lead this workforce, it is not considered an infrastructure issue, and if we did that and changed the language around this, we would have a completely different debate. Does she agree?

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[Andrew Gwynne (Denton and Reddish) (Lab)]

I begin by thanking hon. and right hon. Members for their contributions from across the House. It is the convention to mention Members by their contributions. I apologise that, because of the time restrictions that have been put in place, that is not possible.

I pay tribute to all who work in our social care services, whether they work in the NHS or our councils or are paid or unpaid carers. We have been here before. I have a sense of déjà vu. It was in April that we called for immediate action from the Government to address the crisis in social care, yet here we are, months later, and no progress has been made. Since then, we have had a new Health Secretary and a new Communities Secretary, but still no new ideas and still no Green Paper. There is only so much longer this sector can wait.

Given the lack of support from the Government, and in the face of year-on-year cuts, local government has been forced to step up. With the Cabinet too busy squabbling among themselves and in the absence of any Government action, the Local Government Association has published its Green Paper on social care. It is worth the Government considering some of the responses that the consultation received. According to the District Councils Network, the

“adult social care crisis is the single largest problem facing local government services and their financial sustainability”.

[Karin Smyth]

The Green Paper commends Bristol City Council for its Well Aware project. Will my hon. Friend join me in congratulating Bristol on that online and telephone advice and guidance service, which has proven so popular, and will he or the Minister visit to see how it works in practice?

[Andrew Gwynne]

Absolutely. I am always happy to visit my hon. Friend’s city of Bristol and to see the great work it is doing in very difficult circumstances—Labour local government leading the way and making a difference where it matters.

The LGA estimates that adult social care services face a £3.5 billion funding gap by 2025—just to maintain existing standards of care—but councils in England receive 1.8 million new requests for adult social care a year, the equivalent of almost 5,000 extra cases a day. It is a national scandal. The Government should feel ashamed that 1.4 million older people are now not getting the necessary help to carry out essential tasks, such as washing themselves and dressing. That is 20% more people without care than only two years ago. One of the people experiencing adult social care said of their provision:

“I haven’t washed for over two months. My bedroom floor has only been vacuumed once in three years. My sheets have not been changed in about six months and my pajamas haven’t been changed this year. My care workers don’t have time for cleaning, washing or changing me”.

Those words were taken from a report by the Care and Support Alliance into the state of care in the UK, and it makes for heartbreaking reading, but we have yet to see a Minister even acknowledge that a crisis in local government funding even exists. “We introduced the social care levy,” said the Secretary of State. No, they enabled councils to raise more council tax in a limited way, but a 1% increase in his council’s council tax raises a very different amount from a 1% increase in my area. That only widens the inequalities and the unfairness.

The Secretary of State’s big announcement at the Conservative party conference of an extra £240 million of emergency funding for adult social care should not be celebrated; it should be a source of shame. The Conservative leader of West Sussex Council summed up the response to the announcement:

“I am not skipping round—I am really cross about it. It’s half a crumb. It’s not even a crumb.”

Earlier this year, the former Secretary of State for Health made a candid admission to the British Association of Social Workers, when he accepted his share of responsibility for the lack of progress since the Tories entered government in 2010. The crisis is a result of this Government’s policies. Our Prime Minister has given up and our councils are at breaking point, but the Government remain committed to their programme of cuts, taking £1.3 billion extra funding out of local government next year. Let that sink in for a moment. It is now being reported that nearly 50% of council heads are seriously worried about impending bankruptcy in their councils, which should send shivers down the spines of members of the Government. One of the chief executives surveyed by the Local Government Chronicle said:

“The next three years are secure if we can manage the demand in adults and children’s services...a complete lack of policy means that even with a well-run council and relatively strong local economy we are likely to start to significantly struggle in 2021/22.”

That is the reality, and that is why I commend our motion to the House.

Management of NHS Property

Karin Smyth Excerpts

Wednesday 4th July 2018 Westminster Hall

[Karin Smyth (Bristol South) (Lab)]

I beg to move,

That this House has considered the management of NHS property.

It is a pleasure to serve under your chairmanship, Ms Dorries. [Interruption.]

[Ms Nadine Dorries (in the Chair)]

Order. Mr Zahawi, the debate has started.

[Karin Smyth]

I recognise that the management of NHS property is not the most enthralling subject, but many hon. Members from across the country will recognise that it is a growing problem in their constituencies. The problems are varied and many. My focus today will be on the community and primary care estate.

I will not talk about bricks and mortar or leaking pipes, or outline the detailed and manifold operational challenges posed by an NHS estate that in many parts of the country still relies on pre-1948 infrastructure. Instead, I want to talk about the places our constituents go to when they need care, where they welcome their children into the world and where they say a final goodbye to those they love. They are places where some of our most precious memories are forged, capable of delivering huge happiness and hosting unimaginable grief. They are hard-wired into our emotional DNA and the fabric of the communities in which they sit. They are places that are paid for by our constituents through their taxes, which our constituents feel ownership of and an enormous attachment to. It is in this difference that the notion of local or personal ownership is blown apart. The harsh reality is that our constituents do not own these properties. Moreover, they do not even have a say in how they are run or in their future.

Who owns them? Who runs them? How do they operate? How can users or stakeholders such as MPs influence change? Those questions are hard to answer as control of these special buildings is opaque to the point of absurdity. The lines of accountability are unfathomable and, as so many colleagues will know, incredibly frustrating to deal with. I have spoken to numerous colleagues across the House about these issues.

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful to my hon. Friend for giving way, and grateful to the Minister for listening to my concerns about the Bootham Park Hospital site and intervening on that. A real programme of change for healthcare in York has now been put together. Does my hon. Friend agree that when looking at the estate it is important to develop plans that improve healthcare rather than seeing it just as buildings?

[Karin Smyth]

I agree. The building that my hon. Friend has been working on is iconic, and that case is a good illustration. My hon. Friend the Member for Bristol West (Thangam Debbonaire) has been dealing with a GP surgery in her constituency for a long time and can get no resolution. I have also spoken to my hon. Friends the Members for Stoke-on-Trent Central (Gareth Snell), for Stroud (Dr Drew), for Bishop Auckland (Helen Goodman) and for High Peak (Ruth George)—these problems are happening across the piece.

