Health Care (Sutton)

Paul Burstow Excerpts

Thursday 28th February 2013 Commons Chamber

[Paul Burstow (Sutton and Cheam) (LD)]

I am grateful for this opportunity to address the House and to explain to it and to the Minister the disaster that is playing out in slow motion in the NHS in south-west London. I am talking, of course, about a programme named the “Better Services, Better Value” programme, which was launched by the south-west London primary care trust cluster two years ago. BSBV was set up to address concerns about quality and patient safety. The argument is that London should lead the way to all-consultant rotas to guarantee better care.

Taken at face value, no one could argue with that proposition. We all want great care, and we all want the safest and best care for ourselves, our families and our constituents. BSBV’s answer to this quality challenge, however, is a grandiose reconfiguration of acute care costing over £350 million. It proposes the centralisation of emergency care, maternity and paediatric care on fewer hospital sites in south-west London. The result is the loss of two A and E departments, two maternity units, three paediatric units and other associated services.

Despite quality and safety concerns being the driving force, actual quality today has been discounted. It is assumed that quality will improve, but there is no explanation or evidence to justify the assumption that those things that are not good now will necessarily become better in the future. How that can be made to happen has not been spelled out.

I have to tell the Minister that BSBV is causing huge damage to the NHS in south-west London. It is dividing medical opinion and demoralising staff in hospitals such as my own St Helier hospital. It is also distracting the NHS from the much bigger task of delivering the productivity and quality gains needed to meet the Nicholson challenge. In the wake of the Francis report, it is clear that BSBV has not considered the impact of forced reconfiguration on patient safety. That must be a risk, and it should be properly evaluated and taken into consideration.

I said that BSBV had come up with a grandiose solution. At the top of every list BSBV draws up comes my local hospital, the St Helier hospital. My constituents are being expected to travel for longer and further because of a dogma—that greater specialisation on fewer hospital sites improves outcomes. Last year, however, a paper in the Health Service Management Research journal examined the evidence to support this dogma. Anthony Harrison of the King’s Fund reviewed a large number of studies, some of which were commissioned for the Department, and concluded that there was no evidence of a causal link between volume and outcomes. BSBV, however, relies on that dogma, and tries to shame anyone who argues against it by painting opponents as being “opposed” or in a position of being prepared to support and tolerate poorer outcomes.

As I say, this view is being advanced without evidence. There is some evidence that greater specialisation may well save lives—I do not dispute that—and the reorganisation of hyper-acute stroke care and major trauma across London appears to be a case in point. Those are examples where it certainly makes a difference and they have made a difference across London. It is important, however, that we await the results of studies of how those improvements have been secured before we claim to have a full understanding of all the factors that have played a part in delivering the gains that have been realised.

Although BSBV advances its view of the benefits of centralisation, it fails to examine some of the important downsides. Shockingly, the proponents of BSBV ignore evidence demonstrating a link between mortality and miles travelled to gain access to emergency care. There is as much as a 1% increase in mortality for every extra mile travelled. They ignore evidence showing that St Helier has one of the safest maternity units in London—a unit at which mums want to have their babies. They also fail to consider the benefits of retaining A and E, maternity and paediatric services at St Helier to ensure that the NHS has the capacity to meet rising demand. Demand is rising—birth rates are rising and the number of people needing hospital services is, too.

In pursuit of this dogma, wildly optimistic assumptions are manufactured about the extent to which demand for emergency care can be shifted out of hospital or avoided altogether. Those involved assume, for example, that 10% of A and E attendances can be avoided and that up to 60% of such admissions can be shifted to urgent care, but the evidence for that is weak and is contested by emergency care experts. There is, in fact, a growing body of empirical evidence that calls into question some of the diversion schemes that have been set in place. Even the National Clinical Advisory Team’s evaluation of BSBV last summer questioned the assumptions and urged caution. NCAT says that

“experience elsewhere has shown that on implementation not all of the planned shifts in flow are met.”

It suggests that a more realistic assumption is that about 30% of A and E patients will be shifted to urgent care. More damaging still, its independent assessment warns that the data used to make the assumptions are recognised in emergency care to “lack reliability.”

