GP Extended Access Services: Privatisation

Paul Williams Excerpts

Wednesday 17th October 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

I beg to move,

That this House has considered privatisation of GP extended access services in Stockton, Hartlepool and Darlington.

It is a pleasure to serve under your chairmanship, Mr Hosie, as we explore the important issue of the privatisation of local health services. Before I begin, may I bring to your attention my entry in the Register of Members’ Financial Interests? I have worked in the local extended access service. I have been employed as a GP since my election to Parliament, and before that I was chief executive of Hartlepool & Stockton Health, which is a GP federation established by all local GPs as a non-profit-making venture to allow collaboration between practices and other parts of the NHS. I resigned my position when I was elected, and I served my notice. My partner, Vicky, is a nurse in the local NHS and she derives some income from the GP federation.

As the Minister will know, the Government’s ambition is for all patients to be able to access evening and weekend GP appointments, which is a good thing. It is difficult for each individual GP practice in any area to open every evening and weekend, but it is achievable if GPs work together. In Stockton South in April 2017, Hartlepool & Stockton Health started to deliver extended access appointments between 6.30 pm and 8 pm on weekday evenings, for three hours on a Saturday, and for two hours on a Sunday. Local GPs did that as a collective through their federation.

The federation was set up as a private company—there is as yet no NHS GP federation organisation that it can belong to—but it was designed as a not-for-profit organisation because local GPs insisted on it. They did not want to make any profit out of collaboration. All the money earned by the organisation is reinvested into local primary care—I know the detail of that because it was my job before I came into Parliament to set up and run the organisation.

Evening and weekend GP services have now run for 18 months and they have been a success by all measures. Patients like it:

“Every aspect of my visit was excellent…it was prompt and professional…a lovely experience”

are three of the many comments received as feedback. During the past year, there have been 26,000 extra GP and nurse appointments for routine care. That has not just been good for patients; it has also reduced pressure on local practices. Teesside has one of the highest patient-to-GP ratios—we are an under-doctored area.

Down the road in Darlington, Primary Healthcare Darlington has run an extended access service in the evenings and weekends since 2015 when it received Prime Minister’s Challenge funding. According to all the reports I have received, it has run an equally good service for the people of Darlington. So far, so good. However, in September this year the local clinical commissioning group launched an invitation to tender with two lots—one to run an extended access service in Darlington, and the other in Hartlepool and Stockton. The tender documents requested that organisations bid to run one and a half hours of general practice each evening and a bit longer at the weekends. The bidding process is under way and I am sure the Minister will not want to say anything that might prejudice the process.

I have initiated this debate to ask some big questions. Biggest of all is this: how does privatising this service benefit local patients—the acid test for any NHS change? When local GPs work together to deliver this service, and when the local NHS has all partners collaborating so well, how can it possibly be right to bring in a new private sector provider?

[Alex Cunningham (Stockton North) (Lab)]

I congratulate my hon. Friend, my next-door neighbour, on securing this debate. One thing that concerns me is the potential loss of good will from GPs across the Tees valley who are currently delivering the service. Does that concern him too?

[Dr Williams]

I will come later in my remarks to some of the reasons why the system works well at the moment, and to some of the potential threats that could arise from introducing a private sector provider.

Before I expand my point, let me establish my position so that there can be no confusion or misinterpretation. As I said, extended access services are a good thing. I worked hard before my election to establish them, and they are good for patients and for the NHS. I congratulate Hartlepool and Stockton-on-Tees CCG and Darlington CCG on delivering extra GP services for local patients over the past few years in Darlington and for the past 18 months in Stockton. They have done a good job. I also know that most GP practices are technically private organisations with a contract with the NHS, but there is an important difference between a local GP who is doing the work and making money from that, and a private corporation whose shareholders profit from the NHS.

Having said that, I am on the record as having said that GPs should be employed by the NHS, and I believe that the time has come for the NHS to set up community providers to integrate GPs, community nursing, social care and community health services. GPs should be offered employment in those organisations. The farce that I am describing today makes the case for that type of organisation stronger.

While setting out my credentials, I am also pragmatic and not dogmatic about private and voluntary sector provision within the NHS. Our local counselling services in Stockton are better for having multiple providers. Patients like getting hearing tests on the high street at Specsavers instead of going to the hospital audiology department. What I am describing today, however, is privatisation for privatisation’s sake. It is privatisation because the “rules” say privatise, and not because anyone thinks that privatisation is good for patients. It is probably even privatisation by accident.