[John Howell (Henley) (Con)]

Will the hon. Lady join me in condemning how the parking company Smart Parking operates its fines system at the Townlands Hospital in Henley? It is a monstrous way of dealing with people; intimidating them when they are at their most vulnerable.

[Karin Smyth]

I cannot comment on the specific company, but trying to understand accountability and how systems work is frustrating for local people. Many of us are trying to make sense of it.

The estate was an afterthought for the coalition Government and their disastrous Health and Social Care Act 2012—the Lansley Act. Their laissez-faire approach, which bordered on contempt, has saddled communities across the country with burdens and consequences ever since. The current Government recognised that in their response to the Naylor review, stating:

“The structural changes in recent years have distracted attention away from the importance of the estate as an enabler of high quality care, and the NHS has lost valuable expertise and knowledge in strategic estates planning, development and management.”

As we are developing the 10-year plan to transform our NHS into a more community-based, joined-up system, the function of the community and primary care estate as an enabler of service transformation becomes more critical. Although the Government said in response to Naylor that they want to incentivise local action, in practice there are no mechanisms to do so. My focus is therefore on the local roles of two national bodies: NHS Property Services and Community Health Partnerships.

The Lansley Act nationalised health centres, GP premises and, in my constituency, the South Bristol Community Hospital overnight. When the Government realised that no one was responsible for property managed by primary care trusts—mainly GP premises and health centres in poorer areas—they set up NHS Property Services, which became the landlord and asset manager on behalf of the Secretary of State. Community Health Partnerships took over the primary care trusts’ 20% control of local infrastructure finance trusts—LIFT companies—which were public-private partnerships for new GP premises and community-based services, such as South Bristol Community Hospital.

A key part of the LIFT incentive was that the companies made a profit and from that a dividend was returned to all shareholders, including the primary care trust. The Lansley Act passed that 20% local share to the Secretary of State. That LIFT company is still operating, as others are across the country. Bristol Infracare LIFT paid dividends totalling £823,000 last year and £2,344,000 in 2016. Community Health Partnerships received 40% of that, but 20% should have been retained in the Bristol health economy. In the last two years, that amounts to £633,400 in Bristol alone, and that is replicated across the country. I am here today with a simple message for the Secretary of State, via the Minister: I want control of this asset to be given back to the local health economy, and I want our money back.

The closer one looks at the labyrinthine structures that govern NHS properties, the more it seems that the opaque and impenetrable way in which these companies operate is not accidental. They appear to be purposefully disenfranchising and disempowering local people. Whatever the merits of the Lansley Act—I contend that there are not many—it was supposed to drive devolution, liberation and accountability.

[Julian Sturdy (York Outer) (Con)]

The hon. Lady is making a powerful argument. One of the real problems we find in York is that NHS Property Services is very distant and difficult to engage with. It needs to sit down with local communities, whether in York, Bristol or elsewhere in the country, and engage with them about the assets that need to be reinvested back in those local communities.

[Karin Smyth]

That is exactly the point I want to make, but I will go on to show how that is difficult to do and make a difference.

Patients and frontline practitioners were supposed to be front and centre of the new NHS, but that has simply not happened because, as we have heard, control is ever more centralised. It really did not have to be that way. NHS Property Services was set up as a national body, losing a wealth of local expertise and institutional knowledge in the process. With expensive London headquarters, its teams across the regions are stretched. It spent its first period of existence creating a register of assets and a new market rent system. That resulted in disputed and unpaid rents, which necessitated additional loans from the Department of Health to keep the company afloat and a complicated parcelling of subsidy via NHS England to clinical commissioning groups and GP surgeries. The early years have been an expensive disaster, with GPs and managers across the country not knowing what they were being charged for or who to call to sort out the problems. The profligacy of the system is matched only by its utter uselessness, and that is why I have been pursuing this scandal since I was first elected.

In my constituency two GP health centres and a healthy living centre are directly affected by these problems. The Knowle West healthy living centre was set up in a joint arrangement on Bristol City Council land, with public health services delivered based on the needs of a community that has some of the highest health inequalities in the country. It is no exaggeration to say that for many in the area the centre is a lifeline. However, with public health taken out of the NHS into local government, and the services now largely contracted via a third party, NHS Property Services soon came knocking on the door, bringing with it a charges bill increased by more than 200%. There was no discussion, no legal lease was in place and there was no service level agreement. Not only has the charity that runs the centre been forced to operate under the constant threat of closure, but it is unable to access the simplest forms of support. It recently asked if the windows could be cleaned, only to be told that that was not in the contract.

It has taken me three years to get even a modicum of progress—lobbying the clinical commissioning group and Bristol City Council, talking to local media, and raising the issue at the Public Accounts Committee and actively on social media, which finally resulted in a helpful meeting with the chair of the NHS Property Services board. The issue is still not resolved, however, and we still have some way to go. It has been a battle. It is tiring for everyone concerned—frontline practitioners in particular—debilitating and, most frustrating of all, entirely avoidable.

South Bristol Community Hospital has a similar story. This facility was the focus of a 60-year campaign by local people, and it finally opened in 2012. Established by a partnership between the primary care trust, private equity and Community Health Partnerships, the local link was severed by the Lansley Act, as I said earlier. Now the board that oversees the community hospital meets far away from Bristol and with no Bristol involvement. An employee of Community Health Partnerships supposedly represents us in overseeing the management of the company that runs the hospital. Community Health Partnerships, like NHS Property Services, is an arm’s length body within the Department of Health and Social Care. The lease of the hospital is managed by a local foundation trust, University Hospitals Bristol, cobbled together in a last-minute deal with the primary care trust. Two other NHS bodies and a social enterprise are also tenants in the building. If that sounds confused, conflicted and convoluted, that is because it is.

I have been campaigning as the local Member of Parliament to get more services into the new hospital. It is a superb new building, with 96 community beds and an urgent care centre. A poll that I carried out among my constituents showed that 90% either were unaware of the services available in the building or felt that it was underused. A 2014 Care Quality Commission report found that the operating theatres were utilised only a quarter of the time, and the out-patient department only 55% of the time. We have made great progress since then, but the building is still underused as part of the health economy—on entering the building, people are faced with a whole floor with just a reception desk, and the corridors and lifts are typically empty.

