NHS (Contracts and Conditions)

Philippa Whitford Excerpts

Monday 14th September 2015 Westminster Hall

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

I declare an interest: I am a doctor and member of the British Medical Association, and I still work in the hospital.

We are talking about data showing that people admitted at the weekend are more likely to die within 30 days than those admitted on weekdays. It is important to listen to what Bruce Keogh said, which is that it would be misleading to assume that all of those deaths could be prevented. We use terms as if the deaths were avoidable or talk about people “dying unnecessarily”, but we do not know. We must understand what the data show. There is nothing wrong with the data and nothing that can ever be bigger, because the NHS is the biggest single health service in the world. Professor Freemantle has done the work twice and the pattern is there, but it is not people dying at the weekend; it is important to realise that his data show the reverse. They show fewer people dying on a Saturday or Sunday then dying on a Wednesday. What is higher is the number of people who are admitted, and we need to understand that. As the hon. Member for Totnes (Dr Wollaston) said, they are sicker people. On a Saturday, there are 25% more people in the most ill category and on a Sunday there are 35% more people in that category.

[Mrs Cheryl Gillan in the Chair]

It was said that there was an increased number of deaths among elective patients admitted on a Sunday, and people wondered why that was. As a surgeon with a Monday list, I can say that the norm now is that patients come in on the morning of surgery. So, for me to get permission for someone to come in on a Sunday, let alone a Saturday, means that that person has complex co-morbidity. If we are simply looking at additional populations, we cannot simply use a broad sweep and assume that all of this can be changed, because it cannot be; these people are inherently more ill, whether they are elective patients or emergency patients. Those data are absolutely there and they remain when we re-analyse them or try to balance them, so this issue needs to be tackled.

There are a few myths going around, including the idea that the opt-out clause is a major barrier. The opt-out clause that was cited was for routine work. Consultants do not get to opt out of emergency work at night or at weekends if they work in an acute service. If a consultant works in a service where acute provision is at all relevant, that acute provision is part of what they do and they do not get to opt out of it. Nine out of 10 consultants work out of hours and the other 10% are engaged in specialties for which there is not an acute service.

There has been talk about getting people to work for only 40 hours. My colleagues who are still up the road holding it together work for 48 hours and they simply cannot work more than that because it is illegal under the European working time directive to do so. Most consultants within the acute system work 48 hours a week, and I am sure that those of us who are married to them or simply aware of them will be well aware of that fact; indeed, we will have been told that in no uncertain terms in the last few months.

It is important that we focus what we do on trying to save the lives of those among those 11,000 people who can be saved. When I was a junior doctor, I was aware that getting scans out of hours or at weekends was very difficult, and so patients hit “pause” for a few days. I do not think there is that much difference in services; I find it hard to believe that there is. In Scotland, the situation has been changing for five or 10 years, not by threatening or cajoling people but simply by evolving. Our consultant radiologists cover the entire weekend; our stroke patients get CTs; and our heart attack patients go straight to get angiography, will get an angioplasty there and then, and will go home after breakfast the next morning. So this idea that we have big tracts of those in medicine sitting home watching “Coronation Street” is not true.

The NHS will be cash-strapped; it has to save £22 billion per year in the next five years, which is a big challenge. So now is not the time to say, “We can provide GP services eight to eight, seven days a week.” The pilots have not been successful. The uptake was 50% for Saturday and 12% for Sunday, and some of those pilots reported that there was great difficulty in covering the out-of-hours GP service, which people who feel unwell should be going to, because what was being talked about was totally routine.

Both in hospital and in primary care, we need to focus our attention on improving the access for people who feel unwell, which includes people being able to access a GP and not having to go to A&E with something that means they do not need to be there. That is recognised within the profession, but it is important for people to work together towards that aim rather than pulling out the pin and throwing a grenade at somebody, which is obviously how the profession regards what has happened during the summer. Like many people in Westminster Hall today, I was inundated by messages from colleagues, including from doctors south of the border who I do not know at all. They were very angry at the statement on 16 July that senior doctors do not work outside 9 to 5, which is patently not true.

We need to look at what we should do about these figures. One of the groups that shows the effect of this situation very strikingly is stroke patients. However, research by Bray looked at 103 stroke units, including units where there was seven-day consultant review through the day, and compared them. There was absolutely no difference between that seven-day service and units where there was a routine ward round and no ward rounds at the weekend. What made a significant difference was the ratio of fully trained registered nurses to patients. When that ratio was halved, so that there were twice as many nurses, the mortality was reduced by a third. So, before we go rushing into policy, even if we are working cross-party it is important to understand the data sufficiently to answer the question, “Do we need more doctors or do we actually need more nurses?” That is a pretty important question to answer before any moves are made.