For me, the most important test of any change in the NHS is: how does this benefit patients? The NHS is there to improve health. I have huge respect for all the staff who work in our NHS, and I thank everyone for their efforts, but fundamentally local health services must meet the needs of local patients. How could bringing in a private GP company for an hour and a half each day possibly make things better for patients in my constituency? If there were a list of 101 things to do to improve the NHS in Stockton South, finding a new provider for GP extended access would not be one of them.

Children’s mental health services are in crisis and health inequalities in Stockton are the most stark in the whole country. Our local authority is struggling to deliver effective public health services because of the cuts, and waiting times for autism diagnosis for children have been four years, even though our health and wellbeing board, council and CCG have good plans to reduce that. For general practice, in some parts of Stockton South patients tell me they have to wait four weeks for a GP appointment. Fixing those things should be the priority for our CCG, not being forced to spend time and money on an unnecessary privatisation.

GP extended access is one part of the local NHS that is working well. The model has energised local GPs and, to an extent, local nurses. Eighty-five doctors and 25 nurses have worked in the service. Three years ago, before I was in Parliament, I led a workshop for GPs, and the No. 1 thing they asked me not to introduce was an extended access service. However, working together with the CCG, a model was created that people wanted to work for—one that works for staff and patients. Since GPs own the organisation that they work for, the things that matter are prioritised. The GP federation has a culture lead—an employee of the federation whose job it is to promote a happy, healthy working environment and reduce the pressure on frontline GPs. GPs working in that service are not motivated by profit. They are working as a collective and taking responsibility.

Extended access has also allowed new models of care to be tried, and pharmacist, physiotherapist and counsellor appointments are directly bookable at the weekend. The scheme is popular with patients—96% of GP and 70% of nurse appointments have been used. In short, the service works well. Although most people said at the start that it would not work, the service is popular with patients and well led. Why privatise it? What on earth could be gained? One and a half hours a day of private general practice—it is ridiculous.

More good collaborative things are happening in Hartlepool and Stockton. The local GPs are already working in partnership with the local hospital and the local ambulance service to run the local urgent care centre. Local services are integrated, everyone is talking to each other and most people are happy. Most areas would be delighted to have such a level of engagement and co-operation and such leadership. The service has been put out to tender simply because of the law. The Health and Social Care Act 2012 mandates competitive tender for certain contracts worth more than £615,000 a year.

In this case, I contend that the law is not working. It does not work for patients, it will not work for doctors or NHS leaders and I suspect it is probably not even what the Minister wants. There is hypocrisy here—a fundamental difference between what the Government are saying and what they are doing. I will quote from NHS England’s “Next steps on the NHS Five Year Forward View” document, published in March 2017, which says that it will:

“Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care…hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access.”

That is what the NHS five-year forward view says will happen: GPs will work together to pool responsibility, which is exactly what is happening in my area. If private companies are invited to competitive tender for that, every GP has something to fear from the collaboration. They will do the work of setting up the services and somebody else will then come in and run them.

The Minister’s colleague, the Minister for Health, the hon. Member for North East Cambridgeshire (Stephen Barclay), recently gave evidence to the Health and Social Care Committee inquiry into integration in the NHS. When he was asked about privatisation, he said that

“there are a number of checks and balances in the system in the requirement for CCGs to consult their local populations, their health and wellbeing boards and their oversight and scrutiny committees. On top of that, there are safeguards at a national level of CCGs going through the integrated support and assurance process. Actually, there are a lot of checks and balances as to the fact that this is not privatisation.”

I ask where the checks and balances were to stop the CCG having to put these services out to tender. Why did the Minister not intervene, when it is plain to everybody that it is a ridiculous idea to bring a private company in for an hour and a half each day?

[Alex Cunningham]

What concerns me is that this tender document sounds as though it will lead to a reduction in service, and the working people who access those extra clinics and appointments will not have the same level of service that they currently do. The Minister must intervene to ensure that we at least have the level of service that we have now.

[Dr Williams]

I thank my hon. Friend for highlighting the potential risks to local patients. This is not about defending the interests of the staff who work in the service, however important they are; it is about ensuring that it is the best service for local patients.

Finally, I quote from the 2017 Conservative election manifesto; I am afraid I do not keep my own copy, but it is still available online. It says:

“We expect GPs to come together to provide greater access”.

It also says:

“If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes. This includes the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy. So we will review the operation of the internal market and, in time for the start of the 2018 financial year, we will make non-legislative changes to remove barriers to the integration of care.”

I ask, then, what the Minster has done and how he has acted to remove barriers to integration of care in Stockton.

GPs in the NHS in Darlington and in Hartlepool and Stockton are doing everything they have been asked to do by this Government and the NHS. They have organised themselves into collectives, and together they are delivering social prescribing and pharmacists in practices, promoting nursing in general practice, introducing new technologies, helping physicians’ associates and training. Those are all good things that I am sure the Minster would support. Integration works. Integration is the right strategy: collaboration, not competition.