The rehab unit, by contrast, is always full. The nurses, porters and other staff who keep it going all work tirelessly, but there is no escaping the sense that this facility is only rented or temporary. Everything is contractual and faceless, with rules abounding, while stroke patients spend their days and months staring at white walls because, according to the nursing staff, there are limits to what the landlord will allow—for example, there are no pictures.

The community hospital is on the southern fringe of our city, where 30% of residents do not have access to a car and the public transport links are historically among the worst in the United Kingdom. That same community has the highest rates of cancer, diabetes and asthma in Bristol, yet people are still expected to travel miles across the congested city for services that could easily be on their doorstep. I keep repeating the need for local health organisations to see sense, and my hope is that the logic is finally getting through and that we will see more facilities, such as diagnostics and perhaps even scanners, in the near future. Yet why has it taken such effort and such a long time?

South Bristol Community Hospital is perfectly placed to deliver the vision in the five year forward view and the aspiration of the 10-year plan—integrated with social care, providing a front and back door to other services to support the flow in the rest of the health system. However, progress towards those achievable goals is constantly frustrated by the fragmented ownership, the complicated money flows and the unfathomable accountability arrangements. My constituents, without fail, suffer as a result.

Time does not permit me to outline similar problems relating to the shady use of wholly owned companies, but chief among my objections to such companies is that every one of them is a lost opportunity to look at NHS estate management locally on a more joined-up basis, with some local accountability in the system. How can we promote a collaborative approach across healthcare systems when individual trusts go down their own selfish route?

The Naylor review offered some interesting recommendations to simplify the national management of the estate. The Government chose to establish a ministerial board chaired by a Minister at the national level, and it includes everyone—every NHS organisation seems to be on that board. I tried to map the board, who sits on it and how it links back to local communities, but I am afraid I gave up. Perhaps the Minister will help us with that.

Some big and controversial decisions need to be made about the estate, particularly in London, but they are being considered without any engagement with local communities. Not only does that ignore the wellspring of local knowledge that could help avoid a repeat of previous failures, but it fosters a feeling of communities being “done to”, and it makes any change hard—in most cases, impossible—to deliver. Hence, efficiencies that could be ploughed back into local health communities will not be realised.

Communities have been asked to submit estate strategies across their local health communities via the sustainability and transformation plans. They are now being asked to submit bids to a new capital programme, but how will estates run by NHS Property Services and Community Health Partnerships be factored into the mix? In addition to that complicated picture, NHS foundation trusts have their own schemes in play. Control and leverage of community and primary care estates cannot be done at the national level. That simply will not work. We cannot achieve the transformation for the next 10 years that is being talked about without local control of the architecture to deliver it.

When local leaders plan services as part of the sustainability and transformation plans, or whatever the next iteration of that is called, local people must have a say in how those services are delivered. There must be a mechanism to bring those properties, places and assets—and the people running them—back into the sphere of accountability of local health service communities.

Those are not bits of internal housekeeping; they are ways of doing business that are bad for the local health economy, bad for staff and, most importantly, bad for patients and taxpayers. Local communities across the country would like their voice back, and our local NHS would like its money back. The debate needs to do more than shine a light on a problem. I would like the Government to acknowledge that there is a problem and commit to fixing it, because anything less is a dereliction of responsibility and a huge opportunity wasted.

[The Minister for Health (Stephen Barclay)]

It is a pleasure to serve under your chairmanship once again, Ms Dorries. I pay tribute to the hon. Member for Bristol South (Karin Smyth) for bringing such an important issue before the House.

The hon. Lady opened by saying that property may not be the most exciting of topics but, as her speech set out, it is integral to the healthcare service offered in local settings. The substance of her remarks was whether we can better align the property estate with a place-based approach to healthcare. As we move to a more integrated and place-based approach to health, I think there is cross-party consensus that property has an important role to play as an enabler of that. The hon. Member for York Central (Rachael Maskell) kindly recognised that that is very much the approach that I have taken in my post, and my hon. Friend the Member for York Outer (Julian Sturdy) recognised it in expressing his frustration with one or two meetings and asking whether decisions on property are aligned with the place-based approach.

The first point I will make to the hon. Member for Bristol South is that the long-term plan and the future discussions about the NHS give us the opportunity to look at wider system changes around integration and place-based healthcare, and how property aligns with that—for example in York, which has been discussed—as an enabler of change in a more holistic approach. As such, her remarks are timely as part of that wider debate.

The hon. Lady mentioned Knowle West health park, which, if I am honest, I looked at for the first time when preparing for the debate; I was not as sighted on that as I might have been. The issue is that, if NHS England provided that service, the additional market rent costs would have been reimbursed, but because it is provided by the county council they are not. However, as she recognised, there has been progress in recent weeks, thanks in part to her work. I am happy to take forward a discussion on that offline if that would be helpful, because I recognise that it is an important service and that we need to ensure that, where market rents are applied, it is not counterproductive to those services.

However, that should not get in the way of the wider point. The hon. Lady suggested that the new approach is a backwards step. I simply point out that there has actually been significant progress by NHS Property Services. The previous model had the inherent conflict that the primary care trusts were both the landlord and commissioner of the property, and therefore the use of the estate was quite opaque. As a result, we did not get transparency on the true cost of the estate, meaning that inefficiencies were not being flushed out and estates were not being utilised in the most effective way.

One driver of NHS Property Services applying market rents has been the need to encourage better utilisation of the estate by being more transparent on the actual costs. I point out to the hon. Lady that there has been significant progress as a consequence. Some £200 million in capital receipts has been unlocked, 500 capital investment construction projects are being launched each year and running costs have been reduced by £120 million. On balance, as we look forward to the long-term plan and pick up on some issues that the hon. Lady quite rightly highlighted, it is also important to recognise that the old system often allowed estates to be utilised inefficiently. Having truer market rents has actually enabled more transparency and driven efficiencies, with savings then able to be reinvested into the service.

The hon. Lady also mentioned salaries and bonuses, which again are part of a wider question. On the one hand, these are big businesses and their leaderships compete in a competitive market. There is a wider debate within Parliament on the right value to assign to senior salaries in the public sector in order to attract talent. These are big budgets, so we need to attract people of the right ability; it is a false economy to save a relatively small sum on lower salaries for people who then make incorrect decisions that waste much larger sums. At the same time, salaries should reflect the values of the NHS and should not be out of step with others in the NHS. There is a cross-party debate on that, and I am interested in the hon. Lady’s points about it.

