Rationing of Surgery

Philip Dunne Excerpts

Tuesday 28th February 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

Madam Deputy Speaker, it is a pleasure to join you this evening. I would like to start by paying tribute to the hon. Member for York Central (Rachael Maskell), who speaks with considerable conviction on this subject. She takes a clear personal interest in it, and she does so as a former clinician, as she indicated, so she speaks with a degree of authority.

The hon. Lady has called this evening for a complete review of CCGs’ decisions to amend their pathways for individuals who are smokers or who achieve a certain body mass index, and I will come on to that shortly. However, I would like to try to reassure her that there is no blanket ban in place in our NHS, and it is our intent to ensure that any decisions about individuals are taken according to the best clinical advice for those individuals.

Madam Deputy Speaker, you will be relieved to hear that, although my remarks will take us to the end of proceedings this evening, they will not necessarily take up the full allotted time. I want to start by talking a little about the fact that we are clearly facing challenges across the NHS, given the persistent increases in demand that our clinicians are seeing across all aspects of the NHS. As Members know, and as we discuss in this House seemingly every day, our attempts to meet that rising demand were set out in the “Five Year Forward View”, and have been endorsed by the Government. They recognise three principal challenges facing the NHS: health and wellbeing, care and quality, and finance and efficiency, and there is an interplay between all those pressures.

We also recognised in the “Five Year Forward View” that different areas face different challenges, so the problems facing York and the Vale of York CCG are not necessarily the same as those facing Yeovil. It is an accident as much of history as anything else—a legacy of the development of services across the country and the patchwork that developed over 150 years or so—that each area is dealing with different challenges. In part, of course, it is also a consequence of population, with those areas with greater populations facing different challenges from those with sparser populations and rural pressures.

We firmly believe that the best way to address local differences and challenges is through clinically led decision making taking place as close to the patient as possible. That is the answer the hon. Lady expected me to give, but it remains at the heart of our belief about the way the NHS should operate. GPs, as members of clinical commissioning groups, are better placed to understand the needs of their patients and the services available to them, and to shape them according to local priorities.

[Margaret Greenwood (Wirral West) (Lab)]

The Minister is talking about clinically led decision making, but in Cheshire and Merseyside CCGs, there have been announcements about rationing particular services. Can he see that, from the point of view of the patient, it sounds like this is just about saving money, rather than clinical decisions? If someone has a condition, and they know the money for it is rationed, they have a real feeling that they are not being treated in the same way as someone with a condition for which the money is not being rationed.

[Mr Dunne]

I do not want to get into an argument about what rationing means, but I do not recognise that services are being rationed. There are pressures as a consequence of increasing demand, and the issue is how that demand is dealt with in relation to specific services, although the hon. Lady did not mention where the rationing—to use her word—applies. Does it apply to patients who have similar issues, as suggested by the hon. Member for York Central?

[Margaret Greenwood]

Wirral clinical commissioning group has said that there will be rationing for vasectomies, surgery for damaged skin, surgical face procedures, arthroscopy shoulder surgery—all sorts of things. There are particular conditions—

[Mr Dunne]

The hon. Lady has made the point that she is referring to different conditions. If she would like to write to me about that, then I can give her a considered answer in relation to her CCG.

We firmly believe that decisions about treatments should be made by clinicians as they determine them to be in the best interests of patients. I will go on to develop what I mean by that in this context. We agree with both hon. Members that blanket bans on treatment are not acceptable and that they are incompatible with the NHS constitution. Every person in England entitled to NHS care has the right to receive treatment that is appropriate to his or her needs, and not to be refused access on unreasonable grounds. CCGs have a statutory duty to meet the reasonable health needs of their local population. They also have a duty to have regard to the need to reduce health inequalities, and to act with a view to improve the safety outcomes of the services they commission. To ensure that they commission cost effectively, CCGs must have regard to NICE guidelines.

I am aware that, as both hon. Members have said, some CCGs have changed their commissioning policies in a way that may have been misunderstood. The hon. Member for York Central referred to specific changes to commissioning policies on surgery, and the manner in which those changes were announced and introduced—in particular, asking patients who smoke or are obese to try to give up smoking or to lose weight in order to ensure that they have the best chances of successful treatment without complications.