Why privatise now, and what is the risk of a private company running this service? The tender encourages competition on price. The lower an organisation’s bid, the more likely it is to win the contract. Cutting costs means less money to pay for things such as the culture lead I mentioned, so the kindness, the looking after staff, the encouragement and the “thank you” cards go, and with them much of the goodwill they bring, which my hon. Friend the Member for Stockton North (Alex Cunningham) talked about.

Would local doctors and nurses want to work for a private organisation motivated by profit? Remember, I said that most local GPs were opposed to extended access only three years ago. Their participation has been carefully nurtured; they have ownership of the organisation delivering the service and they now really care about making it a success. How will the tender process take account of that? Today, we have doctors and nurses working in a service motivated by patient care. How can a for-profit company answerable to remote shareholders recreate that ethos? We have seen this Government’s privatisation failures over and over again, with Circle, Serco and Carillion. This Government are saying one thing about NHS collaboration, but doing another.

I have three questions for the Minister, and I will give him plenty of time to respond. First, why did he let this happen and why did he not intervene to stop it? Secondly, what is he going to do to stop this happening again in other parts of the country? What changes to the law does the Minister think would be helpful? Thirdly, how can he expect the public to trust the Tories on their new integrated care system idea if he cannot guarantee that these new multi-million pound contracts to run all the local health services will not be put out to tender in exactly the same way?

In the Minister’s response, I ask him to either defend this ridiculous privatisation of 1.5 hours of GP services a day, risking a great service being taken away from local GPs and given to a private company, or perhaps to concede that this type of privatisation—a consequence of the Conservatives’ 2012 Act—does not help patients and runs counter to the aims expressed in his party’s election manifesto, the stated aims of his ministerial colleagues and the strategy of NHS England. Maybe he will agree that the law needs to be changed. I look forward to his response.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is a pleasure to serve under your chairmanship, Mr Hosie—it is the first time we have done this. I congratulate the hon. Member for Stockton South (Dr Williams), who I always enjoy listening to, on securing this debate on an important issue for him as both a Member of Parliament and member of the important Health and Social Care Committee, and—as I think he is still—a practising GP.

We know that primary care literally, by definition, comes first. It has always been and always will be the bedrock of the national health service. The Secretary of State and I have made that absolutely clear, and the long-term plan, when it is published later this year, will make it even clearer. As the hon. Gentleman rightly says—I think there is unanimity—we are committed to ensuring that everyone can see their GP at a convenient time by increasing the availability of routine evening and weekend appointments. Millions of patients have already benefited thanks to our investment of some £2.4 billion into general practice by 2021. I join him in paying tribute to his colleagues for making the leap and making that available to his constituents.

We have asked all clinical commissioning groups to ensure by March next year that patients have extended access to general practice across the whole of their registered population. That includes ensuring that access is available during peak times of demand such as bank holidays, and across the Easter, Christmas and new year periods. We have made great strides in delivering extended access, with the vast majority of England now offering weekend and evening appointments. Apologies to you, Mr Hosie—this of course is a devolved matter and we are talking about the English health service. That extended access will, as the hon. Member for Stockton South rightly says, help to reduce the pressures on general practice—it is not all squeezed into the original sessions—and, importantly, to reduce pressures across the wider NHS ahead of winter, which is creeping up on us.

Good access is key to improving quality and is not just access for access’s sake. Problems with access make it harder for people to get the right care from the right person at the right time. It is a publicly funded health service and it is there for the public, and that is what the public say they want. However, for us improving access is not simply about all GPs working seven days a week or doing more of the same. There was certainly a comms failure with the 2012 Act, in that it was allowed to be presented as saying that we just wanted GPs to just do more and to work seven days a week. Many people work seven days a week—all MPs certainly do—but improving access was not just about asking GPs to do more of the same. It can be and often is about practices coming together to offer services to a larger population—I have seen it most recently at the brilliant Granta surgery in Cambridge, which does it very well—using technology in different ways to make it easier for patients to access services, and broadening the skills mix. The hon. Gentleman and I have talked about the multidisciplinary team many times. It is also about working smarter in greater partnership across the health and social care system. The Secretary of State was at Granta just last week.