The hon. Lady also raised NHS Property Services’ new offices. My understanding is that the previous model was highly inefficient. It had five different properties, so the move to Gresham Street was a consolidation of those five properties into one. That drives productivity, which is a key issue that we need to unlock within the workforce. Two thirds of NHS costs are in the workforce, so driving workforce productivity is a key objective. I am sure the hon. Lady will agree that the workforce being consolidated in one office enables a degree of productivity and efficiency that would be harder to achieve if they were disparate across five areas.

The hon. Lady mentioned the impact of the rent adjustment on Bristol. Some 15 GP practices in and around the city of Bristol occupy NHS Property Services sites. NHS England has been working with the Avon local medical committee, practices, NHS Property Services and the Bristol, North Somerset and South Gloucestershire clinical commissioning group and has facilitated negotiations between GP practices and NHS Property Services on reviewing the levels of rent and service charges invoiced to GP practices, to ensure that there is transparency on them.

However, as the hon. Lady will be aware, rent and business costs incurred by practices are reimbursed to GPs under the premises cost directions, and GPs should be compensated for any rent changes through that route. The Department has provided an additional £127 million to the NHS England mandate, with effect from the 2016-17 financial year, to fund the increased costs in the NHS of this policy change.

[Karin Smyth]

I am grateful for the Minister’s comments about, and work on, Bristol. I agree that the estate was not always particularly well managed in the local health system previously, and that the correct incentives are needed. However, does he agree that he has outlined a merry-go-round of money keeping the entire system afloat? NHS Property Services exists on a large and continuing Department of Health loan, so it is not, in any sense—as the Minister described—a successfully run property business.

[Stephen Barclay]

I was trying to make the point that greater transparency on the true cost of the estate drives behaviour to use the estate more effectively. Part of the difficulty has been that, because the estate was not adequately charged market rents in some areas, moving to a fairer and more transparent assessment of market rents—these things are independently assessed, I hasten to add—is a difficult adjustment. However, a consequence of correctly assessing the value of the estate is the unlocking of efficiencies where the estate is not being utilised, and that money can then be reinvested into the system.

I absolutely agree with the hon. Lady’s wider point, which I took as the substance of her remarks, that property is the enabler of system change. That also came out in the points raised by my hon. Friend the Member for York Outer, and has been inherent in points made by the hon. Member for York Central in our previous discussions. Property does not sit in a silo but is inherent in the wider service offering, and it also plays into reconfigurations. A key part of clinically led reconfigurations of estates to drive productivity will be what property there is to enable that and how to utilise it.

The point on which there is a degree of cross-party consensus, as my hon. Friend the Member for Henley (John Howell) recognised, is that decisions need to be accountable. Likewise, I am happy to pick up on the point he raised on behalf of his constituents about there being no accountability. That is an absolutely fair challenge to the Department and one that I am very happy to look at. However, I am mindful, as I know he will appreciate, that these are often independent bodies making independent decisions, and we need to look at how they fit into the system.

A further point raised by the hon. Member for Bristol South, although it is slightly outside of the scope of the debate, was about wholly owned subsidiaries, which she also raised in more detail in the estimates debate. I make two points. First, as she knows, subsidiary companies actually give greater flexibility to trusts that want to compete in a local market and perhaps offer higher salaries offset by changes to pensions. That is one way in which trusts are empowered and enabled to hire in a competitive market, for instance in the case of maintenance staff. It is an enabler, and it often results in people getting paid more for a role, although there may be other, less favourable terms and conditions to offset that. I merely point out that those were exactly the arrangements reached for Members, and I do not remember too many press headlines suggesting that Members were being exploited by that change.

Secondly, I remind the hon. Lady that, as I am sure she is well aware, legislation introduced by the last Labour Government enabled wholly owned subsidiaries. Again, I do not recall Labour Ministers, when taking that legislation through the House, suggesting that it would provide a way of exploiting NHS workers or privatising the NHS.

I commend the hon. Lady for the points she raised. This is a timely debate given our discussions with the NHS leadership on the long-term plan. She is absolutely right—Government Members and other Opposition Members also recognised this—about the centrality of property to the place-based approach that we seek to take. I am happy to have a separate discussion with her on Knowle Park to check whether that is now in the right place or whether further work is needed. I look forward to further discussions with her on how we should utilise the property estate in the most effective way.

Question put and agreed to.

Department of Health and Social Care and Ministry of Housing, Communities and Local Government

Karin Smyth Excerpts

Monday 2nd July 2018 Commons Chamber

[Karin Smyth (Bristol South) (Lab)]

The first thing that I wish to highlight is my continuing concern about how wholly owned subsidiary companies are being established in the NHS largely to avoid the payment of VAT, which is not what Parliament intended. Although I recently spoke to people at the Treasury about this matter and they did not seem too concerned about the loss of VAT, it is not what Parliament intended in the estimates. It should be of concern to many Members that trusts are being forced down that route.

I also wish to highlight the tremendous work that has been done in the past few years by many of the Select Committees—some of the Chairs are present—including the Public Accounts Committee, on which I was proud to serve for two years. They have drawn attention to the dreadful state in which the NHS has been left over the past eight years, with the lowest growth in spending in any comparable period in its history. That has left a huge backlog of issues.

After several years of warning, tremendous hard work by Committees and scrutiny in this place, we have the welcome announcement on funding. It is just short of the average rise of 3.7%, but we are grateful for what we have got. The Secretary of State has set five tests to

“show how the NHS will do its part to put the service onto a more sustainable footing”.

He has tasked the NHS with improving productivity, eliminating deficits, reducing unwarranted variation, getting better at managing demand and making use of capital. As well as those five tests, he also said that the NHS needed to be back on track on agreed performance standards, on locking in and further building on safety and on transforming care. He went on to say that the Government will transform cancer care and move money into mental health to deliver parity of esteem. That is quite a list.

[Fiona Onasanya (Peterborough) (Lab)]

Does my hon. Friend agree that mental health has not been given parity of esteem, despite the 2012 legislation?

