NHS Reorganisation

Mike Gapes Excerpts

Wednesday 12th December 2018 Westminster Hall

[Mr Jim Cunningham (Coventry South) (Lab)]

I congratulate my hon. Friend on securing the debate. He touches on the reorganisation way back in 2012. Clinical commissioning groups were created, but they are not accountable to the public—we have problems trying to find out what their budgets are and so forth. We have the same problem with NHS England, which is another very difficult organisation to deal with. As a result of all this reorganisation, we have organisations that are not really accountable to the public, and the public do not get their voices heard.

My hon. Friend touched on staff salaries. If we worked it out, we would probably find that they have had an 8% real-terms cut in wages over the past seven or eight years, on top of which they have to pay car parking charges for the privilege of serving the public. Does he agree that that cannot be right?

[Mike Gapes (in the Chair)]

Order. Can I just request that interventions are not long speeches?

[Faisal Rashid]

I thank my hon. Friend for his intervention. I totally agree with him, and I will come to that point later.

The Health Secretary has not even put out a press release about his most recent set of NHS reforms. I wonder when that will happen. Despite not being locally accountable, CCGs hold more public money than local authorities. That lack of accountability is particularly concerning given the large sums CCGs handle and the potential for vested interests to benefit in ways that do not best serve local populations. For example, although GPs acting as both commissioners and providers of care are allowed to sit on local NHS boards, elected and accountable local officials are not. It is alarming that current arrangements allow for such potentially significant conflicts of interest while resisting local democratic oversight.

I turn to sustainability and transformation partnerships. Since the 2012 Act, we have seen the launch of 44 STPs, covering all aspects of NHS spending in England. That process has been characterised by Government secrecy, with little or no engagement with staff, patients, unions or the public before the publication of plans. Despite being asked by the Government to deliver changes to local health services, STPs were given no statutory status, and their meetings are held in private. In the majority of cases, councils have not been included at all, and a number have passed motions or issued statements condemning the process. Under this Government, changes have been initiated with no proper consultation or engagement locally with the public, patients or staff. Without accountability to local democracy, we cannot ensure that health and care systems are relevant to the people and places they are intended to serve.

STPs’ lack of accountability is even more significant given their role in administering spending reductions. Analysis by the Nuffield Trust found that some STPs are targeting up to 30% reductions in areas of hospital activity, including out-patient care, A&E attendances and emergency in-patient care, over the next four years. Those reductions are being planned in the face of steady growth in all areas of hospital activity. Too often, such initiatives encourage short-term savings, to the long-term detriment and overall cost of the NHS.

We should not forget that hard-working frontline staff bear the brunt of these pressures. It is sadly unsurprising that hospitals report growing shortages of doctors, nurses, midwives and therapists, while these bureaucratic bodies flourish.

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[Mr Jim Cunningham]

My hon. Friend is quite right. One of the things that would help, particularly among women, is reintroducing the education maintenance allowance so we can bring forward student nurses and so forth. I will give a very quick example—I know you have been a bit lenient, Mr Gapes. In Coventry, a certain facility is starting to be moved to Birmingham. That is 16 miles away, so people are going to have to travel quite a distance. We still have difficulties getting through to NHS England, which arbitrarily comes along and says, “This is going to happen.” It looks as though it might happen unless we can find some alternative. Does my hon. Friend agree that that is no way to run a national health service?

[Mike Gapes (in the Chair)]

Order. I remind hon. Members that they should not make lengthy speeches in interventions. I would be grateful if all Members bear that in mind in future. I will not be very kind if I get the sense that we are getting three or four speeches from one Member.

[Faisal Rashid]

Thank you, Mr Gapes. I thank my hon. Friend for his intervention. I agree with him to some extent, but I think his microphone was not working, and it was very difficult to hear what he was saying. That needs to be looked at.

The Warrington and Cheshire STP is completely unworkable. It has the second largest footprint of the 44 STPs, covering 2.5 million people, 12 CCGs and 20 NHS provider organisations. There are so many bodies involved that the STP has been almost impossible to co-ordinate. It required £755 million in capital funding to be deliverable. Against a backdrop of cuts to NHS capital budgets it is unsurprising that the STP has made little progress.