Yet those flawed assumptions are at the heart of BSBV’s grand design. I think that they pose a significant risk to the safety of patients, a risk made worse because those in charge of the programme have not even worked out how to deliver the step change in out-of-hospital care on which their heroic assumptions rely. Nor have they worked out how much it might cost to deliver the changes in primary and community health care. The reports of both NCAT and the gateway review comment on that glaring gap in the BSBV case. NCAT says:

“At present attention is focused on hospital reconfiguration. There should be at least as much concern shown to the developments in primary and community care which are essential prerequisites of that hospital reorganisation.”

The same zeal for centralisation runs through the proposals for maternity services. Although St Helier’s maternity unit is performing above the average in south-west London, although more than 3,400 mums are choosing to have their babies at St Helier every year, and despite welfare and health inequality concerns about women giving birth in more remote locations, those in charge of BSBV are proposing the break-up of an excellent maternity and paediatric team. Again, the evidence calls that zeal into doubt.

I said that BSBV was a distraction from the big challenge facing the NHS—the Nicholson £20 billion challenge, which was identified by the Department of Health back in 2008. The NHS in south-west London has drawn up plans to find £394 million for quality and productivity improvements out of a budget of £2.4 billion by 2016. The money that it frees up will be used to meet rising demand and improve quality. No one disputes the fact that it will be a tough programme to deliver, and I must tell the Minister that BSBV is not helping. In fact, it delivers very little for the Nicholson challenge: just £18 million. Is all the pain that BSBV is inflicting worth it? Those involved in BSBV want to spend a projected £350 million in capital in order to realise that £18 million. I calculate that, according to BSBVs figures, it will take more than 20 years to get a payback on that capital investment. BSBV’s purpose is to tackle quality and safety concerns which we all want to be tackled, to fix consultant rotas, and to deal with other related issues. According to its own figures, that will cost between £4 million and £7 million.

Has not a “do the minimum” or “do the least harm” option been drawn up to find ways of delivering the benefits without all the costs of BSBV’s grand design? No such plan has been developed. To date, those in charge of BSBV have spent £5.5 million. They plan to spend £6 million more this year, and to spend a further £2 million every year while the programme continues. Surely there is a saving to be made there.

We have a grand design in search of a justification: a classic old-fashioned, top-down London NHS-inspired reconfiguration. The goal has been to reach decisions before the old NHS structures are abolished at the end of March, tying the hands of the new GP-led clinical commissioning groups. Yet last year, during the passage of the Health and Social Care Act 2012, it was made clear that there would be new ways of designing health care, and that things would be different. The new design was to be based on a detailed analysis of the current and future needs of the local population, an analysis that would underpin the development of local health and wellbeing strategies which, in turn, would be reflected in the commissioning plans of councils and clinical commissioning groups. The last analysis of that kind that was conducted in my area, in 2009, did not support a wholesale change in acute care, but BSBV is trying to drive a coach and horses through that. Rather than designing services that fit its postcode, it is trying to shoehorn south-west London into its template.

Because BSBV has so clearly predetermined the fate of St Helier, it has caused planning blight. It has derailed the de-merger of Epsom and St Helier hospitals by causing huge uncertainty about the future of both. BSBV has jeopardised the hard-won £219 million rebuild and refurbishment of St Helier hospital, despite the former chief executive of NHS South West London repeatedly stating that this was a fixed point. That blight could be lifted today if the Minister made it clear that it was no part of the Government’s design to allow the old institutions of the NHS—primary care trusts and strategic health authorities—to dictate how the new GP-led clinical commissioning groups act. Furthermore, can the Minister confirm that the NHS Commissioning Board is under a duty to secure the autonomy of CCGs, and that she rejects any recreation of the top-down culture and will ensure that CCGs are empowered to arrange local health care that fits and anticipates the needs of their populations?

I do not underestimate the difficulties that CCGs face in resolving how best to arrange health care services in Epsom, Merton and Sutton, but it is clear that BSBV does not offer a credible mechanism for meeting the challenges. As the principal commissioners of services at the Epsom and St Helier University Hospitals NHS Trust, the Sutton, Merton and Surrey Downs CCGs should be able to shape acute health services for the future. They must be able to commission those services in a way that the three local health and wellbeing boards believe to be right, unfettered by any legacies from the outgoing health commissioners.

I hope that, as the new commissioners of acute and community health services, my local CCGs will take the opportunity arising from the current delay in the BSBV programme to bring it to an end. A clean break from this flawed process will be a clear signal from the CCGs that there will be a fresh start, and that they want to engage with the Epsom and St Helier University Hospitals NHS Trust and the local community, local councils and MPs to map out a future for acute health services that has community and clinical support.

