Healthcare Optimisation Plan: Kirklees

Paula Sherriff Excerpts

Tuesday 12th December 2017 Westminster Hall

[Paula Sherriff (Dewsbury) (Lab)]

I beg to move,

That this House has considered the healthcare optimisation plan, Kirklees.

It is a pleasure to serve under your chairmanship, as always, Mr Hollobone. As is now widely acknowledged, our NHS is under ever-increasing pressure, and budgets are stretched beyond capacity in almost every part of the country. In my area of Kirklees, we face unprecedented cuts and challenges. Both of the local hospitals that serve my constituency have been subjected to downgrades and the closure of vital services.

The financial challenge in health services across Kirklees is unprecedented. There are reports that deficits are forecast to reach record levels by the end of this financial year. Sadly, that is mirrored across the country as a result of the Government’s onslaught of cuts to our public services. To be frank, our NHS is being starved of money to the point at which lives are being put in danger, and financial decisions are being given priority over clinical judgments. Every day, we see the pressure that the NHS is under. Hospital waiting times are up, it is harder than ever to get a GP appointment, ambulance waits are increasing, and hospital wards are seriously understaffed. As the weather turns to freezing, we are all fearful of a repeat of last year’s winter pressures, when people were dying on hospital trolleys, waiting to be seen.

Only this week, the highly respected Lord Kerslake resigned his post as chair of King’s College Hospital board, claiming that NHS funding desperately needs a rethink and that the demands for savings are unrealistic. That came on the back of comments from NHS England’s chairman and its former national medical director, following their disappointment that sufficient money was not made available in last month’s Budget.

The chairman, Professor Sir Malcolm Grant, said:

“We can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available.”

Professor Sir Bruce Keogh added his personal view:

“Budget plugs some, but”

definitely

“not all, of NHS funding gap”,

which would

“force a debate about what the public can and can’t expect from the NHS”.

He added that it was:

“Worrying that longer waits seem likely/unavoidable.”

In the face of such financial pressures, the two clinical commissioning groups covering my constituency, North Kirklees and Greater Huddersfield, have recently released plans to introduce what they refer to as a health optimisation programme, which would restrict access to elective surgery for those who smoke or who are obese. Make no mistake, whatever title is given to the scheme, it is nothing more than a thinly hidden attempt at rationing healthcare for those in need. Smokers would be given six months to quit, and for those who are considered to be obese—measured by a body mass index of more than 30—the requirement would be to lose 10% of their body weight within 12 months.

[Thelma Walker (Colne Valley) (Lab)]

Does my hon. Friend agree with me that the use of BMI to classify whether someone is obese is, frankly, laughable? Does she agree that Greater Huddersfield CCG needs to look at an alternative measure that would not put Huddersfield Giants prop forward Sebastine Ikahihifo, whose BMI is 32.3, in that category?

[Paula Sherriff]

I thank my hon. Friend and neighbour for her very valid intervention. I was just about to say that BMI is very subjective. As we are all aware, some high-performance athletes or bodybuilders have a BMI higher than 30 but are at the peak of health.

Obviously I agree that any moves to aid weight loss and stop people smoking are a good thing, but not at the expense of excluding people from NHS treatment. If the CCGs were so determined to achieve better outcomes in those areas, they would invest in better smoking cessation services and weight-loss programmes, but the reality is that in recent years those services have been among the ones to suffer cuts.

Given the budget restrictions and taking into account the views of the professionals, who advise that there is little if any evidence in support of any improved outcomes as a consequence of such measures, I can only draw the conclusion that the proposals to ration surgery are nothing more than a cost-saving exercise. The CCGs argue vehemently against that view, but North Kirklees CCG admits that health optimisation is one of 21 cost-saving measures identified to meet the existing financial challenge that might see its deficit rise well beyond predicted levels by the end of the financial year. At best, it seems to be an ill-conceived plan that has not been thought through correctly.

As anyone involved in healthcare knows, the providers and commissioners in any area often form a hectic Venn diagram. That is no different in the borough of Kirklees where my constituency lies. The two hospital trusts that serve my constituency are overseen by four CCGs. Of those, only three are considering and proposing to implement a health optimisation programme. That means, in effect, not only a postcode lottery but a waiting list for elective surgery—a smoker from Wakefield might be allowed on to the list while his or her equivalent in Dewsbury, some nine miles away, would be forced to wait six months before even being considered for surgery. That would be completely unjust, unfair and morally wrong. The irony is that those same two patients would have their surgery in the same hospital.

