Healthier Together Programme (Greater Manchester)

Lisa Nandy Excerpts

Tuesday 22nd July 2014 Westminster Hall

[Kate Green]

The hon. Gentleman is absolutely right, and I am pleased to see that the hon. Member for Macclesfield (David Rutley) is also present this afternoon. The ripple effect of the consultation, on hospitals in neighbouring areas and indeed—as I will go on to talk about—on the wider north-west and northern region of the country is quite significant in one reading of what is going on.

It is true that the pressures of rising demand on the NHS are well recognised, as are the cost constraints on social care provision. However, my constituents in Trafford were told all that three or four years ago, and we went through our change programme. We feel that we have been here before and, for us, this is groundhog day and a bit worse than that. We underwent the consultation “A New Health Deal for Trafford”, which took place in 2012 and culminated in the downgrading of Trafford general hospital. Looking at how the current consultation has been launched, I am concerned that a number of lessons that were learned from that Trafford process are being totally ignored.

I say clearly that I am not against sensible reconfiguration of acute services. I am very much in favour of concentrating expertise and specialisms in a small number of expert sites. I am entirely in favour of as much provision as possible being pushed into the community to front-line, preventive, community-based care, and of keeping people at home to receive that care for as long as possible.

However, if this is a consultation about the provision of integrated community-based care, it is not possible to go down the road of consulting about that provision and withdrawing services in acute settings before we are clear what the landscape and the reality of that community provision is. Nor is it possible to go down the route of suggesting that some acute services might be rationalised or closed when existing acute services are under so much pressure already. In particular—I know that my hon. Friend the Member for Wythenshawe and Sale East (Mike Kane) will talk about this issue too—one consequence of the downgrade of Trafford general hospital’s accident and emergency provision is that during the past nine months the waiting times and queues at Wythenshawe hospital have been significant, with little sign yet that they will be reduced.

In addition, I point out that we have some real uncertainty. My hon. Friend the Member for Blackley and Broughton mentioned the uncertainty that exists around trauma services, maternity services and so on, but we also have uncertainties in Trafford in relation to some of the primary provision that will be in place. We know that the NHS local team and the clinical commissioning group envisage a two-hub model of primary care and community-based care for our borough. The provision in the south is largely established, but in the north—including in my constituency, where we have some of the worst health outcomes in the borough—we are still completely unsure what sort of hub will be put in place, as the NHS local team and NHS England are quite unable to tell us what the funding for that kind of hub model will be.

I know that the Secretary of State for Health is aware of that particular situation and I am grateful to him and his office for what they are doing to try to unscramble it, but from the point of view of my constituents the idea that they will be consulted on a major reconfiguration, either of primary care or of acute services, does not inspire their confidence, because currently they simply see deficiencies in those services and particularly because they believe that their voice counts for little when it comes to the decision that will ultimately be taken.

Not only is there pressure in the system, but the NHS seems to make some really perverse decisions as it goes along, because of its rather hand-to-mouth approach to planning this kind of reconfiguration and strategic change. When the decision was taken to downgrade the A and E services at Trafford general hospital, the hon. Member for Altrincham and Sale West (Mr Brady) and the late Paul Goggins, my good friend and former colleague, managed between them to secure around £11 million of new investment in Wythenshawe hospital to provide for the extra capacity that it would need. We are now unclear, of course, about what will happen with that £11 million of investment; it would be good if the Minister could put it on the record today that it will continue. Given that the hospital cannot envisage even its short to medium-term future, that is a worrying situation.

We saw something similar in Trafford, when investment of around £300 million in the intensive care unit was pretty well written off two years later when the new health deal for Trafford was implemented and the ICU was closed down. That may have been the right decision, but it was certainly a waste of money if investment was being poured into a hospital just two or three years before the whole status of that hospital was changed.

[Lisa Nandy (Wigan) (Lab)]

I am grateful to my hon. Friend for giving way, and I apologise for being late for the start of this debate, Mrs Riordan.

Does my hon. Friend agree that part of the problem with the process is that it does not take into account the particular needs, circumstances and history of our individual communities? For example, in Wigan we have invested in a number of our specialist services. However, we are a big borough, we have our own particular health challenges and we have real transport issues as well, which are different from those affecting other areas of Greater Manchester. Quite simply, a centrally driven top-down process that lacks any kind of democracy whatever, as far as I can make out, is not capable of delivering the sort of services that we need in our areas.

[Kate Green]

I absolutely agree with my hon. Friend, and the issue about democracy that she raises is one that we are all particularly concerned about.

