NHS Sustainability and Transformation Plans

Norman Lamb Excerpts

Wednesday 14th September 2016 Commons Chamber

[Ms Abbott]

That is the reason for the secrecy thus far. The Government know that if the public understood what STPs meant, there would be an outcry.

[Norman Lamb (North Norfolk) (LD)]

Does the hon. Lady agree that unless the local community are fully engaged in the process of considering how the health and care system needs to change their area, the process is destined to fail and simply will not work?

[Ms Abbott]

I am grateful to the right hon. Gentleman. For nearly the whole time I have been in Parliament, there have been attempts to reconfigure hospitals and close A&Es and make other changes in London. We have found that when the local community does not take ownership of the plans, it is impossible to take them forward. That secrecy runs counter to making the reorganisations we might have to make.

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[Mr Dunne]

I am delighted to accept that invitation from my neighbour and friend, not least because many of my constituents look to Hereford County hospital for their acute care, but also because it is one of the hospital trusts that are in special measures, which is my specific responsibility. I look forward to seeing my hon. Friend there, perhaps even during the coming recess.

[Norman Lamb]

I wish the Minister all the best in his new role. Does he share my concern about the evidence from around the country that in many areas mental health is peripheral to the STP process? Will he ensure that no STP plan will be accepted unless mental health is central to it?

[Mr Dunne]

I am grateful for that intervention from the right hon. Gentleman, who has taken such a personal interest in this subject. I can confirm that mental health is one of the issues that will be addressed in each of the plans that will be taken forward. I hope that reassurance helps.

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[Dr Whitford]

I totally agree with the hon. Gentleman. I was about to come on to that. However, it is not just the funding, but the entire model. The tariff model that we have at the moment rewards hospitals for doing more minor things, and punishes them for doing more acute things. Taking on more A&E cases and more complex cases, working harder and doing more make their deficits grow. Our problem is that we have all sorts of perverse incentives in the system that mean that organisations will still be looking out for their budgets and their survival instead of working together.

In Scotland, we got rid of hospital trusts and primary care trusts, and, since 2014, we have had integrated joint boards. Those boards were handed joint funding that came from health and the local authority, which meant that the whole business of “your purse or my purse” disappeared. They were then able to start to look at the patient’s journey and the best way to make the pathway smooth. That is what we want to see.

Having a shared vision of where we are trying to go to is crucial. That means that stakeholders—both the people who work in the NHS and the people who use it—need to believe in where we are trying to get to. Public conversations and public involvement are the way forward. We should not be consulting on something that has already been signed off, but involving people in what they would like the plans to be, as that would make those plans much stronger.

We need to make deep-seated changes to the system, as opposed to only talking about the money for the deficits. This is something that the Health Committee has been talking about for ages. The phrase “sustainability” has become shorthand for paying off the deficit. Of the £2.1 billion earmarked for sustainability and transformation, £1.8 billion is for deficits, which leaves only £300 million to change an entire system. I know that we talk about money a lot in here, and of course it is important, but we have far bigger sustainability issues than the £2.5 billion deficit in the NHS. We have an ageing population, and those people are carrying more and more chronic illnesses, which means that we have more demand, more complexity and more complications. That is one of the things that is pushing the NHS to fall over. On the other side of that, we have a shortage in our workforce; we do not have enough nurses or doctors, and that includes specialists, consultants, A&E and particularly general practitioners. Although the advice has been very much that finances were third, and prevention and quality of care were meant to come first and second in delivering the five year forward view, finances seem to be trumping everything else.

It is absolutely correct that health is no longer buildings; there are lots of methods of health that are bringing care closer to patients, and also some things that are taking patients further away from their homes. We have hyper-acute stroke units, and we have urgent cardiac units, where they will get an angiogram and an angioplasty that will prevent heart failure in the future. However, we cannot start this process there; we cannot shut hospitals and units to free up money to do better things. We have to actually go for the transformation and do the better things first. We have to design the service around the pathways we need—that wrap-around care for patients—and then work backwards. If more health and treatment is coming closer to the patient, at some point they will say, “Actually, I don’t go to the hospital very often. I want the hospital to have everything it needs when I need it.” Then we can look at the estate to see whether we have the right size of units and the right type of units in the right place. What concerns me is that the process we have seems to be the other way around—we are starting with hospitals, which is often a very expensive thing to do, and hoping it will deliver everything else.

[Norman Lamb]

rose—

[Dr Whitford]

I give way to Norman.

[Norman Lamb]

I am grateful to the hon. Lady for giving way, even if she used my first name. Does she share my concern that, out of the original sum allocated for this sustainability and transformation process, the vast bulk appears to be going, in effect, to propping up acute trusts that face substantial deficits, and that little is available for transformation?

[Dr Whitford]

As I said, the proposals leave only £300 million. We cannot transform a system on the scale that is being considered with £300 million.

