Health Inequalities

Lucy Allan Excerpts

Wednesday 20th March 2019 Westminster Hall

[Lucy Allan (Telford) (Con)]

I beg to move,

That this House has considered legal duties on the Secretary of State to reduce health inequalities.

It is a pleasure to serve under your chairmanship, Mr Hollobone, and I am delighted to have secured this debate and to raise this important issue.

In 2016, the Health Committee Chair, the hon. Member for Totnes (Dr Wollaston), led a thoughtful and important debate on this issue, noting that in the Prime Minister’s first speech in No. 10 Downing Street she had put reducing health inequalities at the top of her list of priorities. But July 2016 is now a very long time ago, and since that date we have heard a great deal less about that injustice. During that time, inequality of health outcomes between those in affluent areas and those in areas of deprivation has persisted.

That injustice has been obscured by improvements in overall health outcomes—and, of course, by all the other business that has been going on in this place and distracting us from the reasons that so many of us came to Parliament. As the Government unveil the NHS 10-year plan, it is right that we make a conscious effort to revisit the question of health inequalities. I want to do so in particular because I can see unequal health spending by local clinical commissioners in my area. While decision-makers may pay lip service to tackling health inequalities, it is not the driver that it is meant to be under the law.

Of course, the primary causes of health inequalities are complex and varied, from unemployment to poor housing. While no one would suggest that healthcare spending is the answer, we must ensure that all healthcare decision-makers understand their duties and the importance of their obligation to provide access for, and direct spending toward, those most in need. Healthcare spending is the one part of the mix that Government can control, and it is right to expect healthcare spending to be focused on tackling both unequal health outcomes and unequal access to healthcare.

The allocation of funding to local commissioners, which the Minister will probably touch on, rightly includes an adjustment for health inequalities based on the mortality rate. An area with a higher mortality rate, such as my borough of Telford and Wrekin, will get more funding per head than an area with a lower mortality rate, such as neighbouring Shropshire, but that is not the end of the matter, particularly when it comes to major hospital reconfigurations, which are happening in so many places across the country.

While funding may be allocated to separate clinical commissioning groups on the basis of need, when it comes to a major reconfiguration, CCGs will group together to form a joint CCG, bringing widely disparate areas under their umbrella. The funding and resource decisions are then made by the joint CCG, without considering health inequalities between those disparate areas. That is exactly what is happening in my area.

Telford is a post-war new town, created on the east Shropshire coalfield, and it has areas that are among the most deprived in the country. It has, by every measure, significantly worse health outcomes than Shropshire, a county that has better health outcomes than the national average, and significantly better outcomes than Telford, by almost every indicator.

We are experiencing just such a hospital reconfiguration. Telford and Shropshire have combined, and funding for hospital care is allocated to the area as a whole. What we have seen is a joint CCG, representing those disparate areas, deciding to direct the bulk of its funding to the more affluent area, and to move existing resources there from an area of deprivation. That is a clear failure of the duty to narrow health inequalities.

The national health service database has the figures there for all to see. When it comes to health outcomes, Telford and Shropshire are at different ends of the spectrum. For someone living in Telford, the premature mortality rate is 25% higher than for a person living in Shropshire. Children in Telford are far more likely to suffer from obesity or to be hospitalised for dental decay. Tragically, rates of suicide and cancer in Telford are significantly higher than in Shropshire. Smoking rates, inactivity in adults and other such indicators show the very same disparity. The truth is that a shire town in rural England is healthier than a new town built in a former mining area on the east Shropshire coalfield, and NHS spending allocations are required to recognise that greater need. It is that simple—yet in practice, that is not what is happening.

The Health and Social Care Act 2012 makes it clear that there is a requirement to move towards greater investment where levels of deprivation are higher. Under the Act, that is a legal duty on the Secretary of State, NHS England and CCGs. The guidance makes it clear that inequalities

“must be properly and seriously taken into account when making decisions”.

As a former non-executive director of an NHS trust, I know that the NHS constitution requires the NHS to pay attention to sections of society where improvement in health and life expectancy do not keep pace with that in the rest of the population.

It is not enough for the Government or NHS England to hand over the cash to a joint CCG and then say, “Job done,” as far the health inequality duty is concerned. CCGs also have a duty to narrow health inequalities and, if they are not complying—as in my area they are not—I ask the Minister how we can hold them to account. What steps can be taken to enforce that requirement?