It is also important to focus on the emergency side. People say, “Well, Tesco is open 24/7”. Actually, it is not open 24/7 totally. People will not find the fishmonger 24/7; the baker will not be making fresh bread; and there will not a butcher producing fresh cuts of meat. It will be the basic system that is open 24/7, so let us not confuse matters. And frankly, we can generate a person to work in Tesco, stacking shelves or operating the till, an awful lot quicker than we can create a GP, which will take 10 years because there are five years of medical school and then five years of training, or a consultant, which requires five years of medical school and—in my time—about 15 or 16 years of training.

There is no quick fix for this situation and we cannot afford to take on extra staff, but actually the money would be the easiest bit because we do not have the extra staff. The Government talk about 5,000 extra GPs and yet the British Medical Association shows that we will lose 10,000 GPs in the next five years. That means that we would need 15,000 GPs, and we simply cannot produce that number. So we need to ensure that we hang on to all the doctors we have, including the junior doctors, because that partly comes down to what those junior doctors see, including how they see their seniors working and what they think of that as a career. I say that because junior doctors have always gone to places such as Australia but they used to come back; now they are not coming back.

This whole matter could have been handled better, but the issue is working with people. The Scottish Government are also working towards seven-day cover, but they have been very clear that what they are talking about—the priority within that system—is seven-day cover for people who are ill. That means expanding the out-of-hours service for GPs and expanding what is available to us as senior doctors inside hospitals. That is the route that must be followed, and not the use of a grenade.

After the Francis report and the increase in the number of nurses being taken on to try to get the figures that are sought, what we had at the beginning of the summer was trusts that are struggling being told, “Cut back. Don’t use agencies. Don’t replace people unless they’re absolutely crucial.” We need to give serious thought about whether it is actually more nurses that we need before we rush in to bring in a whole lot—

[Maria Caulfield]

I welcome the hon. Lady’s thoughts and agree with a lot of what she has said. On the issue of nurses, does she agree that it is not just the number of nurses that matters but the skills mix? Because of budget constraints, what has happened over the past two decades is that the skill of senior nurses has been cut back, and those senior nurses are now often not on duty at nights and weekends, which has made a crucial difference.

[Dr Whitford]

I made the point that Bray’s paper talked about registered nurses—so, degree nurses—and that reflects the skill mix.

We need to know what the actual problem is rather than just running in and throwing ideas and policies around. Attacking staff who work very hard and for really long hours is not very fruitful. We need NHS staff to believe in the political decisions, the guidance and the direction being taken in the future, so I simply suggest that everyone in this House look at the way forward.

[Mrs Cheryl Gillan (in the Chair)]

When time permits, it is our practice in Westminster Hall that when a Member has been here for the opening speeches and then had to step out temporarily, we give them the opportunity to speak. So I call Andrea Jenkyns to speak.

--- Later in debate ---

[Ben Gummer]

Those are very reasonable questions. If the hon. Lady will allow me to continue with what I was setting out, I will certainly answer them.

That assortment of academic research, together with the wide anecdotal evidence from people who have experienced poor care in good hospitals, either for themselves or for their relatives, led NHS England to conduct the Seven Days a Week forum in 2013, which gathered together clinicians to look at the challenge. It produced a clear strategy for dealing with differences in care quality at weekends, compared with the week, and set out 10 clinical standards that it believes hospitals must meet to eradicate the difference between weekday and weekend working. Many hospitals are implementing the 10 clinical standards on a variable basis during weekdays, so the work done for weekends was helpful in determining a standard clinical approach for maximising the ability to reduce avoidable deaths for weekend and weekday admittances. The product of that forum was taken forward by NHS England and incorporated into its five-year forward view, in which the NHS, separately from the Government, made a commitment to seven-day services. It did so not because of the benefits to patients—as my hon. Friend the Member for Sutton and Cheam (Paul Scully) said, that is a secondary reason for pursuing the agenda—but purely because of the need to reduce excess mortality where possible.

This is a challenge on the scale of infections in hospitals. It is our duty not only to find out precisely why excess deaths are happening—as the hon. Member for Central Ayrshire correctly said, further work is needed and the data must be understood—but to do what we can as quickly as possible to reduce them where we think they are preventable. That is why NHS England incorporated the seven-day service into its five-year forward view. NHS England asked for an additional £30 billion of spending between 2015 and 2020, of which it said £22 billion can be achieved through efficiencies within the service. It is important to point out to the hon. Member for Warrington North, who made that point, that they are not cuts but genuine efficiencies within the organisation. On top of the £22 billion of internal efficiencies though a better use of IT, to which she alluded, and better job rostering—I will turn to that in a minute—there will need to be an injection of £8 billion to make up the rest of the £30 billion. That package will implement the five-year forward view, which includes seven-day services and many other things of great importance and about which all parties agree, such as shifting resources from providers to primary care, social care and the community sector.

