Accident and Emergency Waiting Times
Phillip Lee Excerpts(11 years, 1 month ago)
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Dr Phillip Lee (Bracknell) (Con)
It is a pleasure to follow the hon. Member for Ealing North (Stephen Pound). I agreed with some of the points that he made, but I did not agree with all his conclusions and he may not agree with mine.
It is striking that nobody has mentioned the report that was published today by the NHS Confederation and the Academy of Medical Royal Colleges. That report calls for the closure of hospitals and indicates that the funding model for health care in this country is not sustainable in the medium to long term. It is significant that so many organisations that should be respected by this Chamber have come to such difficult and politically unpalatable conclusions.
I have been encouraged by some of the contributions from the Back Benches in the past hour or so. There has been mention of the drivers of demand in this country and across western society, such as ageing, obesity and increased drug and technology costs. As was mentioned by the hon. Member for Ealing North, there has also been a significant change in attitude, which is difficult politically. Essentially, the population is becoming a bit softer. The generation that survived the war, a more stoic generation, would not think or dream of calling their GP in the middle of the night unless their arms were dropping off, but they are passing away and are being replaced by people who think it appropriate to call their GP at midnight because they have had a sore throat for a couple of hours. Clearly, that is not sustainable.
The challenge of the A and E crisis, which is the reason for this debate, is I suspect a first manifestation of evidence that the system is not fit for purpose. It is not fit for purpose before the baby boomer generation hit their 70s, and we should mull on that. We should also recognise the fact that change is inevitable and that hospital closures and reconfigurations will have to take place. My conclusion on how to deal with that is not party political.
An ideological legacy is in play here. We have a system that was designed for a stoic post-war generation—taxpayer funded and copied only by Cuba. We need to recognise that it is not fit for purpose and we need to have some tough debates with the public about how to fund it going forward. A financial legacy is also relevant. A recent one is the PFI scandal of the last few years, but let us be realistic: this country has significant debts and liabilities five times the size of our economy, so it means we need to be realistic about what we can afford in the future.
In conclusion, I agree with Members who said that we should take the party politics out of this debate. I would like to see a plan of where hospitals should be in the future. We need a hub-and-spoke model for acute hospitals; there has to be a national plan, so that we do not see some hospitals unfairly closed and others retained for various legacy reasons. The plan needs to be cross party; otherwise it will not pass. We need to reflect, too, on GP out-of-hours provision. I think GP surgeries should be open for longer and more appointments should be available for about 12 hours a day. I am not so sure that the current out-of-hours service is sustainable or, indeed, advisable in the longer term. Above all, we need a proper informed and rational debate with the British public about what is affordable, what is do-able and what is in all our best interests.
A and E Departments
Phillip Lee Excerpts(11 years, 2 months ago)
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Mr Hunt
Yes, we have been responsible for a huge increase in performance, many more people being operated on, the virtual elimination of mixed-sex wards, MRSA rates being halved, more operations than ever before, more outpatient operations than ever before and more GP appointments than ever before.
Dr Phillip Lee (Bracknell) (Con)
I am struck by the fact that no mention has yet been made of the drivers of the reported chaos in A and E and the pressures on primary care out of hours. What of ageing? What of obesity? What of the changes in behaviour, the absence of stoicism, the increase in medical technology costs? Whatever the system that either the Government or the Opposition talk about, it will come under pressure. When will we have some reality in this Chamber about the causes of this problem, because the sooner we have, the better we will all be?
Mr Hunt
I recognise my hon. Friend’s clinical background. When I talk to clinicians in A and E wards, they tell me that the long-term drivers of the pressures they are under are an increase in the number of older people and an increase in the acuteness of the conditions of people coming through the doors. That is why at the heart of our long-term solution is a vulnerable older people’s plan that ensures we look after them with the dignity, compassion and respect they deserve.
Mid Staffordshire NHS Foundation Trust
Phillip Lee Excerpts(11 years, 3 months ago)
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Mr Hunt
Of course we need to rely on good information being supplied by hospitals, and that is why we have said today that it will be a criminal offence for hospitals knowingly to supply wrong information. This goes back to an earlier question, and we will work closely with outside bodies, such as the royal colleges, to ensure that we establish the best way to judge, for example, cancer survival rates. One of the lessons of the success of measuring heart surgery survival rates is the importance of having a good risk-adjustment process in place. We will do that across the other 10 specialties that I announced today.
Dr Phillip Lee (Bracknell) (Con)
Although I acknowledge the Secretary of State’s genuine desire to improve hospital standards by the introduction of his new inspectorate, I am concerned about the further reliance on systems above individual responsibility. Will he assure the House that his new inspectorate will not become yet another component of the merry-go-round of management employment schemes currently found in the NHS? Will he also assure me that those implicated in previous hospital management scandals will not be employed as inspectors in the future?
