NHS Sustainability and Transformation Plans

Philippa Whitford Excerpts

Wednesday 14th September 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I am sorry that this is such an acrimonious debate. I welcome the principle of the sustainability and transformation plans, as they are a key opportunity to reverse fragmentation and to reintegrate the NHS, but we have to get it right. To turn this whole matter into just a game of moving the deckchairs on the Titanic is something that we would all regret in a few years’ time. We are talking about a place-based approach, which is very similar to what we have in Scotland. I absolutely welcome it, but the places must be right—they need to cover the whole population and the geography must make sense. That is in the relationships of the organisations that are there, but we have to think of things such as public transport. There is no point plonking a community in an STP if there are no connections to it. How these places are designed is really important, as are the partners that are in them. All of this should be about integration and re-integration from acute care through to primary care and local authority care. We need single pathways and wrap-around patient-centred care.

[Andrew Gwynne]

I have some sympathy with what the hon. Lady is saying. Does she agree that that integration will not happen if any one part of those partnerships is severely underfunded? For example, she mentions local authorities. Many of the pressures in the NHS today are solely as a result of the severe underfunding of adult social care. Do we not need to ensure that the finances are in place for these STPs to work?

[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.

[Dr Murrison]

I always listen with great care to what the hon. Lady has to say, and I agree with a great deal of it. Does she agree that part of the problem in England in relation to delayed discharges has been that we have seen a retrenchment of community hospitals and their beds, which have provided step-up, step-down care—intermediate care beds. Unfortunately, they are no longer available, which means inevitably that hospital discharges are delayed, with all the distress that causes.

[Dr Whitford]

I totally agree with the hon. Gentleman. I think it is about care in the home for those who are able to have that and convalescence for those who require it; that, basically, is the step up, step down. In my health board in Ayrshire and Arran, we have rebuilt the three cottage hospitals. They are now modern, state-of-the-art, small units. That means that our population has less far to travel and that older people will not, in the end, need to come to hospital. Now, we are still in that transition; those units are not doing everything they have the potential for—indeed, we are a rural population. However, certainly in Scotland, there is much more recognition that we need intermediate care between people being at home and being looked after by their GP, and people ending up in a very expensive acute unit. It is not just about finance; any Member who has been in hospital knows they do not want to be there, and nor do our elderly population. These levels of care are therefore crucial, and it is important that that grows out of the STPs. I see that as a crucial opportunity for the NHS, which cannot be missed.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

Does the hon. Lady agree that there is a startling fact about the underfunding of social care that Ministers cannot get away from, whatever they do or say? We have heard today of the case of care workers who are suing the contractor that they work for because they were paid only £3.27 an hour. How can somebody be discharged from hospital in an adequate way when that is the domiciliary care that will be waiting for them? It was interesting to hear the former care Minister, the right hon. Member for North East Bedfordshire (Alistair Burt), say this morning that

“we have not got the cost of…adult social care really sorted out.”

[Dr Whitford]

I totally agree with the hon. Lady. I am not sure whether she took part in the carers debate that we had not that long ago, where I pointed out that unless we develop social care as a profession, then we all face a fairly miserable time in our old age. Nursing is a profession that is recognised and valued, and caring for our older ill population should also be recognised. We need to recognise them, to give them time to do their jobs, to pay them adequately, and to give them a career development structure that means that we bring the best people up and get them running teams.

As I said, I am disappointed by the aggression on both sides of the House. I know that such a debate is always a good tennis match for point-scoring, but the development of the STPs is an opportunity to do things that everyone in this House would agree with. However, if it is not done properly—if it is just a fig leaf whereby we pretend that something is being done—the NHS will suffer and we will be the generation of politicians who moved the deckchairs on the Titanic.

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[Dr Wollaston]

I thank the hon. Gentleman for his intervention. As I said, the plans that are produced at the end of the day will be better if we involve those who are using the services and those providing them, as well as those commissioning them, as we go along, rather than present a plan, even if it is a draft, as a fait accompli, because then it becomes a binary choice rather than one where people can make suggestions to improve the plans as they develop.

