NHS and Social Care Commission

Phillip Lee Excerpts

Thursday 28th January 2016 Commons Chamber

[Dr Phillip Lee (Bracknell) (Con)]

It is a pleasure to follow the hon. Member for Leicester West (Liz Kendall) and other colleagues who have spoken. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing the debate.

I broadly support the call for some cross-party engagement to try to secure the future for the national health service, although I will come on to clarify that in my speech. The right hon. Gentleman may encounter some difficulties in seeking cross-party support for financing the NHS, not least because of some of the contributions so far. There are some profound challenges to financing health and social care, primarily because of the challenges that we, and all western societies, face with an ageing population. I remember the Intergenerational Foundation launch here in Parliament a few years ago. Only the former Member for Dulwich and I turned up. At the time, the subject was not much discussed, but I note that it is now increasingly being discussed. We are beginning to do the maths and realise that we cannot afford the current settlement for financing health and social care and that we will have to discuss it at some length. The problem is that one ends up talking about broadly different political philosophies and approaches. Some people, I suspect more on the Conservative Benches, will want to emphasise the need for personal responsibility; others, I suspect more on the Opposition Benches, will want to emphasise collectivisation and the like. That is why I suggest that discussing the financial settlement is possibly a road to nowhere.

I think there is scope, however, for discussion on the structural organisation of the health service: where our hospitals are located and what each individual hospital does. In a week when we have had yet another dreadful failure of the system with the 111 line and out-of-hours services, it is beholden on us to start to discuss what is offered in the out-of-hours arena: how the services are structured and where patients should go to seek the appropriate care for themselves or their children.

The context has been set out by other colleagues. We know that we have a problem of increasing demand, which is driven mainly by ageing, obesity and the welcome advances in surgical practice, technology and drugs. There is also a problem with the health-seeking behaviour of different generations. In my own clinical practice, I am seeing the passing of the stoic wartime generation. Their attitude towards health, and to symptoms of pain and suffering, is noticeably different from that of their children and that will bring increasing demand on healthcare services. If we consider that together with the large cohort who were born between 1945 and 1955, we have an equation that results in a significant deficit.

On the subject of deficits, since I have been here I have seen many faceless NHS bureaucrats come up with numbers relating to likely demand and shortfall. They are always wrong; the figures are usually underestimated. I said at the time that the £20 billion challenge in the previous Parliament was an underestimate of likely demand and here we are talking about £30 billion. What is next: £40 billion? I am glad that a shadow Minister for mental health has been appointed and that people are waking up to the importance of mental health because demands for mental health services in particular will increase the £30 billion figure.

On hospital structure, essentially we have 19th and 20th century buildings trying to deliver 21st century care. Medical and management staff are trying to do their best within this infrastructure, but to be blunt it is not possible to deliver the very best care in all hospitals and in all locations.

[Dr Philippa Whitford]

Is it not also, to some extent, a failure to engage with the public so that they understand how much 21st century medicine has changed? People who have a heart attack are not going to their local casualty department. They are being taken to a heart unit where they will have an angio and an angioplasty. People do not understand that the big boxy paramedic ambulance has everything that an old A&E used to have.

[Dr Lee]

The hon. Lady is right. Tomorrow I will be working as a doctor. I am very proud to be working as a doctor. I have been very public and open about it throughout my time here and I will continue to practise medicine for the foreseeable future. I encourage her to face down her internal critics, as well as those rather ill-informed external critics in the Scottish Daily Mail. I actually stood for election calling for the closure of my local hospital. I did not want my constituents going to an ill-equipped hospital, or thinking that it provided care that it did not. I have sought to educate my local electorate about the need for a 24-hour angio suite and for a 24-hour stroke unit.

We have made some progress on reconfiguration, particularly on stroke care. In London and in Greater Manchester, stroke services have been consolidated. That is why people are now surviving and survival rates for strokes are improving. Patients are taken to appropriate units and appropriately cared for. The appropriate intervention can be applied within the appropriate time. Sadly, that is not possible across the country. It is available only in areas where difficult decisions about reconfiguration have been taken. On oncology, there is a widespread belief that cancer outcomes are all to do with late diagnosis in primary care. Forgive me, but that is not necessarily the whole story. It is the quality of cancer care when patients reach the hospital—any delay in receiving radiotherapy and so on—that is having a profound impact on cancer outcomes. If we consolidated oncology services into fewer sites, we would get better clinical outcomes.

On out-of-hours care, when I turned up here I said that I would scrap out-of-hours care as it is currently constituted. Most people looked at me and thought, “Are you slightly nuts?” The answer is no. Having done many, many, many sessions in the primary care out-of-hours arena, I realised that there was the potential to delay the care of the acutely unwell in a way that could have an adverse impact and, in extremis, lead to someone’s death. I suspect, without knowing the details, that the case we heard about in the urgent question on Tuesday was such an example. I do not believe it is clinically possible to properly assess a sick child via a telephone. We can go some way towards doing it with an adult, because—guess what?—an adult can express themselves more accurately. With a child, we have to see them and touch them, and, in particular, we have to see the mother’s response towards the child, to assess how acutely unwell they are.