[Karin Smyth]

I do agree, as would most Members, I think. There is a strong willingness in the NHS and in the Department to make it happen, but it is very hard to see it happening on the ground.

The Secretary of State said two interesting things in the interviews that followed the NHS funding announcement. First, he said that the money is contingent on the NHS’s delivery of a plan based on the issues that I just outlined. Secondly, he said that the Government would tell us, the taxpayers, in the autumn how we were going to pay for it. I am not a great fan of the monumental paternalism that seems to have overtaken the Government.

This is a huge missed opportunity to talk to the public about the service that they wish to have in this country and how much it costs—and I mean in respect of the entire NHS budget, not just social care. This could be an opportunity to share with MPs the reality in our health economies. Which areas are doing well? Which area is an outlier in costs, in meeting targets, in safety or in other health outcomes? I do not want any more dashboards or league tables, but I do want a way to improve the debate. I want to be armed with information and for us scrutineers to be able to use this opportunity to take what we know from the estimates and the Select Committees and translate that back into our local health economies.

In this debate, we will be talking about billions of pounds. We are having a very amicable debate here this evening; normally, we trade points over who would do better and how we would spend different parts of the money. Even those of us who are MPs and who are experienced and understand the funding and service planning struggle through the local architecture and the decision-making to know what money we need, where it should be targeted and how on earth our constituents will pay for it.

I tried to look at the issues in my own health economy. Members will be pleased to know that I will not have time to go through all its accounts, which I looked at over the weekend. Bristol has been in balance over the past few years, but, unfortunately, our neighbours have not, and the solution has been to join us together, so now we are all suffering under a huge deficit. It was another £30 million last year. We have an £83 million historic deficit—not in Bristol, but in our neighbouring authorities for which we are now responsible. If we run forward with that deficit over the next five years, that is another £150 million, plus, possibly, the £83 million that we already have. We are then getting very close to the £300 million that the £20 billion equates to in our local health economy.

All hon. Members can take the £20 billion and equate it with their own health economies and start to see what that money will really buy. The £300 million that this may equate to is also roughly equivalent to what the sustainability and transformation partnership said two years ago that it would be short of. This is a long way round and I excuse hon. Members for not keeping up with the numbers, but what I am essentially saying is that the money will allow us to stand still and not much else.

The coalition Government wanted to liberate the NHS, but instead they put a torpedo in the middle of it, fragmented it and then threw it all up in the air. People have done a remarkable job in keeping it going over the past few years. Why not try a different approach? Why do we not liberate the frontline to talk to us about what this money means? Why do we not look at the real demand in our health economies, what that money is and try to make sense of it for local people? Then we should talk to them about how much it would cost to have the level of service and treatment that they think they want. That would be a really liberating thing to do for all those managers and clinicians on the frontline. Local transparency, local accountability, is the only way to go in starting to square the circle of demand, quality and cost. MPs should not be let off the hook and kept outside the production of this new NHS plan and the way that it will be funded by our constituents over the next five months.

In this 70th year, the best present that politicians could give to the NHS would be to stop piling on the priorities, knowing that the money is not enough to meet them all, and to front up the political choices that we have asked people to make and our constituents to pay for.

NHS Long-Term Plan

Karin Smyth Excerpts

Monday 18th June 2018 Commons Chamber

[Mr Hunt]

The hon. Gentleman is right that community pharmacies have a vital role to play. I do not think we use them enough. We need to find better ways for them to help us in the prevention agenda, and one way we are doing that is by integrating medical records so that they can be accessed by pharmacies, which will help them to give good advice to patients.

[Karin Smyth (Bristol South) (Lab)]

May I press the Secretary of State on the issue of transformation and his hint—I think—at ring-fencing? If the people of Bristol South are to be asked to spend more money on the NHS, how will they know that it is being used to improve health outcomes and not simply to bail out local hospital deficits?

[Mr Hunt]

The hon. Lady is right to ask that question, and I encourage her to hold her local NHS to account on that. There are some simple metrics, which we can share with her, that can tell us whether the NHS is using the money wisely, and one of them is whether her local hospitals are managing to reduce their emergency admissions by providing better care in the community. She is right that it is the litmus test of whether the money is being spent wisely.

NHS Outsourcing and Privatisation

Karin Smyth Excerpts

Wednesday 23rd May 2018 Commons Chamber

[Mr Hunt]

That is exactly the point. Sometimes the quality is high in the private sector and sometimes it is low. When it is low, we will clamp down hard just as we do with the NHS.

[Karin Smyth (Bristol South) (Lab)]

I am listening carefully to the Secretary of State’s comments on ideology and the Health and Social Care Act 2012. He will remember that I, in a CCG, was implementing the 2012 Act. Is he saying that he is proud of the Act and that it has worked out as intended?

[Mr Hunt]

As Chinese Premier Zhou Enlai said about the French revolution, it is too early to tell.

As my hon. Friend the Member for Solihull (Julian Knight) alluded to, there is one ideology that we will not compromise on: our belief that the NHS should be free at the point of use and available to all. And why will we not compromise on this? It is because, contrary to Labour’s creation myth about the NHS, it was a Conservative Health Minister, Sir Henry Willink, who first proposed it in 1944. Here are his words from 1944 announcing the setting up of the NHS:

“Whatever your income, if you want to use the service…there’ll be no charge for treatment. The National Health Service will include”—

[Interruption.] I know this is difficult for Labour Members, but let me tell them what the Conservatives said when we were setting up the NHS:

“The National Health Service will include family doctors”

and will

“cover any medicines you may need, specialist advice, and of course hospital treatment whatever the illness”.

Nye Bevan deserves great credit for delivering that Conservative dream, but let us be clear today that no party has a monopoly on compassion, and no party has a monopoly on our NHS. There are some other myths—

--- Later in debate ---

[Karin Smyth (Bristol South) (Lab)]

The biggest issue facing the NHS is the money and the workforce, and going into that mix, we have these wholly owned companies. They are a wheeze to gain income, but the consequences are deeply troubling. They drive further fragmentation of the NHS and, when collaboration should be growing, we instead see each trust going its own way.