Mr Hunt
My hon. Friend is right: we have to ensure that the inspectorate works in the successful way that Ofsted has worked in the school system, and does not make the mistakes that have been made by other regulators inside the NHS system. It is important that it is based on respected peer review, is thorough and is respected in terms of the input that it is able to give hospitals on improving their performance. We will work hard to make sure that we deliver that.
Accountability and Transparency in the NHS
Phillip Lee Excerpts(11 years, 4 months ago)
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Dr Phillip Lee (Bracknell) (Con)
As ever, it is an honour to follow the hon. Member for Vauxhall (Kate Hoey).
Let me begin by congratulating my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing a debate about this important subject. It is a subject that I think should be debated more often in the Chamber, and I find it surprising that fewer Members wish to speak about it than have wished to speak about some of the other issues that we have considered since Christmas. I think all Members should reflect on that.
I believe that the core of this problem is responsibility: responsibility in public life. The general public are fed up—not increasingly fed up, but completely fed up—with hearing about scandal after scandal involving the national health service, the BBC, the newspapers and so on, for which no one takes any responsibility. No one walks. No one looks at themselves in the mirror in the morning and says “I did not do as well as I should have; I am paid a decent wage; the honourable thing to do is resign”—not “be sacked”, but resign.
I do not want to make a speech about Sir David Nicholson. Sir David Nicholson should know that he ought to resign. I cannot comprehend how he can think that his position is sustainable from a moral standpoint, but if no morality is involved, what about competence? He may have been head of the strategic health authority for only a relatively short time, but he was aware of the mortality rates when he was in that job. What did he do about it? If he did nothing about it, why is he still in post? However, I do not want to make this a personal issue.
Having worked in the national health service for 13 or 14 years, I do not need to be told about the problems caused by the culture in that institution. I learnt how it was as a medical student, and I saw it at first hand as a junior doctor. I want to say something about that, and also about competence in general. We need competent individuals in charge of our hospitals and on hospital wards, but I am not sure that we have had them in recent years. I also want to say something about responsibility in the light of that.
The national health service is a huge institution—some might say too huge—and because of its size, the fact that it has grown over the past 60 or 70 years, and the fact that the people who work in it rarely leave, institutionalised behaviour is rife. It is rife in medicine and in management. In my view, former Secretaries of State on both sides of the House display such institutionalised behaviour themselves. They may wish to reflect on that at the end of the debate.
The first debate in the House in which I spoke, apart from the debate during which I made my maiden speech, was a Backbench Business Committee debate about compensation for haemophiliacs. I was struck then by the institutionalised response from the Department of Health. It seemed plain that the Department did not want to set a precedent by doing what was obviously the right thing, namely compensating about 4,000 people and their families for what the system had done to them.
I am therefore not surprised by the Francis report, which those who read it will discover to be a not particularly impressive document. Parts of it have the ring of a Nuremberg defence. It is remarkable that individuals cannot be held responsible for their actions within a system. That system is apparently so perfect that no one within it needs to be good. I think that we need a health service in which individuals, including Secretaries of State, take responsibility for their decisions at every stage.
Dr Lee
I am talking about those who were Secretaries of State in the last Administration. In response to an intervention during his speech, the right hon. Member for Leigh (Andy Burnham) said, “I passed it on to Monitor.” The attitude that leads people to push away the process of decision making and take no responsibility for the outcomes needs to end.
Andy Burnham
Surely, as a clinician, the hon. Gentleman would resent the idea of politicians’ interfering in the independent clinical regulation of hospitals. I did not do nothing. Within days I had asked the Care Quality Commission to investigate the outliers that Brian Jarman had given me. I will not sit here and accept the hon. Gentleman’s suggestion that I complacently did nothing. That is not true, and he should not repeat it in the House.
Dr Lee
Despite that, nothing changed, did it? The CQC has a terrible reputation in my profession, and to have handed the matter over to it—when it was run by someone who was implicated at Mid Staffordshire—is not a defence.
Let me broaden the discussion to something that I may know something about: practising medicine in organisations run by the Department of Health. I can tell the House that the prevailing atmosphere is one in which attention is not drawn to problems. There is a fear for jobs down the line. Let me give an example. When I was a junior doctor, I misused a photocopying machine in a hospital. Within hours, I received a phone call from a middle-grade doctor telling me that if I did that again, it would affect my reference. The phone call, I was told, had been authorised by the then consultant general surgeon at St Mary’s, Ara Darzi. I reflected on that at the time. It made me feel rather intimidated. [Interruption.] The prevailing mood in hospitals was that seeing or doing something wrong could adversely affect a person’s future career.