Integrated care providers represent the latest iteration of the changes. Although ICPs could drastically change health and social care provision if adopted, their implementation is taking place without a vote or a debate. The details setting out what an ICP will do were published during the summer recess, with very little publicity. An ICP can be awarded a contract to deliver a general practice for up to 10 years. Significantly, these contracts can also be awarded to private companies. One of the criteria used to assess bids will be

“whether they are able to deliver value for money,”

moving away from an emphasis on quality and choice. Does the Minister believe that these changes should be made without parliamentary consent?

Mr Gapes, forgive me for using these confusing and seemingly never-ending abbreviations. The communication of the changes has been another major flaw in the process. Indeed, I echo the criticisms in the seventh report of the Health and Social Care Committee, published earlier this year, which noted:

“Understanding of these changes has been hampered by poor communication and a confusing acronym spaghetti of changing titles and terminology, poorly understood even by those working within the system. This has fuelled a climate of suspicion about the underlying purpose of the proposals and missed opportunities to build goodwill for the co-design of local systems that work more effectively in the best interests of those who depend on services.”

This unnecessary use of abbreviations and complex terminology has shut out the public and excluded them from the debate over the future of the NHS. The Government have a clear a responsibility to make the debate around NHS reorganisation far more accountable and accessible to the public.

Moving on to health and social care integration, there is broad consensus that if the NHS is to maintain levels of service provision while making the efficiency gains demanded of it, the integration of services across health and social care is vital. Demands on the NHS are becoming increasingly complex, and long-term integrated care has the potential to transform the lives of millions of patients, as well as improving the patient experience. It has huge potential to save money by cutting down on costly emergency hospital admissions and delayed discharges. However, a recent report on health and social care funding by the Institute of Fiscal Studies revealed:

“Social care is facing high growth in demand pressures, which are projected to rise by around £18 billion by 2033-34, at an annual rate of 3.9%.”

This is not something that can be done on the cheap.

For patients, the lack of integration of health and social care can be a maddening experience. I am sure many Members have heard complaints from constituents about having to constantly repeat their story to any number of different health and social care professionals. In my constituency, a community-led healthcare non-governmental organisation passed on the following patient comment, which sums up the problem well:

“When I get on a plane, there is a lounge, passport control, security, air traffic controllers—lots of separate organisations. But what I experience is a trip from A to B. In health and social care what most people experience is A to Z, B to Z etc. having to repeat their stories each time.”

This confusion is the outcome to be expected from the unnecessary complexity and fragmentation that has characterised NHS reorganisation for several years. The fear is that the next NHS reorganisation will not take into account or optimise the 80% of individuals’ wellbeing impacted by the wider determinants of health—housing, employment and connectedness to the local community.

In my constituency, Warrington Together offers a potential way forward as a locally appropriate, collaborative model of care. Its rationale is a return to the principles of the NHS when it was established in 1948: a single taxpayer-funded organisation working to a single integrated plan; promoting healthy lifestyles; utilising doctors and hospitals, as well as community care, social care and mental healthcare; and striving to keep an entire population well in the most efficient way possible, with enhanced stewardship by those who are locally democratically elected.

Warrington Together offers the opportunity to stimulate a social movement to ensure that changes to healthcare are more accountable to the local population. It has established a third sector health and social care alliance, which is an umbrella group made up of 12 local voluntary health and care providers, who can act with one voice and be contracted as a single entity. That will enable a broad range of providers to come together, offering such diverse care as housing and home repairs, mental health support, and links to local leisure and cultural opportunities. While that is not without its challenges, it represents something we should try to achieve on a national scale: involving local stakeholders to provide integrated health and social care services.

My last topic is healthcare infrastructure. NHS reorganisations need to be informed by infrastructure needs. Buildings need to be more efficient and cost-effective. It is estimated that one third of GP surgeries are conversions of former Victorian terraces, 1960s bungalows or former offices. They are often unfit for purpose and cause significant waste. Innovative and modern infrastructure helps to reduce energy and utilities costs to our NHS, while also protecting our environment. The less money we spend on the maintenance of outdated NHS infrastructure, the more money we can spend on long-term care.