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[Lisa Nandy]

I agree with almost everything the hon. Gentleman has said. Is not the tragedy of this process that, as he and my hon. Friend the Member for Blackley and Broughton (Graham Stringer) said, most of us could get behind some principles underlying the proposal, including greater care in the community locally when people need it, greater specialism and supporting people to get care outside hospital? There is consensus on all those things, but the way the process has been handled, as has been compellingly outlined, has left people feeling that there is simply no point getting involved.

[Mr Nuttall]

The hon. Lady makes a good point. The vast majority of the public would, in an ideal world, like every service to be provided at their local hospital, so that they could have everything just by travelling a couple of miles. In a perfect world, they would have every conceivable treatment available at their nearest hospital. However, they have long since accepted, and we all know, that that is not possible. The clearest example of that in Manchester is, of course, cancer care and Christie’s. People accept that if, sadly, they are diagnosed with cancer, they will have to travel to a specialist cancer care hospital, where they will get better treatment.

It gets a bit more difficult when moving further down the specialism chain. Certainly, we were at the front line in that regard, as were Rochdale and other areas in Greater Manchester, when maternity services were being considered, because people felt that such services ought to be available everywhere. Of course, there are drivers behind this, if truth be known—if truth could be expounded by the health chiefs—in that, whether we like it or not, it comes back to the working time directive, for example, which has had an effect on the configuration of doctors’ working hours.

Medical negligence claims against the health service have also had an impact in this regard. I can understand that, coming from a legal background. People are better protected if they are in an environment where greater numbers of people are working together to watch each other’s backs. That is another driver of these reconfigurations, as some people like to call them.

To get back to the points I was making before that intervention, one of the problems with this consultation, which the hon. Member for Blackley and Broughton mentioned, is that the website and the documents are littered with unintelligible gobbledegook half the time. I am not being patronising, because I do not understand half of it myself, to be perfectly honest. Most people will look at that website and think, “Frankly, it goes over my head.” That will be their general view. I accept that the website and the documents sway wildly the other way as well and have apple pie and motherhood statements that absolutely everyone will agree with, such as “Do I want mum to get that good treatment if she goes into hospital?” No one will say no to that, will they? It is a complete waste of time and effort, and I cannot believe that highly qualified individuals have put together this mishmash of a website and consultation. It is not clearly thought through.

I have no idea of where this will end in terms of the hospitals where there is an option, but I know that my constituents in Bury want access to an accident and emergency department at their local hospital. Going back to what I said about the specialism ladder, by definition, one expects things such as accident and emergency to be available at the nearest general hospital. That is what my constituents will be looking for. If these services are salami-sliced away from Bury, my constituents will be concerned that they will be left with a hospital in name only—one that does not provide them with the services that they have come to expect.

I echo what has been said about Healthwatch England. Bury Healthwatch has e-mailed me and wants me to put on record its concerns about its involvement in this process. I appreciate that it is a new body, but clearly there are problems with the introduction of the legislative order for clinical commissioning groups, the Legislative Reform (Clinical Commissioning Groups) Order 2014. Healthwatch England has written to the Secretary of State about that. I understand that the order will come into force on 1 October. I can only assume that, to meet that deadline, those problems will be dealt with in our September sitting.

To be perfectly honest, demand for health care services will always outstrip supply, under any Government. It does not matter whether it is a Labour Government or a Conservative Government; people’s desire to be healthy and their need to feel that they and their loved ones are receiving the best possible treatment will always result in demand being greater than the ability of the public purse to meet that demand. That is of course largely driven by the fact that so many people think that our NHS is free. Of course it is not free. We all know that it is not free.

In the current year, the NHS is spending something like £119 billion. It is a huge consumer of public funds, and rightly so. It is right that the Government have protected the health care budget. Notwithstanding that, there are pressures, because the population is getting older and new treatments are being discovered and becoming available all the time. I am grateful for the opportunity to put on record my constituents’ concerns, and I am conscious of the fact that others want to put similar concerns on the record.

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[Jonathan Reynolds]

I do agree. That is a matter of extreme concern to me. My understanding is that we have been given a cast-iron pledge that there will be no hospital or A and E closures as part of Healthier Together. The problem with all hospital reconfigurations anywhere—it happened with the maternity services consultation—is that they always appear to people to be about cuts. It is hard to get across the argument that they are about improving services. There is some mixed messaging about the primary outcome of such a process.