Charlotte Leslie
Does my hon. Friend share my regret that Opposition Members are groaning in that way? What he is describing has been very evident for very many years. One need only speak to a doctor to learn that there is a culture of fear. Nearly every doctor knows someone who has tried to speak out against something that has happened. People know that if they do that, there will be counter-allegations against them. The groaning and expressions of surprise from Opposition Members are very sad, because it reveals just how little they were actually talking to clinicians on the ground who have been complaining about this for a decade. I received an e-mail from the spouse of a clinician who said that over the past 15 years the management styles encouraged by the previous Government had made that clinician ill.
Dr Lee
I must get on, I am afraid. I do apologise.
The point I am trying to make is that a certain culture prevails, and into that culture, or environment, the last Administration introduced targets. I do not suggest for one second that the last Administration thought those targets would lead to the type of care that was provided at Mid Staffordshire, but I am not surprised that there were adverse consequences, and I think Opposition Members should reflect on that.
The final thing that I want to say about culture and competence concerns politicians. The right hon. Member for Leigh said that I would not want politicians to interfere in day-to-day care. Of course I would not, but I would like politicians to take responsibility for the service. Let me give an example. There are only about 250 acute trusts in the country, and not that many mortality figures have to be looked at in each trust. It could be done on a monthly basis. However, I am told that it was not done by Secretaries of State in the last Administration. Why? If I were the Secretary of State, the one thing I would want to look at would be clinical outcomes in hospitals. If that is beyond Secretaries of State, one is prompted to ask why they are in post. If those figures had been looked at earlier enough, we might not be having this debate.
Competence and the right culture are only possible with transparency. That is the most important aspect of this whole issue.
Alan Johnson (Kingston upon Hull West and Hessle) (Lab)
Well, there’s a man who knows all the answers!
It was four years ago on Monday when I apologised to this House on behalf of the Government and the national health service for what happened at Stafford. We had just received the report from the Healthcare Commission, and I think it is fair to say that no one with any experience of the NHS could quite believe what had gone on. The people in charge at a time when there were unprecedented resources and investment being put into the NHS had cut staffing on A and E to such an extent that a receptionist with no medical training was triage nursing in A and E.
We need a longer debate. There is nothing ostensibly wrong with the motion, and I agree with my right hon. Friend the Member for Leigh (Andy Burnham) that we should support it, but it is clear from the way it was moved and the last contribution that this is all about the blame game. If I can just quote Francis—[Interruption.] Yes, the hon. Member for Bracknell (Dr Lee) does not agree with Francis or with Ara Darzi and knows everything, and says that Francis was a Nuremberg—
Alan Johnson
No, I am not giving way—at least not to the hon. Gentleman. I have heard enough.
This is what Francis said in paragraph 108 of his report:
“To place too much emphasis on individual blame is to risk perpetuating the illusion that removal of particular individuals is all that is necessary. That is certainly not the case here. To focus, therefore, on blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified and further harm.”
So the man who knows most about what happened at Stafford hospital—and who was entrusted by this Government and their predecessors to conduct not one, but two, inquiries, and who in four volumes running to millions of words sets out what happened, why it happened and how it was allowed to happen—counsels against the very action that this motion appears to propose.
Francis identified who was accountable, and the Secretary of State was absolutely right: it was the chief executive, the chair and the board of the Mid Staffordshire trust. A number of clinicians are also held accountable for the appalling lapse in standards of care at Stafford. This accountability regime is set out in legislation approved by this House.
The Francis findings are consistent with those that emerged from the inquiry into the care of children receiving complex cardiac surgery at Bristol Royal infirmary between 1984 and 1995. In that case, five individuals at the hospital, including the chief executive, were the subject of adverse comments. In respect of both Bristol and Stafford, an argument was made to an inquiry that there was an extenuating failure of national policy. At Stafford, it was national targets; at Bristol, it was inadequate resources.
It is worth recalling the Bristol inquiry’s response. Sir Ian Kennedy said:
“The inadequacy in resources for PCS”—
paediatric cardiac surgery—
“at Bristol was typical of the NHS as a whole. From this, it follows that whatever went wrong at Bristol was not caused by lack of resources. Other centres laboured under the same or similar difficulties.”
We must remember that these were the days when one in every 25 patients on the cardiac waiting list died before they could be operated on, and when somebody with a serious heart condition could wait a year to see the cardiologist, three months to see the consultant and then 18 months to two years for the operation. That is why targets had to be introduced—to get a grip on this awful situation.