This is happening not only in Telford. Across the country, from Lewisham to Huddersfield, the NHS is carrying out controversial restructurings of hospital care similar to the one in Telford, where funding and resources are being targeted toward a single area. If what is happening in Telford is happening elsewhere, decision-makers are ignoring their duties to address inequalities—or maybe they are merely paying lip service to them. It is all very well to commit to narrowing health inequalities, but that commitment is manifested only on a spreadsheet when we do our allocations to CCGs; it is not happening in practice when it comes to spending that allocation of funding.

[Stephen McPartland (Stevenage) (Con)]

I am grateful to my hon. Friend for securing this important debate. In my area, East and North Hertfordshire CCG is being forced to merge its management and executive teams, but so that it does not have to consult with local people, it is going to keep three separate boards. As a result, we are concerned about how decisions will be taken going forward and, although the spending will be going to the three separate CCGs on paper, in reality one committee will be making those decisions and getting the boards to ratify them. The concerns she is raising in her area are repeated around the country.

[Lucy Allan]

I thank my hon. Friend for his intervention, and I am aware of the position he sets out. He is absolutely right; these problems are happening elsewhere with the combination of CCGs coming together and not being able to meet the needs of the individual areas that are receiving the funding.

In Telford, the local hospital trust serving both Telford and Shropshire announced in January, after five years of bizarrely convoluted and contorted deliberation, that it was pleased to announce its investment of a total pot of £312 million in a state-of-the-art critical care unit in the leafy, affluent shire town of Shrewsbury in Shropshire, 19 miles from Telford. In addition, the trust announced that it was pleased to say it would transfer Telford’s women and children’s unit and emergency care from Telford to Shropshire.

I have repeatedly asked the revolving door of hospital management over the past five years to explain how that proposal narrows health inequalities, how that decision improves the health outcomes of the most disadvantaged groups in the area they serve and how it improves health access for the most disadvantaged group if it is moving their provision 19 miles from its current location.

The response to my questions over a significant period has been to take no notice whatever. As an MP I have found, and I know from talking to them that many colleagues have also found, that local hospital trusts and CCGs feel no obligation whatever to respond to or even take notice of elected representatives. Indeed, my right hon. Friend the Member for Hemel Hempstead (Sir Mike Penning) noted in this place just last week, in an excellent debate on his local trust, that he had “absolutely no influence” on any decisions made by the CCG in his area.

As the Shrewsbury and Telford trust felt no obligation to respond to questions on this incredibly important issue, I asked the then Secretary of State if he could seek a response on my behalf. However, even that did not bring so much as an acknowledgement that reducing health inequalities is an important issue for the hospital trust or the CCG when making spending decisions.

The trust seems to feel entirely unaccountable to anyone. The Department of Health and Social Care says that it is accountable to NHS England, and NHS England says that the trust board is accountable to the trust chairman. In reality, there is no accountability. This subject has been raised with me over and over again by local residents who strongly oppose this reallocation of funding from a disadvantaged area to a more advantaged area.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

My hon. Friend will be aware that there are health and wellbeing boards at play in local authorities. How effective has her local health and wellbeing board been at holding the CCG and other parts of the NHS to account, not only for their spending decisions but for how those decisions impact on frontline patient care?

[Lucy Allan]

I thank my hon. Friend for sharing his expertise in this area. My local council and health and wellbeing board have equally not been listened to on this issue. It is a Labour council, but it has tried extremely hard; if there was an opportunity to suggest otherwise, I would perhaps take it, but that is not the case. Both tried hard and have not been listened to. Most frustrating has been that the voice of local people has not been heard. Who do we expect to enforce this statutory duty? We cannot expect constituents to crowdfund a legal process because we want to hold CCGs to account.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Does the hon. Lady share my concerns on integrated care providers? Those should be statutory bodies and not in any way open to being private companies, which can hide behind commercial sensitivity, for exactly the reasons she says.

[Lucy Allan]

I thank the hon. Lady for her comment. There was an interesting debate on that issue on Monday night in the Chamber. This is an important issue, and I have a lot of sympathy with what she says.

On the injustice of unequal health outcomes, I said at the outset that that is of course not about spending more, and that poor health is not only about healthcare but is a much wider issue. However, if the NHS overlooks its statutory, constitutional and moral duty to properly consider health inequalities when making major spending decisions, the Secretary of State has a legal duty to act; he cannot just sit on his hands and say it is down to local clinicians. That response is all the more frustrating in my case because all six voting members of the Telford CCG voted against the transfer of resource from an area of deprivation and to an area of relative affluence, whereas all six voting members of the CCG in the more affluent Shrewsbury naturally voted for the funding resource to be transferred to their area.