In conclusion, I hope that the Minister will be able to confirm the following: first, that the local clinical commissioning groups are free to scrap BSBV; secondly, that a “do minimum” option is a must-do when it comes to reconfigurations; and thirdly that the Department of Health will take a close and critical look at this old-style, top-down reconfiguration from BSBV. BSBV is based on flawed assumptions and poor data, and it is time to stop wasting money on this discredited process. We need a fresh start in south-west London, not tired, old, worn-out NHS reconfiguration of the very worst sort. I hope the Minister can help.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

I pay tribute to my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) for his long service and the great work he did as a Department of Health Minister and for securing this debate. He has made a number of very good and important points—although I do not agree with everything he said—and I assure him that my officials will read his speech, and if I fail to respond to any of his points now, we will write to him. He has asked a number of questions, and I may not be able to answer all of them—and strongly suspect I will not be able to give the sort of answers he would like.

My right hon. Friend is standing up for his constituents’ health services, which is absolutely right. It is right that Members come to the House and speak up on behalf of their constituents. On hospitals and health care services, at the end of the day we all want the same thing: the very best services for our constituents. Everyone is entitled to the very best health services.

As my right hon. Friend will know, it is not my role to defend or to rubbish the “Better Services, Better Value” process. He has made some very good points, but I have no doubt that it was set up for the very best of reasons. There are no proposals at this stage, but there is a huge consultation stage. I am told the underlying reason for setting up the BSBV was to ensure that everyone in south-west London and Surrey Downs has the very best health services seven days a week, 24 hours a day.

A number of hon. Members who represent the area covered by the review have rightly made representations. Some, like my right hon. Friend, have spoken in this House. He has also been to see me, as have others, including my right hon. Friend the Deputy Leader of the House, and the Under-Secretary of State for Transport, my hon. Friend the Member for Wimbledon (Stephen Hammond), is coming to see me next week. My hon. Friend the Member for Croydon Central (Gavin Barwell) and the hon. Member for Mitcham and Morden (Siobhain McDonagh) spoke in the most recent debate on the future of A and E services, which was held only a few weeks ago. I shall refer to some of those speeches.

The area affected by the reconfiguration covers south-west London and the Surrey Downs. South-west London has a population of 1.4 million, the Surrey Downs have a population of 280,000 and between them they enjoy a health service that is funded to the tune of £2.8 billion a year. As my right hon. Friend the Member for Sutton and Cheam has made clear, although much of this is about saving money and meeting the Nicholson challenge —a scheme introduced under the previous Government and supported at the time by both Opposition parties, and one that continues because we recognise that those savings must be carried through—this is not about cuts. If anybody makes that case, as I have said before, they do no service to anybody or to the debate. This is not about brutal cuts but about trying to deliver the best service for people throughout the whole area seven days a week, 24 hours a day.

My right hon. Friend the Prime Minister, when he presented the Francis report to this place and answered various questions on it, gave an answer that we should all remember. I have used it before, but let me repeat it now. He said:

“Let me refer again…to one of the things that may need to change in our political debate. If we are really going to put quality and patient care upfront”—

which is something on which we all agree—

“we must sometimes look at the facts concerning the level of service in some hospitals and some care homes, and not always—as we have all done, me included”—

and it includes me, too—

“reach for the button that says ‘Oppose the local change”’.—[Official Report, 6 February 2013; Vol. 558, c. 288.]

I agree with those words. We are all beholden, whatever part we play in reconfiguring and reorganising health services, to ensure that we do not have an immediate knee-jerk reaction to oppose change. I am not saying that my right hon. Friend the Member for Sutton and Cheam has done that, but others have. Change is the right vehicle and the right driver to ensure that the people of this country get the best services.

To explain how difficult it is to make a reconfiguration, let me refer to the speech made by the hon. Member for Mitcham and Morden in the recent debate on A and E services. She said:

“My local NHS says it needs to reconfigure services because it has to deliver £370 million of savings each year—a reduction of around 24%, or how much it costs each year to keep St Helier hospital going. A programme has been set up, laughingly called “Better Services, Better Value”, to decide which of four local hospitals—St Helier, St George’s, Kingston or Croydon—should lose its A and E department. That is despite the fact that, across south-west London, the number of people going to A and E is going up by 20%, and that the birth rate in our part of London continues to rise.”—[Official Report, 7 February 2013; Vol. 558, c. 515.]