My principal problem with specialisation is the one that arises with specialisation in any field. Greater Manchester’s geography makes it hard to get from one borough to another. Public transport and the railway system are not configured to operate in that way. I should love the opposite to be true—if we had the resources and local autonomy to make public transport work differently. That will come one day, I think, but it is not true at the minute. I did not by any measure expect to become an MP in the 2010 general election, and my daughter was booked in to be born at St. Mary’s, because I worked in the centre of the city and it was easier to have appointments there than to get back to Tameside for them. Frankly, we were concerned about the possibility of labour starting in Tameside at the wrong time, because of the journey to get to St Mary’s and what that might mean. I think that that would be the same for many people, whatever the health issue: the journey is not easy in a car, but by public transport it is almost untenable. That would be people’s primary concern when they thought about the outcome of such a consultation

[Lisa Nandy]

I am grateful to my hon. Friend for raising that matter, because I do not think that the Healthier Together team has given it enough thought. My constituency has not only chronic transport problems, including traffic and the fact that some areas of the borough are densely populated and quite far from the existing hospital, but also large, tightly knit families who often do not have a huge number of resources. When a loved one is suddenly taken ill, the whole family wants to visit, which is particularly problematic and something that the team has not thought about. Does my hon. Friend agree?

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[The Minister of State, Department of Health (Norman Lamb)]

It is a pleasure to serve under your chairmanship, Mrs Riordan. I congratulate the hon. Member for Blackley and Broughton (Graham Stringer) on securing the debate. The opportunity to debate important issues at the start of a process is welcome. I also thank my hon. Friend the Member for Bury North (Mr Nuttall) and the hon. Members for Wythenshawe and Sale East (Mike Kane), for Stalybridge and Hyde (Jonathan Reynolds), for Stretford and Urmston (Kate Green) and the shadow Minister—[Interruption.] I thank my hon. Friend the Member for Harrogate and Knaresborough (Andrew Jones) for ensuring that I also thank the hon. Member for Wigan (Lisa Nandy) for her important interventions.

The impression that I got from all hon. Members is that there is a recognition that things need to change and of the importance of developing an integrated system of out-of-hospital support and strong primary care. Some hon. Members also recognised the importance of specialisms in specific cases, but concerns centred on the nature of the consultation. The shadow Minister was extremely fair in describing the process’s objective as a good one and the hon. Member for Wythenshawe and Sale East said that the aim is right, so there is something of real value to achieve here if it is possible. I completely understand, however, why hon. Members feel the need to speak up for and express concerns on behalf of their communities.

[Lisa Nandy]

rose—

[Norman Lamb]

I will give way in a moment, but I was about to comment on the intervention of the hon. Lady, whom I rudely left out of my list earlier, in which she mentioned the lack of democratic legitimacy. The reforms have strengthened legitimacy. Until the reforms, there was no local democratic accountability for the NHS, but every area now has a health and wellbeing board. Interestingly, Lord Peter Smith, who I think is from the hon. Lady’s own community, said:

“We accept the case for change made in this consultation document…Remember it is not buildings that deliver good health care, it is the dedicated NHS staff who make it possible.”

To pick up on the point made by the hon. Member for Stalybridge and Hyde, Lord Smith, a local Labour leader, also talked about the move being towards greater integration:

“We are clear that this improvement in integration and in GP services needs to be up and running before the changes to the hospital services are introduced”—

clear support there for the objective.

[Lisa Nandy]

The Minister is right. Like the leader of my council, I accept the case for greater integration. I wanted to make one point, because the Minister seems to be suggesting that the concerns centre only on the consultation. I have a real concern, which I am not sure has been expressed clearly so far, about how the consultation sets up hospitals as either specialist or local.

My hospital specialises already, and it is rightly fighting to retain that because good outcomes are delivered. That does not mean that my hospital can, or should, do everything. Indeed, many of my constituents travel, for example, to the Christie for cancer care, as the hon. Member for Bury North (Mr Nuttall) said. There is, however, a real issue about some hospitals being specialist and some being local, but with nothing in between.

[Norman Lamb]

I take that concern on board, and the hon. Lady should respond to the consultation. It is really important for hon. Members to do that.

Incidentally, I should say something on behalf of my hon. Friend the Member for Cheadle (Mark Hunter), because he is a Whip and so is unable to speak in the debate, although he has attended it all. He has expressed particular concerns about the potential implications for the University Hospital of South Manchester and Stepping Hill, and about options 4.1 and 4.2. It is important that I place that on the record.

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[Norman Lamb]

The hon. Lady has moved on, so let me make some progress.

It is important to recognise that we are discussing proposals that originated with local clinicians. Dr Chris Brookes, who is not a politician or a bureaucrat, who too often get condemned, but an accident and emergency consultant and a medical director of Healthier Together, says—

[Lisa Nandy]

Will the Minister give way?

[Norman Lamb]

May I make this point? I am sure that the hon. Lady will be interested to hear it. Dr Brookes said:

“Currently, there are too many variations in the quality of treatment, whether its emergency surgery or getting to see a GP when you need to. Not one of our hospitals in Greater Manchester meet all the national quality and safety standards.”