Health Professionals: Regulation
Phillip Lee Excerpts(11 years, 4 months ago)
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Dr Poulter
I say to my hon. Friend that the Department of Health has, like everyone who works for it, made it clear that gagging clauses are not and have never been acceptable in the NHS. There is a distinction to make between confidentiality clauses, which might be part of any financial settlement with anyone who works in either the commercial sector or the public sector, and a gagging clause. It is the duty of any front-line professional, according to and as part of their registration with the General Medical Council or the Nursing and Midwifery Council, to speak out when there are issues of concern. That is a part of good professionalism. That is what being a good professional is about. It is about someone saying that they recognise that there has been unacceptably poor care in a hospital or a care setting and that they have a duty, because they are a registered doctor or nurse, to speak out to highlight where problems have occurred. The point is that at Mid Staffordshire there was clearly a failure of that professionalism not only on the front line but at every level. Gagging clauses have never been considered by the Department of Health, certainly under the current Government, to be an acceptable part of the NHS. That was made very clear in a recent letter written by my right hon. Friend the Secretary of State to NHS hospitals and chief executives.
Dr Phillip Lee (Bracknell) (Con)
On the subject of gagging clauses, did the settlement that formed part of the severance payment of the former chief executive of Mid Staffs include a gagging clause? If the Minister cannot tell me that today, will he put it in writing?
Dr Poulter
I shall endeavour to write to my hon. Friend to clarify as I do not have the information immediately to hand. That does not detract from the fact, however, that a gagging clause in any form is unacceptable to this Government, should be unacceptable to everybody in this House and is unacceptable to every doctor and nurse who works in the NHS. We will continue to do all we can through the contractual duty of candour and through strengthening the NHS constitution to make it easier for NHS staff to feel that they can speak out openly and feel supported in doing so, so that we have an open and transparent NHS of which we can be proud.
My hon. Friend the Member for North East Cambridgeshire also raised a very important point about open and transparent data on surgical outcomes. It was Professor Sir Bruce Keogh, the current NHS medical director, who put together the purple book of cardiac surgery, which has made a huge difference through greater transparency of outcomes in that specialty. That was in reply to the findings of the Bristol heart surgery inquiry, and it is regrettable that we have not seen similar advances in openness and sharing of data in other specialities in the NHS. That is not necessarily because the data do not exist, because they often do. In some specialties, such as urogynaecology, national databases are being put together to consider the long-term data on certain operations, which, to some extent, will give data on individual surgeons.
In the NHS, we often have a plethora of data and a lot of audit information that is collected at a local level, and we must ensure that those data are used in a better way in future. A lot of work can be done to add transparency and to share audit data in different trusts so that they are openly comparable to build a national picture of certain types of care and how we can improve patient care. That was a good point that was well made, and I know that Sir Bruce Keogh is continuing and will continue to develop that work in his role on the NHS Commissioning Board. I had a very encouraging meeting recently with a number of senior surgeons who recognise the importance of such work in their specialties. I am sure that the NHS will continue to develop it at a greater pace in the future, not least because of what we have heard from the Mid Staffs inquiry.
In conclusion, throughout the debate the point has been made that we have legislation in place to protect whistleblowers, but it has not been effective—[Interruption.] My hon. Friend the Member for Bracknell (Dr Lee) says from a sedentary position that it does not work. He is absolutely right—it has not been effective and that is why we are considering the Mid Staffs inquiry and the issues of culture that have existed and that have failed and let down patients. We will have a robust response to those failings to put right what has gone wrong and to ensure as best we can that another Mid Staffs will never happen again in the NHS. I am sure that we will all support what our right hon. Friend the Secretary of State says in his further response later this month.
Question put and agreed to.
Acute and Emergency Services
Phillip Lee Excerpts(11 years, 9 months ago)
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Dr Phillip Lee (Bracknell) (Con)
NHS hospitals face mounting financial, work force and demographic pressures. The stark reality is that health care provision in the future will require consolidation of acute and emergency services in fewer locations, and an increase in the provision of chronic care in the community through locally based clinics. That is not a political choice, but a clinically driven reality. It is widely believed among those in the medical profession that the reconfiguration of hospital services can provide a powerful means of improving quality in an environment where money and skilled health care workers are scarce. In some places, reconfiguration and changes to hospital services are already a necessity, not an option.
That is the case in the Thames Valley region, of which my Bracknell constituency is part. That is why I have recently introduced a strategy proposal for the provision of health care in the Thames Valley region, in which I call for a consolidated hospital—what some have described as a super-hospital—on the M4 at junction 8/9. A “Royal Thames Valley hospital” at this location, if it is ever built, would have crucial advantages. The existing transport infrastructure means that services could be provided, within easy reach of people’s homes, to a population of the greatest possible size. This model has a multitude of benefits, which include economies of scale and sharing of medical information and manpower, and it is supported by many senior medical professionals as being the key to saving the national health service.