In our case, Telford CCG was made to vote again until it came up with the right answer and allowed that transfer of funding. [Interruption.] That is very topical, yes. This whole issue reminds me exactly of Brexit. I wish I had not come on to that point; this should be a Brexit-free zone, for a change, so that we can all maintain our sanity. However, it is similar in the way that those in power have not been listening to the people. It is extremely important to note that, if we give that sort of funding to relatively affluent areas and take resource away from the most disadvantaged, we are doing something wrong. No Government could think that that was a good idea. I am grateful to the new Health Secretary, who came to Telford to visit our Princess Royal Hospital earlier this month and took the time to see for himself the fantastic work being done in the very areas that the management is seeking to close and to transfer 19 miles away to Shrewsbury hospital.

I would like to get something else off my chest, to further illustrate the problem of unequal health spending. Six months ago the Government gave the Shrewsbury and Telford Hospital Trust £3 million for winter pressures. The trust decided to spend all of it in Shrewsbury—all of it—despite there being no evidence that the decision reduced health inequalities between the areas that it serves and not even an indication that it had considered health inequalities when making that decision.

No Government could possibly condone transferring resources from an area of need to an area of greater affluence and better health outcomes. The Government have a legal responsibility to ensure that that does not happen. Everyone in this room will agree that NHS funding decisions must focus on the areas of greatest need, and where that is not happening, we cannot ignore it. The trust has been able to forge ahead with a plan that has never made sense to local people, that was roundly opposed by a consultation that took place, bizarrely, two years after the original decision was made, and despite MPs and councillors vocally pointing out the plan’s shortcomings and its failure to address health inequalities. The hospital trust and CCGs carried on regardless. It cannot be down to local people to enforce the Act. I can only conclude that decision-makers perhaps do not understand their duty to narrow health inequalities or—of more concern—that they do not understand the extent of the need, disadvantage and health inequality in the area they serve.

The flat-out refusal to even discuss the reconfiguration’s impact on health benefits and outcomes for the most disadvantaged has been extraordinary. I have written letter after letter for a considerably longer period than the consultation lasted and I have not received any answers. My trust treats the issue as if it was entirely irrelevant to its reconfiguration plan. If it is not able to show how its plans narrow health inequalities, it must think again.

I know that once the Secretary of State receives the relevant documentation from my local council, he will carefully consider whether to call in the Telford proposal for review by an independent reconfiguration panel. For that, I am most grateful. I hope the panel will look closely at the failure to address need and disadvantage and, on those grounds alone—there are many others—throw out the scheme. If the Government are committed to reducing health inequalities and not only focusing on better health for all, they need more than just warm words. I ask the Minister to remind hospital trusts and commissioners generally, and the Shrewsbury and Telford Hospital Trust and its commissioners specifically, to give due regard to their duty to demonstrate how their spending decisions narrow health inequalities.

In conclusion, I ask the Minister to keep focusing on this issue. It is so easy to lose sight of the reason we all came to this place, and it is too easy for the Department or the Minister to believe that health spending is allocated and targeted towards need, and that we do not have to look beyond the spreadsheet. We have to ensure that it is happening in practice on the ground. We cannot simply say that we have done our bit and that there is no need to look any further. Health inequalities are a shameful injustice of unequal lives and unequal life chances. I know that the Secretary State wants to ensure that no NHS decision-maker allocates funding in a way that exacerbates this injustice, whether in Telford or any other area.

[Mr Philip Hollobone (in the Chair)]

The debate can last until 5.30 pm. I am obliged to call the Front-Bench spokespeople no later than 5.07 pm. The guideline time limits are five minutes for the Scottish National party spokesperson, five minutes for Her Majesty’s Opposition’s spokesperson and 10 minutes for the Minister, with the mover of the motion having two minutes at the end to sum up the debate. The next 18 minutes will be for Back- Bench Members. You can all contribute if you speak for no more than four and a half minutes each.

--- Later in debate ---

[Lucy Allan]

I thank all Members for participating in the debate this afternoon. I am grateful to have heard not only their contributions but their passion for the subject, which I share. The Minister has been very kind in making a commitment to transparency and better communication by decision makers when it comes to major changes in local areas, and I will hold her to that commitment.

Health inequality is such an important issue, which we do not talk about enough in this place. We must do better, as the hon. Member for Strangford (Jim Shannon) said. I loved that the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) mentioned that there is hope for improving life chances and opportunities for those most in need. We all have to keep focusing on this issue and keep it on the agenda, despite the whirlwind of everything else that is going on around us. It has been refreshing to talk about something that we are all passionate about and will change lives. I again thank the Minister. I will gladly continue to work with her to ensure that the issues in Telford are addressed.

Question put and agreed to.

Resolved,

That this House has considered legal duties on the Secretary of State to reduce health inequalities.