As I said, the guidance talks about prevention. We need to be tackling health inequalities. We need to be focusing on health and wellbeing—and by that I do mean physical and mental wellbeing. We need to be strengthening public health—something else that has been cut. We need to be looking at the quality of health and care, and that means right across into social care. We must fund social care, because it can make a difference to things like delayed discharges. We are not even three years into the integration in Scotland—we are only two and a half years into it—but delayed discharges have dropped 9%. Yet, the last time the Secretary of State was in the Health Committee, they had gone up 32% in NHS England. So literally just moving things around and allowing one part of the system to fail will mean that the entire system fails.

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[Norman Lamb (North Norfolk) (LD)]

I want to start by saying that I very much agree with the point made by the hon. Member for Central Ayrshire (Dr Whitford) that this ought to present a real opportunity. It has brought people together, and discussions have started across organisations that in the past have not talked to each other nearly enough—both across the health and social care divide, and also bringing in people from outside the health service and social care system—but I fear that the opportunity will be fatally undermined for three central reasons.

First, there is the point that I made in my challenge to the Minister, on mental health: unless every STP addresses the burden of mental ill health in every community centrally as part of its plan, it will fail. There is no doubt about that. I noted the Minister’s attempt to reassure me, but the parliamentary answer I received recently did not reassure me, because it appears that it is not going to be a requirement that every plan must centrally address this problem. I understand that the more developed plans will do so, but if this is not done, it will absolutely fail. We are dealing often with some of the people who are failed most by the system, and who use A&E departments more than any other people, yet my fear is this will be a massive missed opportunity in that regard.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I thank the right hon. Gentleman for giving way, because I want to make the point again—I will say it very clearly—that if an STP does not come forward with very clear plans as to how the mental health and dementia programmes are going to move forward quickly, it will not go ahead. That cannot be clearer.

[Norman Lamb]

I am grateful to the Minister for that, and I hope that that message goes out across the country, because Andy Bell from the Centre for Mental Health today has again raised concern about the process in many parts of the country.

The second issue that causes me very real concern is the financial backdrop and the ability to deliver on the plans given the finances that are available. We have already heard that the bulk of the money that is available is going into clearing the deficits of providers, rather than into the transformation that is so necessary in order, as the hon. Member for Spelthorne (Kwasi Kwarteng) made clear, to spend money more efficiently and effectively in delivering care for our communities.

Chris Ham, chief executive of the King’s Fund and a well-respected commentator, says that its assessment of the draft plans

“shows that, in the absence of eye-watering efficiency improvements, there will be a financial gap running into hundreds of millions of pounds by 2020/21 in most of the footprints”—

not across the country, but in most footprints. This is completely unachievable, and he questions the deliverability of plans which include the closure of cottage hospitals in many areas—the very things that can keep people out of acute hospitals, yet we are planning in many areas to close them down. This seems to me to make no sense at all.

There is a related concern about governance. Currently in the NHS we regulate organisations, not systems, so within an STP footprint every organisation still has to focus on its own financial survival, rather than looking at the best approach for the entire health and care system in that locality. I fear that that in itself will be a central flaw.

Finally, there is the question of openness and transparency. I note the point that there will be a consultation process, but let me just tell the Government that if they really think that a formal consultation process after full draft plans have been produced in a secret process will in any way convince the public that they are being properly involved, it will fail. It is inevitable that it will fail. People are so suspicious of consultation processes that they simply do not believe that they are being properly engaged in them.

The hon. Member for Spelthorne made a good point: people are often prepared to go on a journey. They are prepared to listen to potentially radical changes and potentially to use money more effectively, but the only way they will do that is if they are involved from the start—involved in shaping the proposals, rather than responding to something that has been fixed behind closed doors. The hon. Member for Bedford (Richard Fuller) knows full well how the public react when they are presented with what looks like a fait accompli. If the public are not involved in the development of plans to close cottage hospitals, to slim down acute hospitals and to merge hospitals around the country, we should be in no doubt that those plans will be rejected. The Government will be facing a political disaster if they plough on in this way. They must, for example, open up and involve the non-executive directors, who have been told that they cannot even be part of the discussions. That is ridiculous. For goodness’ sake, if we are to take people with us, we have to take them on a journey, engage with them and involve them in the plans.

[Matthew Pennycook (Greenwich and Woolwich) (Lab)]

rose—

[Norman Lamb]

I will give way very briefly to the hon. Gentleman—[Interruption.] I am being given a clear signal by Mr Deputy Speaker that I should not—

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. You have only 30 seconds to go.

[Norman Lamb]

I take your point, Mr Deputy Speaker, and I am sorry for my ill discipline.

I will conclude by saying that this is the right approach but it will be undermined because of the rushed process which does not involve the public, because it does not take people with it on the journey and because there is not enough money to deliver the transformation that is required.

[Several hon. Members rose—]