When reading further into the small print of how health optimisation would work, I became even more alarmed. The decision on whether people can be referred for treatment would lie initially with their GP. He or she is able to make the decision on whether to refer or to put the patient on the health optimisation programme. Patients put on the programme would have six months to quit smoking or 12 months to lose weight. After that time they would be referred to a specialist who would decide if they qualified for treatment. My understanding is that that means, in effect, people could lose 10% of their body weight in the hope of receiving a knee or hip replacement, for example, only to be told that they do not qualify for the surgery. Not only that, but one month from the end of the programme, patients are asked if they still wish to be referred. That is where louder alarm bells started to ring for me. It is absolutely clear that the decision on whether to operate, or whether the patient needs surgery, must be made by the relevant surgeon and not by people who do not have all the facts in front of them.

I ask Members to picture this scenario: Mrs Smith has been told that she has to lose 3 stone before she can be referred to a specialist regarding the pain in her knee. She tries to lose weight but finds it incredibly difficult, not least because her knee pain prevents her from exercising. Mainly being housebound affects her mental health, causing depression, which in turn leads to comfort eating. She tries to attend the weight management group that she was referred to but becomes disheartened and embarrassed when each week her weight either stays the same or increases, so she stops going. After 11 months she receives a letter asking her if she still wants a referral to an orthopaedic specialist to look at her knee. She knows that her weight has actually increased so she ignores the letter, because the thought of having to face up to her weight gain is far too humiliating. The pain in her knee is now excruciating, but she dare not face the surgeon when she feels such a failure. That could be a very real outcome if the plans are implemented. The NHS might save money and waiting lists could look far better, but what about the human cost? I implore the Minister to think about just that—the human cost.

A list of exceptions in the rationing proposals include: conditions that are immediately life threatening; patients who require emergency surgery or have a clinically urgent need where undue delay would cause clinical risk of harm; and patients undergoing surgery for cancer. Nowhere do the proposals mention any measure of the patient’s quality of life. I have heard stories from constituents who have had to give up work because their mobility has become so restricted while waiting for knee or hip operations, or whose weight has increased to levels of obesity simply because they cannot walk or exercise like they used to. How does naming and shaming those people on a rationing list improve their quality of life?

I also ask the Minister where the rationing ends. Is there a plan to stop providing surgery and treatment for, perhaps, people who play rugby, or teenagers who break their leg horse riding? Would we say, “No, you can’t have surgery, because your own actions led to this”? What about people who drink alcohol moderately? Would we say, “You cannot have treatment for your liver sclerosis because this is a lifestyle choice”? Is this the start of the beginning of a much bigger rationing programme?

In preparation for the health optimisation programme, Greater Huddersfield and North Kirklees CCGs stated that they had carried out a public engagement exercise. On research, I found the questions that they had asked, which included: “Please tell us how we could encourage people in Kirklees to live a healthy lifestyle?”; “Please tell us what support you think should be available to help people lose weight and stop smoking before their surgery?”; “When and how do you think that support should be provided?”; and, “Please use this space to provide any additional comments you have about supporting people to lose weight or stop smoking?”. Nowhere did the questions ask for opinions on whether people should be excluded from surgery because they are overweight or smoke. The CCGs’ failure to be up front and honest about their proposals can only indicate their embarrassment at having to implement such a scheme simply as a result of budget restraints.

Statistics show that approximately 30% of the population of Kirklees either smoke or have a BMI of more than 30, so almost one in every three people in my constituency could be turned down for elective surgery. North Kirklees and Greater Huddersfield CCGs acknowledge that there is not enough existing provision to support people being put on to the health optimisation programme, whether in smoking cessation services or weight-loss programmes. In the health optimisation programme proposal, the CCGs state that they will undertake a tender exercise for a

“‘Zero Value - Activity based’ contract with additional providers”.

What that means is anyone’s guess, but I strongly suspect that no new money will be made available, given the financial position of our local NHS services.

The plans have so many pitfalls that they simply must not be implemented, and the Minister can be sure that I will fight them every step of the way. Clinical commissioning groups should not face such intolerable choices. I do not believe that anyone delivering healthcare entered the profession to make cuts or to restrict people from receiving treatment that they desperately need to improve their quality of life. I therefore call on the CCGs to halt their plans to introduce the health optimisation programme for all the reasons that I have listed and many more. I ask the Government to listen to the experts, including the Royal College of Surgeons, to put an end to the draconian cuts and to provide us with a fully funded healthcare system that is accessible to all.