That is another hon. Member who would join my right hon. Friend in opposing any changes, cuts, closures and so on at St Helier.

[Paul Burstow]

The Minister is responding fully to the points I have made so far, but let me demonstrate the distinction between my point and that made by the hon. Member for Mitcham and Morden (Siobhain McDonagh). She has conflated the BSBV programme, which is a reconfiguration, with the Nicholson challenge. The Nicholson challenge is being taken forward separately in south London and BSBV does not deliver on it.

[Anna Soubry]

I am grateful to my right hon. Friend because I was going to agree with him that the hon. Lady’s analysis was not correct. The point that I am trying to make is that she seeks to defend her hospital, as my right hon. Friend does. She does not want changes that in any way undermine her hospital, and she makes that case with some passion. It is interesting that my hon. Friend the Member for Croydon Central, who also took part in that debate, made a speech that completely contradicted what the hon. Lady had said.

--- Later in debate ---

[Anna Soubry]

That is a peculiar, old-fashioned procedure, but none the less valuable and enjoyable, Mr Deputy Speaker.

My hon. Friend the Member for Croydon Central argued in the same debate in favour of the BSBV review on the basis that, according to one of the many reports that form part of the review, Croydon Health Services NHS Trust—in other words, his hospital—should have 16 whole-time equivalent consultants, but it has 4.9; St Helier should have 12 but has 4.5; Kingston hospital NHS trust should have 16 but has 10; and St George’s should have at least 16 but has 21. That suggests that departments across south-west London, with the exception of the one at St George’s, do not have anything like the recommended level of consultant cover. He went on, as we might imagine because he, too, wants the very best for his hospital and his constituents, to make the case that BSBV would deliver exactly what he wants for his constituency.

[Paul Burstow]

The hon. Member for Croydon Central (Gavin Barwell) made some important points in that debate, but he did not go on to make the key point that when we look at the figures for BSBV, we see that the cost of delivering the improvement that he and I both want is between £4 million and £7 million, yet under BSBV £350 million would be spent to do that.

[Anna Soubry]

All I can say is, a good point well made, and move on towards my concluding remarks.

My right hon. Friend has asked me a number of questions. If I do not reply in full, I assure him that I will in a letter. I am told that a “do minimum” option should exist. I know that he knows this, because he was a Minister in the Department of Health, but I want to remind everyone that, for this scheme or any reconfiguration scheme to go forward to full public consultation, it has to pass four tests that were clearly laid down by my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) when he was Secretary of State for Health. The four tests are support from GP commissioners, strengthened public and patient engagement, clear clinical evidence and support for patient choice.

In conclusion, I shall deal with my right hon. Friend’s three final questions. I am told that a “do minimum” option should exist. In relation to whether CCGs are free to withdraw from the process, I think it is important that I read out what I am told; I do not want ever to be accused of not saying things I have been advised on. I am told that local CCGs are already a key to BSBV. However, and perhaps more important, after 1 April CCGs will be in the driving seat and by definition BSBV would be unable to continue without their support. That would seem extremely obvious.

[Paul Burstow]

That is very helpful. Given that CCGs will be in the driving seat from 1 April, does that mean they can hit the ejector button and get BSBV out?

[Anna Soubry]

I do not know the answer to that, and of course I would not put it in those terms, but I shall make further inquiries and certainly write to my right hon. Friend so that he has a proper and full answer to that very important question, which I have no doubt many other right hon. and hon. Members would like to ask in relation to other reconfigurations, notably in the south of England.

My right hon. Friend’s other question, in effect, was: would someone at the Department of Health look at BSBV? As he knows, from 1 April the NHS Commissioning Board will have responsibility for determining whether the four tests have been met, prior to a public consultation on BSBV. The Secretary of State only becomes involved quite some way down the line. I will not—I nearly said I was going to bore you, Mr Deputy Speaker; I would not dream of doing such a thing. However, the intervention of the Secretary of State can only occur much later down the line, when the matter has been referred to him by the overview and scrutiny committee of any local authority, by way of an independent reconfiguration panel, and so on.

As I said, my right hon. Friend has raised some important points. If they have not been addressed by me, they will be by way of a letter. I congratulate him again on having secured the debate.

Question put and agreed to.