[Dr Philippa Whitford]

I know that Scotland is a lot easier to get around in population terms, although size and transport are not always that easy, but one of the mechanisms that the Scottish Government use when developing strategies is what they call the national conversation, whereby the ministerial team literally go walkabout and have meetings to hear from people directly before anything goes on paper.

[Dr Wollaston]

If we get too caught up in the process of consultation, we will not address the other serious hurdles in the way of STPs achieving their aims, chief among which is the issue of finance. The NHS is now in its seventh year of a historic level of austerity, and the average of a 1.1% annual uplift in funding for the NHS over the past six years represents an extraordinary challenge in the context of increasing demand. It is good that we are living longer, but we are doing so with much more complex conditions, and the treatments available to tackle them are more expensive. We need to be clear that, because of that, and even though the settlement for health has undoubtedly been generous in relation to other Departments, a significant gap is opening up in health, and the situation is even worse in social care.

Figures from the Association of Directors of Adult Social Services show that 400,000 fewer people are in receipt of social care packages in 2015-16 than there were in 2009-10, and not only are fewer people receiving social care packages, but those packages are smaller. Many STPs are about transferring care into the community. We need to make sure not only that the funding is available to provide those social care packages, but that we have the workforce to deliver them. The proposal in the area that I represent is to close two community hospitals that are used by my constituents. As a former rural general practitioner, I know just how important those facilities are to local people. They are special to them not only because of the step-up, step-down care that they provide and to which the hon. Lady has referred, but because these are the places that more people like to be at the end of their lives. They provide personal care and allow people, particularly those in rural areas who are doubly disadvantaged by not being able to travel to larger local centres, the opportunity to be treated closer to home.

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[Richard Fuller (Bedford) (Con)]

Change in life is frequently a source of anxiety or downright scary. When people are young and change schools, when they get married or when they start a job, that change is scary. There is nothing scarier for a community than change in how its health services are provided, so perhaps it is not surprising that the NHS has found managing change to be one of the most profoundly difficult things to accomplish.

As the hon. Member for Central Ayrshire (Dr Whitford) mentioned, we frequently face substantial or overwhelming challenges in society, with people growing older and having more complex needs, and the requirement for more expensive equipment and supplies to meet ever increasing standards for and expectations of healthcare in our country. The NHS was presented with two options for change. One is radical and will meet those challenges in a fine future that offers great health outcomes for all, but sounds a little too scary. The other option is the incremental approach, which will move things along a little bit. It will not deal with the fundamentals but it will enable us to feel that we retain the institutions and structures with which we are familiar.

As someone who was born in Bedford hospital, grew up in Bedford and now represents Bedford, I am very familiar with each of the buildings and institutions in my community. To see them change is a very scary thing. When we consider processes of change, we have to recognise that the population start from that position of anxiety. It is therefore important that Members do not play on those anxieties. It is not effective opposition to create scare stories ahead of an outcome. That is not in the public interest. We can raise concerns, yes, but in a way that looks to the sensitivities of local situations. That is what I would like to focus on in my remarks: the specific circumstances of my part of the country.

I welcome the STP approach because of the integration of care with health and because it provides local authorities with a voice, for the first time, in decision making about local care choices. For the first time, the NHS will not be getting its own way, if this process lives up to the promise of local decision making. That will be helpful in getting local support and control. In my own locality, we have a cross-party community approach. We have a Liberal Democrat mayor, a Liberal-Labour group on the council and Conservative Members of Parliament. We are all united in an approach of wanting our voice heard on local care in the NHS. An STP is a way of us having that.

[Dr Philippa Whitford]

Would it not therefore have been more effective, particularly if there is cross-party working in the local authority, to have local consultation early on about what could be gained in exchange for what might be felt to be lost?

[Richard Fuller]

I very much appreciate the hon. Lady’s question, because it gets to my point. I am actually quite sceptical about what consultation means. She might not know that Bedford has been through a review process for our acute services. I was trying to measure the length of that process in terms of Members of Parliament for Corby: it preceded Louise Mensch becoming Member of Parliament, carried on through the whole period of Andy Sawford being Member of Parliament, and is now taking up the time of my hon. Friend the Member for Corby (Tom Pursglove). We do not involve Corby any more; it is now just Bedford and Milton Keynes. That process included consultation and participation, with the NHS saying that it wanted to listen to people. It consulted them, yes. Did it listen to them? No. It was the NHS’s own process. It ticked all the boxes, but it was a complete and utter disgrace to local accountability.