I am sure that all hon. Members present are concerned about that. He goes on to say something which, if we think about it, is shocking:

“At present your chance of being operated on by a consultant surgeon in an emergency at the weekend is much less than midweek. Your chance of recovering well from surgery carried out by a consultant is greatly improved.

But it’s not just about hospitals. It’s about access to a GP, and better community-based services—more services provided locally or at home and joining up the care provided by local authorities.”

That is a clinician making the case for integration.

Before I turn to the Healthier Together changes, it is probably best to make a few points about service changes in the NHS generally and Government policy towards them. The Government are clear that the design of health services, including front-line services and A and E, is a matter for the local NHS and, critically, the health and wellbeing boards, which have democratic accountability. Our reforms put doctors in charge of the care that people receive and how it is delivered to best serve their populations.

The NHS has a responsibility to ensure that people have access to the best and safest health care possible, which means that it must plan ahead and look at how best to secure safe and sustainable NHS health care provision—not only to meet today’s needs, but to plan ahead for next 10 or 20 years.

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[Norman Lamb]

I really cannot. I have been pretty generous in giving way many times, so I will make a bit more progress.

It is therefore for NHS commissioners and providers to work together with local authorities, patients and the public in bringing forward proposals that will improve the quality and sustainability of local health care services. Government policy has been to emphasise local autonomy and flexibility in how NHS organisations plan and deliver service changes, subject to meeting legal requirements, staying within the spirit of Department of Health guidance and ensuring schemes can demonstrate robust evidence against four tests. Those are that there is support from GP commissioners; there is a focus on improving patient outcomes; that schemes consider patient choice; and that they are based on sound clinical evidence.

I recognise that change is often difficult to achieve because the consequences of not getting it right could be so profound—hon. Members have been absolutely right to raise their concerns. It is therefore right that the NHS does not rush into change without fully understanding all the potential consequences, sometimes including unintended consequences. Change can be difficult to explain to patients who have had quite reasonable anxieties exacerbated by speculation—in many cases, in the media—about whether this or that service might close. Services are sometimes described as closing when in fact they are simply being provided in a neighbouring facility or changing for the better in response to advances in treatment.

For example, my hon. Friend the Member for Macclesfield (David Rutley) referred to the possibility of hospitals closing, but I am not aware of any proposal to close hospitals. When we communicate to patients and the public, it is important that we are clear on what this issue is and is not about, so as not to raise anxieties. From my perspective, we have to be careful to avoid ramping up anxieties inappropriately by playing on fears. We see that too often; unfortunately, it stifles genuine debate and discussion about what health services will need to change in order to do better in future. But I applaud all hon. Members for speaking in this debate very reasonably and about legitimate concerns.

The right hon. Member for Leigh (Andy Burnham) has agreed that the NHS needs to have the freedom to change the way services are provided. He said:

“If local hospitals are to grow into integrated providers of whole-person care, then it will make sense to continue to separate general care from specialist care”—

the point made by the hon. Member for Wigan a moment ago—

“and continue to centralise the latter. So hospitals will need to change and we shouldn’t fear that.”

Perhaps the hon. Lady will take the point better from her party’s health spokesperson than from a Minister, but the right hon. Member for Leigh was making the case for the specialisation of services.

[Lisa Nandy]

I thank the Minister for being so generous in giving way. He seems to be setting up straw men that he then batters down. As far as I can work out, there is no disagreement from me or any Member on either the Government or Opposition Benches about the need for specialisation, integrated health care and locally delivered services. That is not what we are talking about. We are talking about a process that lacks democracy, that has been top down and centrally driven and that the public have lost confidence in.

[Norman Lamb]

To be fair, when I indicated earlier that the issue is about process, the hon. Lady came back at me—as is her right—to say that it is not just about process but about the model of separating specialisms from general hospitals. I therefore quoted what the shadow Secretary of State for Health had said in that regard.

I turn to the specific case raised by the hon. Member for Blackley and Broughton in this debate. Healthier Together was launched by the NHS in Manchester in February 2012 and is part of the Greater Manchester programme for health and social care reform, which seeks to improve outcomes for all Greater Manchester residents. The scheme is substantial, involving 12 CCGs and 12 hospital sites across Greater Manchester. As the consultation sets out, the case for change aims to improve access to integrated care and primary care, community-based care and in-hospital care services, including urgent and emergency care, acute medicine, general surgery and children’s and women’s services.

The House should appreciate that although those are the services being looked at, there are interdependencies with the core in-hospital services, including anaesthetics, critical care, neonatal services and clinical support such as diagnostic services. Changes in one area might have consequential effects elsewhere, as hon. Members have pointed out, and those effects have to be fully understood.

I should also repeat that the proposed changes are not a top-down restructuring. They are led by local clinicians who know the needs of their patients better than anyone. They believe that the clinical case for change—