If these changes for wholly owned companies were driven by service improvement and the appetite of staff for change, the managers and boards of the trusts would be doing their jobs, which is to identify the need for improvement in these services and to speak to their staff about how to achieve it. However, in almost every case, the changes have been progressed in secret, with little or no staff engagement or consultation and with no documents being made public. It is very hard to get the documents from these trusts. Worse still, we are now in an uncontrollable hiving off of NHS assets to these new companies, with no discernible safeguards to prevent the assets, or indeed the whole company, from being sold off to anyone else. They are one step away from being taken outside the NHS to any other provider.

In response to some of my written questions, I have discerned a bit of change in the Government on the NHS. I asked how many trusts have had to change the terms of their authorisation, which was a requirement in the Health and Social Care (Community Health and Standards) Act 2003, to protect the transferred assets. On 11 May, the Government said:

“There is no requirement to change the terms of authorisation when setting up a wholly owned subsidiary and therefore, the Department does not hold the information requested. If trusts hold community interest assets then these are considered public assets and cannot be sold unless subject to a Departmental/Secretary of State approval, however this is only a limited number of assets.

For other assets trusts should consider whether transactions are ‘reportable’ under the transactions guidance and therefore would be subject to a review if above the thresholds outlined.

NHS Improvement has committed to:

The proposed creation of subsidiary companies becoming a reportable transaction to NHS Improvement under the Transactions Guidance, irrespective of size; and”

NHS Improvement will be looking at “subsequent changes”.

While a tick-box exercise and oversight by NHS Improvement is welcome, that is closing the door after the horse has bolted. In answer to another question about continued onward sale, I was told that there would be restrictions where disposal would affect commissioner-requested services. The 2003 Act does not say that. Section 16 talks about NHS foundation trusts not disposing of protected property

“without the approval of the regulator”

and says that protected property is the

“property of the trust designated as protected in its authorisation.”

I think there has been a change in that period and I would like to understand why. If the Minister cannot answer that today, I am happy to write to him.

We have essentially no assurance as to how the transfer of these wholly owned companies to any private bidder, one step on, can be stopped. How would local people ever know? How would the staff now? We cannot get any information from most of these trusts. They are not answering FOI requests and that is why this is essentially of such continued concern.

The first step to remedying this shambles would be to close the VAT loophole, which I do not have time to talk about today. Meanwhile, NHS Improvement should not be encouraging the recreation of a two-tier workforce, especially at a time of such overwhelming concern about the availability of a skilled workforce. This is ever more important with Brexit looming. NHSI is a Government body funded by the taxpayer and accountable through the Secretary of State to Parliament. That it is encouraging and permitting these deals, and doing so in secret, is a disgrace. It should not be allowed. As NHSI is subject to ministerial oversight, the Secretary of State needs to tell it to stop it.

NHS 70th Anniversary

Karin Smyth Excerpts

Wednesday 16th May 2018 Westminster Hall

[Karin Smyth (Bristol South) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Hosie. As my hon. Friend the Member for Blaenau Gwent (Nick Smith) said, the antecedents of the NHS are to be found in Tredegar and in the Beveridge report, which preceded it. Disease was one of Beveridge’s five great evils. Infectious diseases such as polio, diphtheria and tuberculosis caused people to die in their early and mid-50s on average. The need for a sufficient and healthy labour force to rebuild the economy necessitated combating those diseases, which also caused a high rate of infant mortality. The need for a better, longer-living workforce drove much of what Beveridge looked at.

There was in fact a good deal of state funding provision before 1948 to cope with the devastation of disease, but what Bevan did, against tremendous opposition within the service and politically, was to centralise the system, nationalise hospital provision, create standards across the country and, crucially, give people the assurance that they would always be seen and treated, based on their need, not their ability to pay.

The health service was built on a tripartite structure of hospital, GP and community services. In return for good terms and conditions, clinical freedom and autonomy in the system, the doctors finally agreed and the NHS was born. It was a wonderful achievement, but it was also a wonderful compromise. Over the past 70 years, the tensions in that compromise—the local versus the national, the role of clinical autonomy, priorities and the quality of the service—have regularly surfaced. There are always crises—astonishingly, every year there is a winter.

We now treat 1 million people every 36 hours, and employ nearly 2 million people. We are very grateful for everything they do, and we celebrate them today on this 70th year. However, the challenges are different today, and the service should therefore be different in the next 70 years. This anniversary is an opportunity to celebrate the achievement, revisit the compromise and set a course that is as resilient for the next 70 years. The diseases that are with us today—cancer, and cardiovascular, respiratory and liver disease—are very different. Depending on a person’s social class, dietary risks, tobacco and obesity are the biggest contributors to early death and disability. Alcohol and drug misuse, and lack of physical activity, are also key. We are finally starting to appreciate the impact of mental health and social isolation on physical health.

Life expectancy has increased, but the prevalence of people living with one or more limiting long-term illnesses has changed the picture of healthcare demand, and that requires the system to change. In Bristol, women live an average of 64 years in good health, but a further 19 years in poor health. For men, the figures are 63 and 15 years, but that average masks a huge range in social class. Several areas of my Bristol South constituency are in the bottom 5% in England for male life expectancy. In 2010 the Marmot review told us that such health inequalities cost us approximately £36 billion to £40 billion in lost taxes and costs in welfare and to the NHS—that is a huge amount of money. We must prevent and manage life-limiting diseases and address the silent misery of families who support and cope with people living with them.

Accountability is a major issue for the service in the next 70 years. We need to start treating patients and the public as assets to the health service, not as nuisances. We need somehow to introduce democratic accountability into decision making. The complex fragmentation of the health service makes it wholly unclear where responsibility, and hence accountability, lies. From the bottom up, hundreds of bodies are involved. The 200-odd clinical commissioning groups are members’ clubs with no element of either direct or representative democracy, and they are plagued with conflicts of interest. At the top, there is not just the Department and Ministers, but a raft of arm’s length bodies, which Members of Parliament find it impossible to navigate. I worked in the system for a CCG, and I still find it really difficult—it is an absolute mess.

One reason for the mess is the disaster of the Health and Social Care Act 2012, but the NHS has been poor on accountability since the early centralisation. It has always been fragmented in a way that makes accountability harder, and it has always seen itself as separate from the rest of the local system, which has democratic accountability. That is a problem. It has always been riven by powerful vested interests that distort the general accountability. That is a key part of Bevan’s compromise, and I think we need to revisit it.