The problem, with all best intentions, is that with a telephone service these types of incidents are always going to happen. It was no different with NHS Direct; the medical profession used to get very frustrated with that, and 111 is the same. The symptoms of sepsis can be the symptoms of many things, so if we tighten the protocols we end up flooding the service with more and more people worried that their child has sepsis when, actually, it is not that common.

I would revisit the whole out-of-hours settlement. We could get away with having fewer doctors during antisocial hours primarily looking after the housebound and those who are terminally ill. The list of patients who could be visited by said doctor would be compiled by GP practices in that region. Patients would not get a visit unless the GP practice has said they are entitled to a visit because of a diagnosis of being either terminally ill or housebound. In future, I would put the resources into urgent care centres. For now, I would put one in each casualty to sift through. I would make sure it was a doctor. Forgive me, but doctors are taught to triage and to diagnose. No other healthcare professionals are taught in the same way. The best thing to do is to put one’s most experienced and qualified person at the front end, because then proper triage can take place.

[Dr Tania Mathias (Twickenham) (Con)]

In my constituency, the borough has a brilliant GP-led out-of-hours system that I would invite the Secretary of State to considering rolling out. I appreciate the idea of a commission, but we already have the vanguards and out-of-hours services, such as the one being led from Teddington memorial hospital, which I believe set the right standards. What can a commission do that we cannot do without one?

[Dr Lee]

I thank my hon. Friend for her intervention because it allows me to elaborate. A couple of years ago, I had a meeting with the right hon. Member for Leigh (Andy Burnham)—all the polls were saying that the Opposition would win the election, so I thought I would have a meeting with him in advance. I said, “Look, Andy, you’re going to have a problem. We’ve got all these hospitals. We know some of them are not fit for purpose. We know we’ve probably got too many because of how healthcare has changed. Some 80% of care delivered in the NHS is for chronic conditions. Why don’t you have a cross-party commission so that all the parties can share the political pain of deciding which hospitals should be retained as acute hospitals, delivering the 24-hour stroke and angiography suites, the surgical interventions and the like, and then have more community hospitals, with urgent care centres attached”—the hub-and-spoke model. At the time, he looked at me and said, “Well, maybe”, and made no commitment.

My point was that it was extremely difficult for colleagues in marginal seats to come out and say what I said in my constituency, which was that the current local hospital settlement was not in the best interests of my constituents. It is very hard to do that in a marginal seat, be it Labour, Conservative or whatever, so, with a cross-party commission, we could all share the pain.

All the royal colleges, particularly the paediatricians and obstetricians, know that staffing in some district general hospitals is not ideal. It is extremely difficult to provide the level of care we know we can deliver. How do we get to that point? A couple of years ago, I thought that having all the parties and independent experts in a room would be one way of going from approximately 200 to 100 such hospitals in England and Wales. That is the sort of scale change I am talking about. I hope that that answers the question from my hon. Friend the Member for Twickenham (Dr Mathias).

[Dr Philippa Whitford]

In my constituency, we have hospitals that have grown organically and are not far apart, but we have also seen an increase in the number of modern community hospitals—what people would have called cottage hospitals. The hon. Gentleman says that many of our patients require the management of chronic diseases. We need to take that closer to the public. It is the highly specialised things that should be centralised. The public would accept that, provided they do not get the sense of their hospital disappearing and provided they are aware that other services are coming closer to them.

[Dr Lee]

Again, I agree with the hon. Lady—we are making a habit of this. I held a series of public meetings at which people were initially against my position, but when they understood that I was trying to provide more services closer to home, but that this might mean their having to travel a bit further for acute care, they accepted it and became broadly supportive.

I am under no illusions about the difficulty of all this, but if there is one goal we should all seek in the NHS, it is better clinical outcomes. At the moment, clinical outcomes are not as good as they should be. The much-trumpeted Commonwealth Fund report made that clear. Part of the problem—perhaps a significant part—is where the care is currently being delivered. The junior doctors strikes, which have just been paused; the consultant contracts; the nursing contracts to come—all these would be made easier with a structure in place that is more easily staffed. It would be easier to avoid husband-and-wife doctor teams being split if we had bigger hospitals with bigger staff pools to provide the cover.

We need to concentrate first on the structure of healthcare, and social care—I am conscious I have not spoken about social care, but of course it should be integrated; it is so obvious. But let us concentrate on the structure of healthcare first, as part of a cross-party approach, and then perhaps we can have a debate about finance. I suggest to the right hon. Member for North Norfolk, however, that finance might be a harder nut to crack than the hospitals, on which I think there is a broad consensus that we are all in it for the same outcomes: people recovering from their illnesses; people being treated appropriately when they have operations; and ultimately everybody, irrespective of means, leading long, health lives.