Nevertheless, I sense a lack of the strategic leadership that is required to deliver the change that we all need. A major stumbling-block in many hospital reconfigurations is public concern about change, and the political opposition that follows. Politicians will have to make decisions on the basis of the quality, safety and efficiency of health care, while retaining strong public engagement in decision making. That is why I have already begun to hold regular public meetings throughout the Thames Valley region.
Steve Baker (Wycombe) (Con)
As my hon. Friend knows, he has set a number of hares running in my constituency. Will he concede that a number of NHS professionals, managerial and clinical, differ with him and think that a network of hospitals is an effective and incremental way forward?
Dr Lee
I thank my hon. Friend for that intervention. Yes, I concede that some—not many—local clinicians share that view. Whenever one presents something different that is a challenge to the status quo, one will come up against vested interests, particularly in the national health service. Many of my colleagues in the Chamber need to start engaging with the public on the issue. It is coming round the corner, and we should all try to provide the political environment in which the change can take place.
I would like first to set the context, say why I support this change, and talk about the current difficulties in our health care system, and those that we will face in the future. In the past 50 years, according to the King’s Fund, the number of acute hospitals has reduced by 85% and the number of sites at which elements of highly specialist care is delivered has reduced even further. In England, general acute care is now delivered in just over 200 hospitals, and at the same time the average size of hospital has grown from 68 beds, according to a Ministry of Health document in 1962, to just over 400 beds. The average acute trust has just over 580 beds. These changes reflect developments in medical practice.
Advances in medicine and surgery have driven clinical staff and equipment to become more specialised. As skilled specialist staff are scarce and budgets are limited, services have been centralised on to fewer, larger sites, in order to ensure that patients are cared for by staff with the necessary skills and supporting specialist equipment. In addition, there has been decreasing reliance on bed rest as part of treatment; for example, most routine surgery is now undertaken as day surgery. The average length of stay in hospital is currently just less than six days and 80% of all patients have stays of less than three days.
Having surveyed both NHS trusts and the public on service change, the Foundation Trust Network found that 90% of NHS trusts said that a major change, such as a hospital merger, closure or changing the way in which services are provided, was necessary in their area in the next two years. Critically, eight in 10 trusts felt that a reconfiguration in their area would lead to maintained or improved patient outcomes which would not be possible if the change did not take place. Of those NHS trusts indicating that a reconfiguration would be necessary, 35% felt that there was a consensus locally about how this should take place. Local councillors were felt to be a barrier to service change in 49% of cases, as were other NHS trusts in 48% of cases, and MPs in 40% of cases.
Finally, market research organisation ICM’s polling of the public shows conflicting views. Four out of 10 people initially stated that they would prefer to be treated locally, but when asked to rank the importance of having services close to home versus accessing specialist care when being treated for a serious condition, more than half said that it was more important to be treated in a unit that specialised in their treatment area. That number rose to 60% if the respondent was talking about a loved one receiving the treatment rather than themselves. Three in 10 said that it was most important to have a hospital close to where they lived in such a case, suggesting that while people value the convenience and accessibility of local care, ultimately access to specialist expertise matters more where a serious condition is involved.
Demographic changes and the shifting burden of disease will require a fundamental shift from the hospital as the core focus of health service delivery to the community, to provide elective care and minor treatments from the community level in much-cherished community hospitals, and all major surgery and acute care from a central hub hospital, ideally located on a motorway.
In any reconfiguration of hospital services there are four drivers: quality—that is, better health care—work force, cost and access. The challenge is to try to arrive at a configuration that optimises all those elements as far as that is possible, given the complex trade-offs that exist between them. Quality considerations include access to highly trained professionals in all disciplines, compliance with clinical guidelines, and access to diagnostic technologies and other support services, as well as strong clinical governance. More recently, there has been pressure on trusts to meet challenging funding needs, which is putting greater emphasis upon operational systems and environments to work together to meet the targets and improve patient safety in acute care settings. There are also interdependencies between services—for example, withdrawal of paediatric services can threaten obstetric services, which rely on paediatricians to provide care for the newborn child.
There is wide variation in the quality of care delivered by NHS hospitals. Reconfiguring services can be a powerful means of addressing this variation. An often cited successful example is here in London. It has been estimated that the recent reconfiguration of stroke services will save more than 400 lives a year. This is through the establishment of stroke networks that have concentrated specialist stroke expertise and diagnostics in fewer units, while retaining local access to stroke rehabilitation services in local community hospitals. Other examples include vascular surgery, where the mortality rate is lower in high-volume hospitals than low-volume hospitals, and paediatric heart surgery, where there are plans to cut the number of hospitals undertaking surgery to improve outcomes.