I do not have distrust of Pauline Philip, chief executive officer and leader of our STP, and I do not need to know everything. I want to know that our local authorities are having their voice heard in the process just as much as our local CCG, as they are our representatives. I feel relatively comfortable that the process will lead to options that are more acceptable to the population, because it involves local authorities as well as the NHS. We should, however, expect the outcomes of the process to be highly varied around the country. Some will be correct and acceptable, and will go forward. Others will be controversial, and others will be downright wrong. We should not curse this whole process across the country, because it achieves a difference in outcome in different parts of the country. We should be prepared to look at each on its own merits and judge them accordingly.

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[Kwasi Kwarteng (Spelthorne) (Con)]

It is a great honour to be able to speak in this important debate. We have heard some very interesting contributions, and some contributions which were, perhaps, less constructive. I will not state publicly which are which, but I would like to take up what was said by the right hon. Member for Newcastle upon Tyne East (Mr Brown), who spoke of Labour’s commitment to meeting the OECD’s health spending average in 2001.

I think it perfectly acceptable, in a discussion of this kind, to point out that in 2001 the Labour Government had succeeded in running a balanced budget for four years, more or less, and we thought at the time that we had the money to meet that commitment. Having been a member of the Labour Government, the right hon. Gentleman will recall that over the next nine or 10 years we ran consecutive deficits, and as a consequence of policy that I happen to believe was misguided in many instances we had a deficit of £160 billion when the coalition Government took office in 2010. Given the circumstances, it was inevitable that there would be a constraint on finance, and that is something that we have to speak about.

If I recall correctly, the hon. Member for Central Ayrshire (Dr Whitford), whose speech I enjoyed very much, said that we kept talking about finance, and that it should be the third consideration. I wish it were as easy as that—I wish we could relegate finance to a subordinate, back-burner role—but I do not think that that would be fair to the country, or to our constituents.

[Dr Philippa Whitford]

Will the hon. Gentleman give way?

[Kwasi Kwarteng]

Forgive me; I cannot. The debate is very constrained now, in terms of time.

The right hon. Gentleman talked, obviously, about the budget constraints, but he also talked about the fact that we were not spending enough money. I think that the STPs present the opportunity for a serious engagement with what all Members recognise is an ongoing problem. We have a growing population and an ageing population, and inevitably, whether we like it or not, issues of finance and resources will become increasingly important.

I am pleased to learn that local consultation will be at the centre of the draft proposal, because that is essential, and it is what our constituents want. There are two hospitals in my area; one is just outside my constituency but many of my constituents go to it, while Ashford hospital is in the centre of Spelthorne. A number of the facilities have been downgraded—it has been a difficult time—but the borough council and I, as the local Member of Parliament, always tried to explain to residents what was driving the decisions and the changes that we sought to make, and they were broadly very understanding. I think that people throughout the country are very sensible when we explain to them and carry them with us, and that they take a measured view of health services. They realise that the old NHS of Nye Bevan and 1948 has had to evolve. I believe that they are much more open to evolution and change than many Members of Parliament.

The last point that I want to make is slightly negative. I have attended many debates of this kind—not necessarily on the health service, but on the economy and welfare—and all that I hear from Labour Members is the same old mantra: “Stop the cuts, more money.” That seems to be their sole solution to every single problem that we face as a country. It is said that to a man with a hammer, every problem is a nail. Labour Members seem to think that “Stop the cuts, more money” is the answer to everything, and I consider that entirely unconstructive. I find it very disappointing to hear no constructive ideas and no proposals for reform, and to observe no appetite for fresh thinking and absolutely nothing in the way of intellectual engagement with the real problems that we face as a nation. I find it very disappointing to take part in yet another debate and hear the same old mantra: “Stop the cuts, more money.”