It is not for me, particularly as someone without a clinical background, to comment on any of the individual cases that the hon. Lady mentioned. She did not go into specific detail, but she touched on a number of patients who have been offered an alternative pathway treatment—I think that is how the NHS would express the changed circumstances in which their treatment was offered. It is right that clinicians make decisions on an individual basis about the right treatment options for their patients as they present. In some cases, that may involve a direct route to surgery, while in others it may involve some other intervention that might put the patient into a better place to be able to respond most positively to the treatment. If that involves surgery in due course, putting themselves in a better place may lead to better outcomes.

To give an example, tomorrow I am hosting a roundtable on maternity with clinicians and leaders of the all-party parliamentary group on trying to prevent stillbirth. One of the key messages that we try to give expectant mothers is to stop smoking, because, as the hon. Lady recognises, there is a clear correlation between smoking, including smoking prior to pregnancy, and harm in pregnancy. As an ardent non-smoker, I am absolutely convinced that giving up smoking is a desirable outcome for as many of the population as possible who are able to do so. However, it is not for politicians, even those, if I may say so, who have been clinicians, to seek to take over the clinical pathway decision making for their constituents—although of course the hon. Lady was not trying to do that. It is right that clinicians make those decisions based on the individual circumstances.

In relation to Vale of York CCG, I understand that the policy development that the hon. Lady described was developed by Dr Alison Forrester, who is the CCG’s healthcare public health adviser. It was agreed by the CCG clinical executive under the responsibility of Shaun O’Connell, who is the GP lead on the CCG. It was reviewed by NHS England, so the review of the Vale of York CCG’s proposals that the hon. Lady has called for has taken place. NHS England has been working with it to ensure that its policies are in the best interests of patients.

[Rachael Maskell]

The reality is that since the policy has been introduced clinicians have not had jurisdiction over which pathway their patient should follow and which they believe is in their best interests. They are being diverted off that path due to the policy. Clinicians are therefore saying that they should be able to determine the right assessments and treatments for those patients. Also, as part of the NHS constitution, patients need to be part of the co-production of their own healthcare in the future.

[Mr Dunne]

I cannot speak for the CCG. I presume that the hon. Lady’s comments are based on her conversations not only with the clinicians to whom she has referred, but with the CCG management. I assume that the CCG in her area is predominantly led by GPs, as is the case in most other areas. I have referred to the GP lead on the CCG and GPs are involved in making these decisions.

The hon. Lady has rightly said that patients who need an urgent intervention will not be affected by the policy. Patients who may have a need and are supported by their clinicians have an opportunity to apply for an individual funding request. She might like to encourage some of the patients to whom has referred to do that, to see how that process goes. That might be a route for some of those individuals.

I am in danger of breaching my promise to conclude my remarks before the set time. I want to give the hon. Lady an appreciation of the pressures that her own area is under and put the issue in a national context. We recognise that the Vale of York has had some financial pressures in recent years. Its budget increased to £394 million this year—that 3% increase is close to the average across England—and it will rise to £402 million next year. However, we recognise that the CCG is in deficit this year. It was subject to directions from last September, as part of which an interim accountable officer was appointed and is working with NHS England to put together a medium-term financial strategy. NHS England recognises that there have been pressures in the area and it is seeking to get on top of them.

On procedures, across England as a whole—this gives an idea of the demand—there were 11.6 million operations in 2016, which was 1.9 million more than in 2010, meaning a 16% increase across the country. More locally, the York Teaching Hospital NHS Foundation Trust performed more than 106,000 operations in the last financial year, which was almost 53,000 more than in 2009-10.

[Rachael Maskell]

rose—

[Mr Dunne]

I am afraid that I have to conclude. As far as the performance of referral to treatment is concerned, the Vale of York has performed better than many other areas in the country. The percentage of patients seen within 18 weeks of referral in the Vale of York was 94% in December 2015, compared with 92% in the north of England. In 2014, the figure was 95% compared with 94% in the north of England and 93% across England. It is therefore outperforming its peers in the area and across the country. I hope that the hon. Lady recognises that.

Question put and agreed to.