With reference to stroke mortality rates across acute hospital sites across England, it is estimated that there would be 2,117 fewer deaths per year from stroke in England with increased ambulance services to specialist centres. That clearly demonstrates that centralisation of stroke and trauma centres would benefit a larger proportion of the population and would reduce mortality rates and thereby improve the quality of care.
Alongside those changes, there is a need to shift the location of care for older people who do not require specialist care in a hospital setting. The Royal College of Physicians estimates that almost two thirds of people admitted to hospital are over 65. People over 85 account for 25% of bed days. As we have noted, older people make up the majority of patients in hospital beds, yet many could be cared for elsewhere if appropriate facilities were available. In particular, end-of-life care illustrates the inappropriate use of hospitals. Notwithstanding recent increases in the proportion of people dying at home, many still die in hospital even though they would prefer to be cared for in a hospice or their own home. One of the challenges in this regard is to make community services available 24/7, to stop hospitals becoming the default setting because of a lack of other options.
I will move on to work force pressures. Since the application of the European working time directive to junior doctors, there has been a 50% increase in the number of junior medical staff required to fill a rota and provide 24/7 care, which many units have struggled to achieve. According to a report by the Royal College of Physicians, three quarters of hospital consultants report being under more pressure now than they were three years ago and more than a quarter of medical registrars report an unmanageable work load. I draw colleagues’ attention to the report, “Hospitals on the edge? The time for action”, which is well worth a read and should be borne in mind when discussing or defending local hospital services.
Recruiting into emergency medicine is also becoming difficult and application rates into training schemes involving general medicine are also in decline. According to the RCP, there is an increasing reliance on locums and unfilled consultant posts. That will have a negative effect on emergency care, which is vital to all. There is also an increasing recognition that services such as emergency surgery might be unsafe out of hours, and the provision of those services needs to be concentrated in fewer centres that are better able to provide senior medical cover.
Improving the quality of care often entails making available senior medical cover in some services on a 24/7 basis. That in turn means reducing the number of hospitals providing those services, to enable consultant medical staff to operate effective rotas in the evenings and at weekends. That would also reduce mortality rates, as most deaths happen on poorly staffed wards at weekends. The most contentious issues concern changes in the provision of accident and emergency and maternity services because of the importance attached to those services by patients and the public. Many of the changes derive from work force shortages, for example among consultants and midwives, making the current model of care unsustainable. That is leading to increasing differentiation in how services are provided. For example, some hospitals provide midwife-led maternity care and others no longer provide accident and emergency services at night.
I will now move on to cost. The merger of particular services, such as intensive care, A and E services and cardiac surgery, could improve quality and save money. NHS London, for example, has demonstrated that the recent reconfiguration of stroke services has achieved an improvement in quality as well as significant cost savings. The Department of Health estimates that in the last quarter of 2011-12, 10 out of 72 NHS acute and ambulance trusts were rated as “underperforming” or “challenged” on their financial performance. Of 143 foundation trusts, Monitor reports that 10 had a financial risk rating of 1 or 2—on a scale of 1 to 5, 1 being high—and that 11 were in breach of the terms of their authorisation on financial grounds. Twenty trusts have declared themselves unviable in their current form, including Heatherwood and Wexham Park Hospitals NHS Foundation Trust, which serves part of my constituency.
One of the most comprehensive reviews for clinical and financial evidence was Lord Darzi’s review of the NHS. He argues that future technological advances will result in an expanding number of diagnostic tests and therapies that could be provided more cost-effectively in a smaller number of regional specialist centres, such as the one I have suggested for junction 8/9 on the M4, rather than a large number of low-volume district general hospitals, which is currently the pattern in large parts of the country. For example, the Audit Commission has identified 25 operations or admissions and estimated that 75% of surgeries should be carried out as day cases. It estimates that if all trusts achieved an average 75% day case rate across these procedures, at least 390,000 bed days could be freed up. That would save £78 million, based on £200 per elective patient bed day.
Lord Darzi further explains that minimally invasive techniques will continue to improve. In the next 10 years, endoluminal surgery—entering the body through its natural holes, such as the throat—will become the standard method for treating many complex cases. Better diagnostics will also help most surgery to become non-invasive. Minimally invasive surgery means smaller scars and less risk of post-operative infection, which means patients will also recover more rapidly.
Furthermore, there is an argument for reducing the number of administrative staff required, which will be more cost-effective and save money that could be better spent on the quality of care. Hence, reconfiguration can deliver improvements in quality and safety without significant additional cost.
There are strong political and policy pressures to sustain, and where possible increase, local access to services, particularly those needed in an emergency such as A and E and maternity care. We have an ageing population, and the majority of hospital users will rely on public transport to take them to hospital. Transport systems will have to be put in place so that people can access the central hub hospitals.