I would like to finish with a quote that I have used many times before, both in this Chamber and away from it. Nye Bevan, the founder of our great national health service, said that the NHS will last as long as there are folk left with the faith to fight for it. I will never lose faith or stop fighting. I hope that the Minister will say the same.

[Mr Philip Hollobone (in the Chair)]

The debate can last until 5.30 pm. There is one Member who wishes to speak, and before the debate ends, Paula Sherriff will have three minutes to make her concluding remarks. The guideline limits on speeches are ten minutes for Her Majesty’s Opposition and ten minutes for the Minister, but I expect that they will be able to speak a little longer. I call Rachael Maskell.

--- Later in debate ---

[Mr Dunne]

I do not accept that. It is important that we use all the tools at our disposal to encourage the public to lead healthy lives where possible. These measures form part of the suite of measures that are necessary to bring that about.

The Government have backed the five year forward view. Opposition Members raised the issue of finances. We have committed to a real-terms increase in funding through the spending review period. Most recently, in the Budget only last month, we committed an additional £2.8 billion on top of the £8 billion real-terms increase by 2020. We are providing significant extra resource, but we recognise that different areas of the country will face different challenges and so will develop different approaches to how they use their resources most effectively in patients’ interests. That will inevitably involve making difficult decisions. It is right that we trust local NHS organisations, clinically led, to make those decisions, rather than second-guessing them centrally.

Having said that, we have set certain expectations of the system, one of which is that blanket bans on treatments are completely unacceptable and incompatible with the NHS constitution. That is why I refute the challenge from Opposition Members to say whether or not we are imposing rationing on the NHS. The local management responsible for the NHS in their areas have to respect the constitution and should not introduce blanket bans, but they do have to look at ways to provide care for their populations in a manner that lives within the budgets they have been provided with.

[Paula Sherriff]

I have listened to the Minister carefully. Can he explain why he feels it is acceptable that someone in Wakefield could have surgery, while someone nine miles away in Dewsbury could not? They might both be smokers, and the surgery would be carried out by the same surgeon, probably in the same hospital. Are we not in danger of going into a very big postcode lottery once again?

[Mr Dunne]

The hon. Lady made that point in her remarks, and I will try to address it. She can pick me up on that again.

[Mr Dunne]

I will come on to that. We are talking primarily about what is happening in North Kirklees and Greater Huddersfield CCG areas, which have not yet implemented this policy. I will explain why I do not think that that should be the case.

On the healthcare optimisation plan, I take the gentle chiding from the hon. Member for Ellesmere Port and Neston (Justin Madders) about the way in which the NHS describes proposals. I have some sympathy with what he says about the way in which language is used, but this is a plan to encourage greater public health among the population of North Kirklees and Greater Huddersfield CCG areas, for which they are responsible. I talked to the CCGs in preparation for the debate and was advised that they do not see this as a blanket ban on treatment. I have emphasised to them that they should not do so and that there should not be a blanket ban on treatment.

I will describe the proposals, as I understand them. They have been developed by the CCGs since autumn 2016, and the objective is that patients who are overweight with a body mass index of 30 or above will have 12 months to lose at least 10% of their overall weight or to reduce their BMI to less than 30, while patients who smoke will be encouraged to take up to six months to quit smoking before undergoing routine surgery. Those who quit smoking for four weeks or achieve their target weight loss will be able to be referred for surgery under the policy.

The development of the plan coincided with the UK’s childhood obesity strategy and the proposed introduction of the soft drinks industry levy, reflecting the Government’s commitment to tackling the major public health problems affecting large sections of society. The hon. Member for Dewsbury and the hon. Member for York Central recognised the need to address the obesity crisis in this country. I am grateful for their support and that of the Opposition spokesman, the hon. Member for Ellesmere Port and Neston. I think we are united in recognising that something has to be done about this. I hope they support the proposals that the Government have made for the obesity strategy and the considerable progress we have made in reducing smoking since 2010. Hon. Members have made the point that the policy should not be at the expense of treatment if treatment is urgent or, if there is no treatment, it might lead to degradation of the health condition of the patient subject to the policy.

[Paula Sherriff]

I thank the Minister for his generosity in giving way. Does he agree that the decision must be made by a surgeon? That is so important, because they are highly trained and are surely the ones who can come to a decision on whether the patient can wait.