Presented with a well-made case that is supported by, dare I say it, experts or informed leaders, the public will make difficult decisions. I know local politics can make things difficult when tough issues such as service changes are necessary, but excluding people does not make that any easier. Making a hard case to local people and their MPs is challenging work, but if that does not happen decisions gain no legitimacy. We can keep the “N” in the NHS, but we need to give local people far more control to make it more resilient for the next 70 years.

It looks like we are going that way. We have heard about the experience in Scotland, and this is also a devolved matter in Wales. Very interesting things are happening in Manchester, but we need a much better debate about what local looks like. We must recognise that the key issues for now are the money and the workforce. Technology gives us huge opportunities, including on some of the workforce issues.

I want to finish by talking about leadership. I joined the health service as a manager in the late 1980s, and I am very proud of the role that managers play in the services. General management, which was introduced in the 1980s, has few friends, partly because it was associated with the Thatcher era of reforms, and partly because it threatens clinical autonomy and freedom, which were fundamental to Bevan’s compromise. We should use this anniversary to celebrate managers and leadership in the NHS. We need good clinical and non-clinical managers to make the changes we want to see, deliver the efficiencies we need and keep making the system safer. I hope that they can also help leaders make the NHS more open and accountable. We need that for the next 70 years.

--- Later in debate ---

[Mrs Sharon Hodgson (Washington and Sunderland West) (Lab)]

Mr Hosie, it is a pleasure to serve under your chairmanship this morning in this very important debate.

I start by thanking my hon. Friend the Member for Blaenau Gwent (Nick Smith) for securing the debate and for his excellent speech. He is rightly proud of his roots in his wonderful constituency and the connection that it holds with Nye Bevan and the founding of the NHS. I am sure that he and his constituents will enjoy the 70th anniversary celebrations, and I look forward to hearing all about them.

I would also like to thank the other hon. Members who spoke this morning for their thoughtful contributions to the debate—the hon. Members for Ayr, Carrick and Cumnock (Bill Grant), for Henley (John Howell), for Caithness, Sutherland and Easter Ross (Jamie Stone) and for Airdrie and Shotts (Neil Gray), who speaks for the Scottish National party, and my hon. Friends the Members for Coatbridge, Chryston and Bellshill (Hugh Gaffney), for York Central (Rachael Maskell) and for Bristol South (Karin Smyth).

This is the first speech that I am giving on the 70th birthday celebrations of the NHS, and it is a genuine honour and privilege to be able to do so here today as the shadow Minister for public health. On 5 July, 70 years ago, the Health Secretary, Aneurin Bevan, was handed the keys to Park Hospital in Manchester, now known as Trafford General Hospital, and launched our national health service. I have my own little photocopied memento of a leaflet distributed before that launch—I wish I had a better copy, but I treasure this one. It says:

“Your new National Health Service begins on 5th July. What is it? How do you get it?

It will provide you with all medical, dental, and nursing care. Everyone—rich or poor, man, woman or child—can use it or any part of it.”

It went on to say:

“But it is not a ‘charity’. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”

The crux of it for our citizens was that they would no longer have to make that awful decision—the choice between debt or, in some unfortunate cases, death. Everyone would now receive healthcare publicly provided and free at the point of use.

I have got my own family anecdote which, as we have the time, I am going to share with you all this morning. I am sure we have all got these family anecdotes. Mine involves my Aunty Ella and my mam. My Aunty Ella was born before the start of world war two and my mam was born in 1945—so you can see straightaway that there is going to be a great anecdote here.

Now, I do not know why—they must just have been unlucky—but in both of their childhoods they suffered from pneumonia. Pre the NHS, when it was my Aunty Ella who had pneumonia, my nana had to go to the doctor’s surgery every morning, where he would hold out his hand, and into his hand she would place a coin—a shilling or whatever. Then she would hold out her hand and into her hand he would place a tablet—obviously, penicillin or some form of medicine. Then she would go home and give it to my Aunty Ella. This went on nearly a week.

My nana was very poor, working class, and she says that in those days, in order to get the money to get that tablet, she would pay a visit to the pawn shop on her way, and pawn whatever was valuable to her at that moment. It tended to be sheets, or a son’s suit or her husband’s suit. She did that in order to get the tablet.

Now fast forward to when my mam, who was born in ’45, got pneumonia, after the health service came in in ’48. My nana did not have to pawn anything; she did not have to go to the doctor’s surgery at all, because a district nurse knocked on the door every day and went upstairs to where my mam was lying in bed with pneumonia, gave her an injection and left. No pawning of sheets, no handing over of money, no stress—that was the difference. Therefore, all of us—I do believe that it is all of us—are committed to those founding principles. We on the Opposition side of the House especially, will continue to fight against the privatisation of our NHS for those reasons.

To quote a phrase often falsely attributed, I now understand, to Bevan, but one I repeat because it rings true no matter who said it:

“The NHS will last as long as there are folk with the faith to fight for it.”

I am pleased to say that 70 years on, there are still plenty of people with the faith left to fight for it. I hope that we will all—though maybe not us personally—be celebrating our NHS for 70 years more, and 70 years after that, and so on. It changed the lives of people then and it is still changing the lives of people today.

Bevan had huge ambitions, but he never would have imagined all those years ago the successes we have had in medicine because of the development of the NHS. I will talk about a few of them now. In 1952, Francis Crick, a British scientist, and James Watson, an American student, made one of the most important scientific breakthroughs of the 20th century, when they discovered the molecular structure of DNA. The discovery helped revolutionise medical treatments in the NHS and elsewhere, improving prevention and treatment of disease. For example, we know now that a BRCA gene mutation can cause a number of cancers in both men and women, who now have the option to have preventive surgery in order to reduce their risk of developing cancer.

In 1954, Sir Richard Doll, a British scientist, published a study in The British Medical Journal co-written with Sir Austin Bradford Hill, which established the link between smoking and lung cancer. That very important study has since led to increased smoking cessation policies from successive Governments, including the ban on smoking in public spaces by the Labour Government in 2006 and the current Government’s—and the Minister’s—tobacco control plan. Smoking prevalence is decreasing across the country, and I am pleased to say that smoking rates in the north-east are declining faster than the national average, thanks in no small part to support from programmes such as Fresh North East, which has seen around 165,000 people quit smoking since 2005.