This programme was not invented by the Secretary of State in a speech given to annoy doctors and consultants, much as that might be the impression given by some people on Twitter. It is the policy response of a Government taking seriously the clinical evidence and advice of NHS England, led by Professor Sir Bruce Keogh. We are responding to give NHS England and the providers tools with which they can deliver a seven-day NHS service in hospitals and GP practices.

I turn to the changes in the contracts, which are at the heart of the petition and the speech of the hon. Member for Warrington North. The contract terms are based on a review by the doctors and dentists pay review body, which identified a number of areas where contract reform is needed, including the systems of opt-out and on call. It asked a completely reasonable question: why should it be that some members of the workforce, who are expected to work at weekends as part of their normal shift patterns, do not have the option of an opt-out from their contract, while others—who tend, as it happens, to be far more highly paid than those who do not have the option of an opt-out—do? It proposed a series of changes, which in our view make up a far better contract for both junior doctors and consultants. On balance, we feel that it presents a real opportunity for consultants and doctors to improve not only their working conditions but, in some cases, their pay.

To take some salient examples from the consultants’ contract, we want a far more equitable and reasonable distribution of clinical excellence awards—many consultants are privately critical of how they are awarded—within not a cut to the total consultant budget, but exactly the same existing pay framework.

[Dr Philippa Whitford]

To point out a slight difference, we do not have those awards in Scotland. We have local discretionary points, but the national clinical awards have been done away with for quite some time. Much as we also struggle with staff, we have not been haemorrhaging them south on that basis.

[Ben Gummer]

The hon. Lady points out that contractual differences already exist between NHS Scotland and NHS England. Officials have looked with interest at the experience of NHS Scotland—one of the pleasures of the devolved NHS system is that we can all learn things from one another. I hope that the new replacement of the clinical excellence award will be perceived as far fairer by clinicians and will reward those surgeons who are giving their utmost in academic research and the professional development of others. That is a tangible improvement to consultants’ terms.

It is important to point out, as several of my hon. Friends have done, that we are talking about ensuring that, at most, consultants work no more than one weekend in every four. That is the basis on which they will be contracted to work in a seven-day NHS. We are not talking about seven days at a time, but about shift rotas and patterns, as many people in professional life already recognise, not least some of those who have spoken in this Chamber. We need to get to a situation in which NHS professionals at the top, as well as those at the bottom, are trusted to organise their life and work patterns according to the professionalism they hold so dear. Many consultants in the NHS want to move to contract reform so that they may express their professionalism in that way, and we need to ensure that it happens so as to bring them with us, rather than its being forced on them.

For that reason, I am delighted that the consultants committee of the BMA has agreed to rejoin negotiations. It has seen that there is a basis for reaching an agreement, which suggests—contrary to some of what has been said by Opposition Members—that things are being done with a sense of collaboration. We have wanted to enter the negotiations for some time. The BMA, for reasons no doubt connected with the election—probably understandably—decided to withdraw from negotiations, but it has now come back. We and the consultants committee can reach a good position on the proposed contract.

The junior doctors’ contract is a proposal of great strength, not least because we include a significant increase in basic pay rates, which should be welcomed across the board. The contract addresses one of the points made by the hon. Member for Warrington North and does something important for the way in which junior doctors are perceived by their management. Instead of offering, in effect, danger money for excess hours, which is surely not the way to manage a workforce, it gives junior doctors a right to a review of their hours, so that they may properly manage their work rotas and patterns. For the first time, that will be enshrined in their contract. They will have far more predictable work patterns; providers—employers—will be forced to think seriously about work-life balance when constructing the roster; and, on pay and on the offer to juniors for their working life, the proposed contract will produce a far happier outcome.

I had hoped that the juniors committee would already have agreed to come back to the table, and I remain hopeful. The committee is meeting imminently—in six minutes’ time, in fact—and I hope that it is listening to the words in this Chamber, because hon. Members and others listening have heard nothing from both Government and Opposition Members but unalloyed praise for NHS staff and a real desire to work cross-party to secure the kinds of advances in quality that everyone wishes to see. With the juniors at the table, we could reach a constructive and reasonable resolution to the need to change their contract. That need was impressed on Ministers not only by the DDRB—the review body on doctors and dentists remuneration, but by the NHS’s own independent pay review body. Many in the service, perhaps more quietly than those who have been most exercised on Twitter, know that it is necessary.