I have a number of questions for the Minister to answer. How can he justify the creation of ICPs without a parliamentary vote or debate? Does he acknowledge that ICPs are moving away from an emphasis on quality and choice by allowing bids to be assessed based on whether they are able to deliver value for money? How can he explain the Government’s decision to keep accountable, elected local officials out of the NHS’s decision-making process? Without accountability to local democracy, how can he ensure that health and social care systems are relevant to the people and places they are intended to serve? Will he now acknowledge that the Health and Social Care Act 2012 has been a disaster for the NHS, creating a fragmented and overcomplicated system that fails to meet patients’ needs?

The 2012 reforms have been likened by one commentator to

“a football team reorganised in such a way that the defenders, midfielders and forwards have to contract formally with one another for a certain number of tackles, saves, passes and goals, according to a general plan laid out by the manager, even though all the money comes from the same source: the club, and ultimately the fans. To make things more complicated, on match days, fans are encouraged to swap their tickets for another game, at another stadium, with other teams.”

Is that not an effective summary of these reforms? Finally, does the Minister agree that the unnecessary use of abbreviations and complex terminology has functioned to shut out the public and exclude them from the debate over the future of the NHS?

--- Later in debate ---

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Member for Warrington South (Faisal Rashid) for bringing the debate. It is a pleasure to follow the hon. Member for Mitcham and Morden (Siobhain McDonagh). The Minister will not be able to answer all my questions because, as everyone knows, health is devolved to Northern Ireland. However, I will illustrate the issues with NHS reorganisation with some stories from the Province. The Minister has a close parliamentary aide from Northern Ireland, so he knows a wee bit about Northern Ireland.

I thank the House of Commons Library for the help it always gives us. Sometimes its information is enormously helpful, and today is one of those days. I have listened with great interest to the contributions so far; it is clear that, no matter the make-up of the constituency—whether Strangford in Northern Ireland, Mitcham and Morden, Warrington South or constituencies in Glasgow, Cardiff or wherever—there are issues. The NHS is struggling UK-wide, and either the pressure goes or its ability to treat will go. We are caught betwixt those two.

I welcome the Government’s commitment to spending £20 billion extra on the NHS, which is a credit to them. My constituency is on the seaside, and lots of people head that way to retire; I suspect things are the same in many constituencies. Our elderly population is growing, and the future demand on healthcare will be enormous. That is why the £20 billion that the Government have set aside is so helpful—because it gives a golden opportunity to plan ahead. The hon. Member for Warrington South was clear about where that should go.

The Library briefing—I am sure that the Minister has had chance to read it; I know that other Members have—contains six simple lessons from the Nuffield Trust, which are very helpful.

“Lesson 1: Avoid the temptations of a grand plan”.

This refers to the complex and heterogeneous nature of healthcare. We all know that it is complex; that is the very nature of healthcare. There are no one-size-fits-all policies that can address the issues. There has to be more than that.

“Lesson 2: Listen to the public—and don’t pretend you will if you won’t”.

As elected representatives, we know how these things work. When constituents come to us and tell us a problem, we listen intently and respond accordingly. This debate will hopefully be an occasion when we can do just that.

“Lesson 3: Don’t treat the workforce as an afterthought”.

It is very important that the workforce are part of a focused reorganisation plan. With the input of the workforce, there is a way forward.

“Lesson 4: Make sure the funding follows the plan”.

If funding commitments are made, they should be in there.

“Lesson 5: Don’t overrate structural reorganisation”.

In other words, it will not be sufficient to add more to the system that is operating on its own without building that structure up.

“Lesson 6: You need a plan your staff can follow”.

Create a policy and strategy that staff can get behind and support. The best way of doing that is to make sure that staff are involved in the creation of the plan, with staff values reflected in targets. All those things are vastly important, and I know that the Minister, who is a compassionate man and understands the issues well, will be able to respond even to the very generic terms that I put that in.