How do we achieve the utopia I am seeking in the location and structure of national health service hospitals? I fear that we will need something that we do not currently have: some central direction. This project will take many years to achieve, and we need a cross-party committee to draw up a plan that applies to the whole of England and Wales, so that we can decide where the hospitals, including the community hospitals, are required. If we do that, I am convinced that we will be in a position to deliver the best care in the western world to all our constituents.
Community Hospitals
Phillip Lee Excerpts(11 years, 10 months ago)
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Dr Phillip Lee (Bracknell) (Con)
I congratulate my hon. Friend the Member for Totnes (Dr Wollaston) on securing this debate, and I congratulate my hon. Friend the Member for Broxtowe (Anna Soubry) on gaining her place on the Front Bench. I wish her luck in her new role.
We are discussing community hospitals, which provide an important service in offering care to all our communities. I think there could be a renaissance in community hospital provision in the coming decades, not least because the vast majority of money in the national health service is spent not on all the exciting acute and surgical kit, but on the provision of care to the chronically unwell. Where better for the chronically unwell to be treated than in their communities?
I am particularly interested in this subject because I have recently published on it—and I commend my own publication to all colleagues in the Chamber! It is a 70-page document that my office and I managed to put together, and it was published in May this year. In it, I call for the closure of some acute hospitals and for the merger of community hospitals around what is commonly described as the hub-and-spoke health care model.
I am told by some experienced and seasoned politicians that this is quite dangerous stuff. I have called in the press for the local maternity unit not to reopen, and I have argued that having a casualty department at my local district general hospital would not be in the best interests of my constituents. People may say, “Good luck with your single term in office, Phillip”, but the reality is—I am being serious here—that what I am saying is in all our best interests. I would say that it is in the interests of those on both sides of the House—it is a pity that so few Opposition Members are in their places today—that we get behind the reality of what is happening in the delivery of health care.
I have not met anyone working in the medical profession who does not support the principle of the consolidation of acute and surgical services and the provision of chronic care in community settings, so this is undeniable. If anyone meets such a person, please put them in touch with me, as I would be interested to hear the argument for the status quo.
The reality is that acute and medical/surgical care is becoming increasingly complex, increasingly expensive to deliver and, in particular, increasingly difficult to staff. Nowadays, we do not have the “Sir Tufton Bufton” general surgeon as once there was; we have different qualified surgeons within the broad field of general surgery. If I have something wrong with my upper gastro-intestinal tract, I want to go to an upper GI specialist. I do not want to go to someone who does it occasionally; I want to go to someone who does it daily. This is clearly not possible on every district general site in the country.
We are beginning to see the realities. There is a consolidation of services ongoing in the south of London. It is politically sensitive, I gather, but it is going to happen, so everybody needs to wake up to it. It has already happened in Norwich; it is happening in Cambridge; and I gather it has happened in Swindon. That this is happening everywhere around the country is, I believe, a positive move. I do not seek to make any political point or to any political capital out of it because I know that if there were a Labour Government, it would be happening in any case. I would encourage not just existing MPs, but candidates at the next election to be more honest about this. As I say, it is really in all our best interests. Ultimately, we are here to try to secure a health service that provides the very best for all our constituents.
Let me move on to my specific regional case. To provide some background, I still work as a doctor, and I intend to continue working as one—not least because one morning in Slough is enough reality to keep my feet on the ground. In that capacity, I have formed the impression that what we need on the ground in Buckinghamshire, Berkshire and south-east Oxfordshire is a consolidation of acute and surgical services.
Having looked after approximately 50,000 patients in about 50 general practices throughout the Thames valley, referred patients to every acute centre and worked with every hospital except the Royal Berkshire, I feel that I may have something to say about this issue. I have concluded that we need a new hospital at junction 8/9 of the M4, and I am not alone in thinking that. Deloitte, which was paid significantly more money than I was to produce its wonderful report in 1989, reached exactly the same conclusion, and that was before Wycombe general hospital had been downgraded as a fully fledged acute surgical site.
I am in favour of the retention of all community hospitals in the region except two. One is Heatherwood, the hospital that has traditionally served my constituency— people may say that I just talk the talk, but in this instance I am walking the walk—and the other is St Mark’s in Maidenhead. I want to enhance the delivery of chronic medical services on the Brants Bridge site in Bracknell. That is the plan, and I am trying to build some grass-roots support for it. I am trying to emphasise—this brings me back to the topic of the debate—the importance of community hospitals, the importance of the services that they offer now, and the fact that they can offer enhanced services in the future.
Given an ageing and increasingly retired population and a diminishing economic position, we shall have to sell off sites to find the necessary capital funds. However, this is a positive story. We can have new acute emergency hospitals throughout the country, although I recognise that in rural areas they will have to be supported by helicopters and the like. We can provide better services, both in the community and in the central, specialised hospitals, delivering the very best health care in the 21st century. That is why I am a proud supporter of community hospitals. I hope that all Members of Parliament of all parties will step up to the plate and be honest about the situation, so that care for all patients can be improved in future.