In 1958, vaccinations for polio and diphtheria were launched, to reduce deaths from both diseases. I am pleased to say both those terrible diseases have now been eradicated from the UK. Others, such as TB and MMR vaccinations, have now become a key part of NHS prevention work. We were in this Chamber just two weeks ago debating the extension of the HPV vaccination to boys after its successful roll-out to girls in order to prevent cancers caused by that virus. Bevan could never have imagined such developments—or maybe he did, such was his vision.

In 1960, doctors at the Royal Infirmary of Edinburgh completed the UK’s first kidney transplant, using a set of 49-year-old twins. Incidentally—perhaps it was the pneumonia—my Aunty Ella, who I have mentioned once already, went on to have kidney failure; and just a decade after the first transplant in Edinburgh, she became one of the first to receive a kidney transplant in Newcastle Freeman Hospital. That helped her live long enough not only to see her own children grow up, but to see her first grandchildren born. In 1968, a team of 18 doctors and nurses at the National Heart Hospital in London, led by surgeon Donald Ross, carried out the first heart transplant in this country. There are now more than 50,000 people living with a functioning transplant thanks to organ donation and transplantation in the UK, giving them more time to spend and treasure with their families.

In 1988, breast cancer screening was introduced, offering mammograms to women over 50. We have now increased the number of women who are eligible for breast screening. That helps with early diagnosis and survival rates, which are now at 78% for 10 years or more—excellent figures. None of this would have happened if it were not for our NHS and the everyday heroes that work within it. The NHS is the UK’s largest employer, with over 1.5 million staff from all over the world and more than 350 different careers. Those people are kind, caring and passionate about their patients. They just want to get on and do their job, but sadly, they are finding this more and more difficult, with funding cuts and thousands of unfilled vacancies, when more and more is expected of them.

We on the Opposition side of the House do not take our NHS or the workforce for granted, and neither should the Government. It has to be said that for the last eight years, the NHS has been in crisis. We have ever-growing waiting lists, patients waiting on trolleys in overcrowded hospitals, and people being told not to go to A&E unless it is an absolute emergency. Earlier this year, the Prime Minister announced a funding plan to mark the 70th anniversary of the NHS. I hope the Minister will inform the House how much of that funding will go to improving and establishing public health services. There is a huge funding gap within the NHS, but with the right public health services we can help people to live healthier lives and support them in their endeavour to do so, which, in turn, will save money.

It is estimated by the King’s Fund that since local authorities became responsible for public health budgets in 2015, on a like-for-like basis, public health spending has fallen by 5.2%. That follows a £200 million in-year cut to public health spending in 2015-16 and there are further real-term cuts to come, averaging 3.9% each year between 2016-17 and 2020-21. On the ground, that means cuts to spending on tackling drug misuse in adults—cut by more than £22 million compared with just last year—and smoking cessation services—cut by almost £16 million. Spending to tackle obesity has also fallen, by 18.5% between 2015-16 and 2016-17, again with further cuts in the pipeline in the years to come. These are vital services for local communities, which would benefit their health and life expectancy, but sadly, they continue to be cut due to lack of funding.

As my hon. Friend the Member for Blaenau Gwent said in his excellent opening speech, an ounce of prevention is better than a pound of cure—a line that I will certainly be stealing for future speeches—and that is why, 70 years on, we must focus on public health initiatives. That is why I am so pleased that he made today’s debate about public health, rather than its just being on the 70th anniversary generally. Not only can such initiatives help people live healthier lives, but they will save the NHS—and, in turn, the Treasury—money. I think the technical term for that is a no-brainer.

In closing, I will return to Bevan’s wise words. He said:

“No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.”

This Government have the means to make people in this country some of the healthiest in the world. I hope that they will take those means and ensure that vital public health services are provided to society to do just that.

[Karin Smyth]

My hon. Friend is making an excellent speech, as usual. Does she agree that one of the issues with devolution, and some of the experimentation we have seen, is the separation of knowledge between the health service and providers of our public services, particularly in England? We can learn from the experience that has been gained, particularly in Wales, where there is much more integration between those areas, and transfer the learning about public health that has come into local authorities, so that they understand the need to work better with local health services.

[Mrs Hodgson]

Absolutely. That point had not been covered, so I am pleased that my hon. Friend has made it. There is best practice in Wales, and even in Scotland—we are always hearing in these debates about some of the wonderful things going on in Scotland, aren’t we, Minister? We should learn from where there is best practice. Where good things are happening, that knowledge should be spread across the NHS, especially if it will lead to better public health and, in turn, save money.

I was just coming to the end of my contribution. I just wanted to say that we want to go on to see more successes, such as the ones I listed earlier, over the next 70 years. I am sure we will. With medical technology and science the way they are, we probably cannot even imagine the sorts of advances that we will see. I hope those will all be within the publicly funded national health service that we are all so proud of, for many years to come.

Learning Disabilities Mortality Review

Karin Smyth Excerpts

Tuesday 8th May 2018 Commons Chamber

[Caroline Dinenage]

My right hon. Friend is right to raise the Mencap report, because in many cases it reflects the recommendations that have been put forward in this particular report. The mandate to NHS England requires a reduction in the health gap between people with mental health problems, learning disabilities and autism and the population as a whole, and requests support for them to live full, healthy and independent lives. That is something that NHS England has a mandate to deliver, and we of course support it in doing that.

[Karin Smyth (Bristol South) (Lab)]

If it is a crime to politicise the vulnerability of some people and the Government’s cuts, I stand guilty as charged. Further to the question from my hon. Friend the Member for Leicester West (Liz Kendall), what we have seen since 2013 is the complete decimation of services working together on the ground. This is a local government and health issue locally, so may I press the Minister to tell us what action will be taken to make this happen at local level?

[Caroline Dinenage]

It is not about that. This is about inquiring into the deaths of people who have died in our care. Despite all the really difficult decisions we have had to make to deal with the financial challenges this country faced, which the hon. Lady’s party will be well aware of, we have made progress on this issue in terms of transforming care and the healthcare checks on people with learning disabilities, and this very report on the learning from deaths programme proves how absolutely committed we are to ensuring that not one single one of those deaths goes unrecognised or uninvestigated.