For Hansard and for the record, I will highlight an issue that I know is important across the whole of the United Kingdom of Great Britain and Northern Ireland: GP out-of-hours services. I emphasise the importance of that service, but we have particular problems with it in my constituency of Strangford. Part of any strategy or plan for NHS reorganisation should look at that.

My local health board is the South Eastern Health and Social Care Trust—clearly, not the responsibility of the Minister—which covers my entire constituency. On selected days just last month, the GP out-of-hours service in the main town in my constituency, Newtownards, had to close because it was understaffed, and there are particular reasons for that. People could either follow the advice and go to the nearest South Eastern Trust facility in Downpatrick, some 40 minutes away from Ards—for those who dare to live in Portavogie in the Ards peninsula, not that far from me, it is an hour and 20 minutes—or they could go to the A&E department, which was standing room only. The choice puts massive undue burden on an already drowning service.

I suggest to the Minister—as I have suggested at home; I think it would be helpful—that, whenever GPs commit themselves to operating an out-of-hours service, there may need to be another method of addressing the issues of those who use the service. For instance, why not have a staff nurse to treat minor ailments, taking pressure off the GPs? There are ways of doing things. There does not always have to be a GP there. GPs are predominantly overburdened; they certainly are in my constituency, and I suspect they are everywhere else as well.

I will give the example of my parliamentary aide from just last week, which I believe, unfortunately, is the tip of the iceberg. Her daughter, who has just turned three, is treated in an asthma clinic. She had an extremely high temperature that would not come down to the normal range and which had been going on for nearly two weeks. Her little body fought so hard to control the infection that it was going through that her breathing rate was double what it should have been. The out-of-hours service was rung, and four hours later the call was returned—a long time when the mother and family are getting panicky. The child was lifted out of sleep and brought to a waiting room full of other children who were equally unwell.

Had the service not been able to sound out her lungs, she would have had to travel to the Ulster Hospital, which she ultimately had to do the following week, as her ear infection burst an ear drum. Unfortunately, she is one of many. My aide met doctors who were harassed—not because they were nasty people, but because of their workload—but doing the best they could. When she asked whether there is insufficient funding to pay for out-of-hours care she was told that there is insufficient desire. How do we inspire doctors to be part of the out-of-hours service, which can only function with GPs who want to be part of it?

The new remuneration system came into operation in Northern Ireland in 2003. Although the system was designed to give GP practices much more flexibility on how they deliver services, allowing them to choose how to organise patient care and rewarding them for the quality of that care, the introduction of the new general medical services contract also allowed GPs to opt out of providing out-of-hours services, leaving the system essentially on its knees.

The fact is that the A&E in the Ulster Hospital in Dundonald simply cannot cope without the service. The fact is that nursing homes that rely on GPs coming out to drivers into patients who are in agony and pain, or to call time of death, need the service, as do parents who need someone to sound out the chest of their asthmatic child without being subjected to a four-hour wait in a room with ill, injured and drunk people in the middle of a cold winter’s night.

The service is vital. I read a report in July this year that referred to Wales as having similar circumstances and similar difficulties with their GP service. I am interested to know whether the shadow Minister or the Minister are aware of similar circumstances across the UK mainland. I suspect any MP in touch with their constituents, as we all are, will be able to replicate the stories that I am telling.

I very much respect GPs and the hard work that they do and their right to a social life. No longer do we expect the village doctor to be on call every day and night, but we need them to be available. There are no longer enforceable contracts, and I believe that, in any new NHS reorganisation or strategy, we must find another way of operating the out-of-hours service that gives the care that our constituents want at the times that they need it, which is usually out-of-hours or whenever they are under pressure.

I spoke very recently to a recently retired GP. He had been doing the night shift four nights a week, but realised that that was too much and pulled out. Perhaps if he had been asked to do only one or two nights, he would have stayed. Too much has been asked of too few people. We need to ensure that funding and people are available.