The hon. Gentleman mentioned the Health and Social Care Act 2012 and asked in effect why we do not just do away with the requirement in that Act—the section 75 rules—so that CCGs are, as he says, no longer required to tender for contracts. Let me assure the hon. Gentleman and you, Mr Hosie, that any fears of privatisation of our NHS are, we think, completely groundless. I do not accept the title of the debate on the Order Paper. The Government are fully committed to the NHS as a public service that is free at the point of need, as it has been since day one in 1948—70 years ago this year, of course—whether care is provided by NHS organisations, as the vast majority is, or by the private, voluntary or social enterprise sectors. That guiding principle remains absolutely the case today. The mechanisms for deciding who provides what service may vary, but the basic structure of our NHS remains exactly the same. The key question is, and will remain, the pragmatic one: how do we best secure the outcomes that we want for patients and the best possible value for the taxpayer? I completely respect the fact that the hon. Gentleman started his speech by saying exactly that. He is spot on, of course.

We should avoid the blanket assumption that one form or other of provision is always the best or worst, as the evidence does not support that sort of sweeping conclusion, which the hon. Gentleman understands. As long as patients receive care that is high quality, timely and free at the point of use, the status of the provider is of little if any significance. That has been the policy of successive Governments for many years. It was certainly the policy of the last Labour Government and was what Tony Blair believed when he was in office. I know that many Opposition Back Benchers do not share the ideology of those on their current Front Bench, which is to make those sweeping conclusions that one form of provision is bad and one good. Where healthcare is free at the point of use, people are not as concerned about who provides the care as we think and often hear in the House. The British social attitudes survey showed that 43% of people had no preference whatever between a private provider, an NHS provider and a not-for-profit organisation.

A clear framework for public sector procurement is both necessary and, we think, desirable, just as it has been since it was introduced in 2006, under a previous Government, to implement the EU procurement directive. It is necessary to ensure that where a local, clinically led CCG decides that it is in the interests of patients and taxpayers to look at a range of potential providers for a service, it is able to do so. That is in the best interests of patients and taxpayers. Securing the best possible treatment for a patient is what we all want to achieve, but we also have to use NHS resources for the good of all patients. Achieving value for money is not just about making the numbers add up. It is about how we ensure that everyone gets the quality of treatment that they deserve.

[Dr Paul Williams]

The Minister has said that the CCG puts things out to procurement when it decides that that is in the interest of patients. Do I understand from his words that the local CCG had the option within the law of not going out to procurement on this service?

[Steve Brine]

I might have to send the hon. Gentleman a note on that, but I will repeat what I said, just for the purposes of accuracy—I know he is seeing the relevant people later this week. Where the clinically led CCG decides that it is in the interests of patients and taxpayers to look at a range of potential providers for a service, it is able to do so. Those are the words I have for him. What we need and have is a sensible, proportionate framework that effectively balances the need of commissioners to secure the best-quality service at the best price with their need to ensure the security and sustainability of supply. It has worked that way and worked well for the past 12 years.

--- Later in debate ---

[Steve Brine]

Let me repeat that the local, clinically led CCG absolutely decided that it was in the interests of patients and taxpayers to look at a range of potential providers for the service that they wanted to be provided. That is the process that it is going through. The hon. Member for Stockton South rightly said that he would not expect me to wade into the middle of the procurement process. I cannot do that, but I will say that sensible, dynamic commissioning will be central to the NHS meeting the challenges that it faces today and in the future despite the commitment to increase the funding by £20.5 billion a year. That is vital to ensure that the NHS delivers on our triple aim of improving quality of care, cost control and population health which, as I am the Public Health Minister and absolutely focused on prevention, is one of my and the new Secretary of State’s key priorities. It is central. To achieve that triple aim, NHS commissioning will need to continue to develop as it has done since its inception. NHS England has designed a new commissioning capability programme to support commissioning systems. The programme provides tailored support delivered through place-based solutions to equip NHS commissioners with the skills they need to deliver on the challenges of today and the future.

Let me stress one of the fundamental principles of the 2012 reforms of the NHS—I served for many weeks on the Standing Committee that considered the Bill. That principle is delegating power away from Whitehall and Ministers such as me, who come and go with political cycles, to local clinical commissioning groups. They are led by fantastic GPs and other local health experts, who are best placed to make the important decisions that matter to local people. Darlington CCG and the Hartlepool and Stockton-on-Tees CCG are rightly making the decisions about how best to ensure that people in their areas have access to a GP when it suits them. Bids for local extended access GP services are currently being closely assessed with a view to the contract starting in April 2019. I have faith that those local commissioners will award this contract in a way that, as I have set out, improves access and quality for patients. Let me say that very clearly: I have faith that those local commissioners will award the contract in a way that I think the hon. Member for Stockton South will find satisfactory.

[Dr Williams]

rose—

[Steve Brine]

We still have two minutes, so I will let the hon. Gentleman come in again.

[Dr Williams]

If the Minister had been asked for his advice as the Minister with responsibility for primary care by the CCG about whether it should put this out to tender, what would his response have been?