[Mr Dunne]

I will come on to that. The short answer is that I agree that the relevant clinicians should make those decisions.

Going back to where the CCGs are in this process, as I said earlier, they have not yet introduced the proposal. They have been working with the local population and with Healthwatch Kirklees, and have held a number of engagement events with local authorities and interested stakeholders to try to understand the reaction of those parties to the proposal. An engagement event was conducted in March and April of this year, and one with Kirklees Council in August and September of this year.

The CCGs have listened and responded to some of the points made. They have made several changes to their original proposals, including exempting children from the programme. They also recognise the limitations—amusingly identified by hon. Members in their contributions—of using BMI as a measure of body weight. Therefore, for example, people with high muscle mass should be excluded from the BMI calculation for the reasons that were well explained earlier in the debate.

The CCGs are including safeguards in the proposals, and they intend that, in exceptional circumstances, normal individual funding request processes will continue to apply. Hon. Members have criticised that as imposing an undue obligation on the individual to seek that route to secure treatment. That is effectively an appeal mechanism that applies across the NHS and is a well-worn and well-understood path for clinicians to support individual funding requests for patients where needed, which we should continue.

Both the hon. Member for Dewsbury and the hon. Member for York Central used the expression “lives at risk”. I would gently say that there is absolutely no intention that policies such as this should lead to lives being at risk. They are about trying to put individuals in a position where their own circumstances would lead to better outcomes from the proposed surgery. The hon. Ladies have called for evidence supporting the proposition —it was raised by the hon. Member for York Central when we met at the end of last month. I have asked for that evidence. A number of research papers support the propositions made by the CCG, in particular on the question whether obesity at the time of surgery is associated with a wide range of problems. Sustaining weight loss is the key. Rapid weight loss followed by rapid weight gain clearly do not help the patient, but the evidence from the research papers provided to me is that maintained weight loss or cessation of smoking undoubtedly and clearly have clinical benefits for the patient. There is evidence to support that.

I will come back to the point raised earlier on by the hon. Member for Dewsbury and the hon. Member for York Central, but I absolutely recognise that the clinician primarily responsible for the care, whether that is the GP or the secondary clinician, should have discretion to ensure that a referral is made, should a non-referral of a patient or a delayed procedure outweigh any benefits from a period of improving health and reducing risk factors prior to a routine operation. We will encourage the CCGs to ensure that that is in their final proposals, once those are made.

--- Later in debate ---

[Paula Sherriff]

I thank the Minister for his considered response. Like the vast majority of MPs in the House from all parties, I care deeply about the NHS. However, I am getting slightly fed up with the platitudes that we hear day in, day out from the Government regarding their putting extra funding in. The NHS is in crisis, and I say that as someone who worked in the health service for nearly 13 years immediately before becoming an MP. I hear it from ex-colleagues of different political persuasions nearly every single day.

I maintain that the concept of the health optimisation plan in Kirklees, and undoubtedly those elsewhere, is deeply flawed. I plead with the Minister to use his influence to engage with the CCGs and to encourage them to go with option 4. I think we all agree that stopping smoking and losing weight is a good thing—my goodness, I could follow some of that advice—but not at the expense of people being in pain and potentially affecting their mental health, or of having a postcode lottery. I discussed the Wakefield-Dewsbury case with the Minister. That is happening, and it will happen because of the false borders to which my hon. Friend the Member for York Central (Rachael Maskell) rightly alluded.

My mum suffers from severe rheumatoid arthritis and has had it since childhood. She is 73 on Friday. A few years ago she started taking a drug that gives her a quality of life that she never had—she started using it as a guinea pig and has continued to use it. It used to take her hours every day to open her hand. She was in so much pain. I once found her at the top of the stairs and she could not go down them. She was crying.

She said to me on the phone one day that she is terrified that the Government will stop her receiving those drugs, because they are not cheap. I told her not to be silly. She knows that her quality of life would severely deteriorate once again if they did, and that she would probably be in a wheelchair. I am not sure I could say that to her now, because this plan is rationing, plain and simple. I cannot have that conversation and tell her that the Government will not stop her receiving the drugs because they are expensive.

I want the Minister think about that in the wider context. She is a 73-year-old woman. Is her life, and those of all the people affected, worth less than ours? We would not stand for our healthcare being rationed. I certainly would not.