I know he will be mortified, but I am going to name one local GP, because he is a very popular and well liked GP in my constituency. Dr Doyle has his own practice and can be found a lot more than is right, and than is probably his duty, in the out-of-hours surgery. He makes time to help his patients by writing support letters for personal independence payment and employment and support allowance applications and he genuinely cares. I am not saying that others do not care; I am picking out this man as a representative of what happens. I look at Dr Doyle and wonder how much longer he and others like him can possibly continue. We need to spread the burden through the area.

I would urge the Health and Social Care Committee here to look at what is happening with the out-of-hours service, see the good that it does and perhaps look at a different way in which the out-of-hours provision could work. The Select Committee on Northern Ireland Affairs, on which I serve as one of the members from my party, is doing inquiries into many things, and one of them is health. People from Northern Ireland with a knowledge of and interest in health are coming here to make presentations to the Committee. And one thing that crops up is the out-of-hours service.

The question is how we adjust to the demands on the health service for the future. I started my comments by saying how much I genuinely welcome the £20 billion that the Government have set aside. We will get some of that through the Barnett consequential, so we are very pleased, but I see the needs in my constituency among the elderly population. I am also very keen that there should be early diagnosis and that preventive steps should be taken in delivering a health service for the future. If we do that, we will be doing the right thing. We must not just react all the time. Let us have a strategy that looks forward and aims to prevent things happening.

I am a type 2 diabetic, and many in the House are, as it turns out. Our Prime Minister is a type 1 diabetic. We all live with our particular ailments. But how much better would it have been if I had known about my condition earlier. I suspect that I was a diabetic for perhaps a year before I was diagnosed as one. I did not know at the time what the issue was. It was only when I went for a check-up with a doctor that I suddenly realised when he told me what was wrong. That makes me wonder whether there are steps that we can take for education, awareness and prevention. That is what we should be doing.

The Northern Ireland Affairs Committee will come to a conclusion in our inquiry on the health service in Northern Ireland, but I will conclude my speech today with this point for the Minister. The problems that I have referred to are specific in some cases to Northern Ireland and to my constituency in particular, but I believe that problems exist UK-wide and therefore that the response must be UK-wide as well.

[Mike Gapes (in the Chair)]

Order. I think that there will be a vote imminently. If so, we will break for 15 minutes and get back as quickly as possible.

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

Thank you, Mr Gapes. I am sure hon. Members will be keen to return for the remainder of my speech, however long that turns out to be. It is of course a pleasure to serve under your chairmanship.

I congratulate my hon. Friend the Member for Warrington South (Faisal Rashid) on securing this extremely important debate. It is also very timely as we eagerly await the NHS long-term plan. He made a powerful case about the weaknesses in the Government’s approach and the disgraceful lack of parliamentary oversight of very significant changes to local and national services. I agree that the creation of the NHS was one of the great achievements of this House and this country.

My hon. Friend was right in his analysis of the Health and Social Care Act 2012. He highlighted his concern about accountability in CCGs and the potential for conflicts of interest in them. He also highlighted the lack of transparency that has characterised the STP process since its inception, and he summed up the benefits, from the patient’s perspective, of good integration —of course, no one wants to have to repeat their story on multiple occasions.

My hon. Friend talked about the challenges that the NHS faces with its infrastructure. He will know that those challenges have been exacerbated by the continual capital raids on budgets. His analogy about a football team was amusing—sadly, my own team appears to be taking things rather too seriously at the moment—but it did sum up a lot of the confusion and the illogical approach that we have to healthcare in this country. He was of course right to say that the hard-working staff of the NHS bear the brunt of these many pressures. He also made the point that many of the changes that we have been talking about have not been made in the most open way.

We also heard from my hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh). She followed up her question to the Prime Minister with a much more detailed, and devastating, critique of the proposals that affect her constituency. I was staggered to hear that £50 million has been spent on consultation so far. It was also disturbing to hear how bad things are at her accident and emergency department now, before we enter the real depths of winter. I was staggered to hear about the approach to consultation there. I am sure the Minister will want to address that. [Interruption.]

[Mike Gapes (in the Chair)]

Order. We will break for 15 minutes, I hope, and come back as soon as possible.