Community Hospitals (North-East)
Phillip Lee Excerpts(12 years, 1 month ago)
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Tom Blenkinsop
The current Prime Minister, when he was Leader of the Opposition, identified Northern Ireland and the north-east as areas where the public service cuts should primarily take place. That is the similarity. Of course, the north-east leads all other regions in the United Kingdom on exports, so there was some smoke and mirrors in that argument. There are indeed a number of Members who are introducing petitions against the closure of health services, including a number who are in the Cabinet.
The centralisation process is well under way at Guisborough hospital, in my constituency, and that is just one example of what is happening across the north-east. The hospital has already been forced to operate a reduced service owing to staffing pressures, opening only from 9 am to 5 pm on weekdays and 8 am to 8 pm at weekends instead of the usual round-the-clock service. The Chaloner ward there is an eight-bed unit providing palliative, post-operative and respite care, with dedicated nursing care for a variety of medical conditions. There is also an out-patient suite and a minor injuries unit. Closing the Chaloner ward could eventually mean the end of the hospital. The maternity service has already been lost, and closing the ward would leave only a residual out-patient service and the Priory ward on the site. East Cleveland hospital, in the Brotton area of my constituency, offers even more limited services than Guisborough, and I have often spoken to constituents who have been forced to seek treatment elsewhere.
My main concern is that hospitals such as Guisborough and Brotton will become marginalised owing to a continuous reduction of funding from South Tees Hospitals NHS Foundation Trust, as more and more services are consolidated at James Cook university hospital. It takes nearly an hour to reach that hospital by bus from Guisborough, and even longer from the more rural parts of my constituency—and that is under the very generous assumption that such bus services will still be available.
It may be politically expedient for some to argue that such decisions are solely the responsibility of the relevant trust and are somehow detached from being the responsibility of central Government, but they are unfortunately a worrying national trend. No one trust can take the blame, and the scrutiny must instead be of the Government who force them into such a position. For example, I have read that in Sutton,
“a cloud has gathered over St Helier”
district general hospital, where accident and emergency services are under threat, to such an extent that the Minister of State, the hon. Member for Sutton and Cheam, has started a petition against the closure in his own constituency, despite the fact that it seems to be part of a broader pattern that is perhaps caused by his own Department’s policies.
Given all the campaigns that are emerging throughout the country to save services at local hospitals, I find myself asking why there seems to be such a decline in the provision of services. Despite the Government’s localism agenda, it appears that services are becoming more centralised to larger hospitals, leaving community hospitals with empty beds and abandoned wards.
Dr Phillip Lee (Bracknell) (Con)
Does the hon. Gentleman agree that the consolidation of acute and emergency services, and the reconfiguration of services in the north-east and across the country, are about not just the cuts and austerity to which he refers—I do not agree with him on that—but the changes in how health care is provided? Does he also agree that the community hospitals that he seeks to support are best placed to deliver chronic care, not acute care?
Tom Blenkinsop
There is an element of truth in what the hon. Gentleman says, but I will come to that when I make suggestions. Community hospitals have a role as part of an overall package, but I have seen an erosion of those services in my locality. The reason I have introduced this debate is that a pattern is emerging in the north-east and across the country in how services are allocated by trusts.
Mental Health
Phillip Lee Excerpts(12 years, 1 month ago)
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Dr Phillip Lee (Bracknell) (Con)
I congratulate my hon. Friend the Member for Loughborough (Nicky Morgan) on securing this important debate. There have been some very impressive speeches, not least from the hon. Member for North Durham (Mr Jones). I have the pleasure of being, like him, a member of the Administration Committee because very early on in my time here at Westminster I realised that there were quite significant mental health problems among my colleagues. A few of them had approached me so I went to the usual channels, wanting to know what support was available for colleagues. As a consequence, I was put on the Administration Committee and I am now also on the medical panel. I am encouraged by the support available to colleagues if they choose to use it.
I congratulate the shadow Front-Bench team on what appears to be a decision to lead with mental health. It is an important decision that is politically astute and those on the Government Front Bench ought perhaps to reflect on their goals in that area. My advice would be not to be overambitious.
I want to reflect on my experience in this area, my family experience and my professional experience before saying a few brief words on GP commissioning. I have heard mention of the police and the concerns about their involvement in this area, so I shall comment on that. Finally, I want to mention the Human Rights Act.
At a family level, at the last count there were three suicides in my extended family. I know a number of people who have had depression and, unfortunately, a family member has recently been diagnosed with early onset dementia. I myself have had moments of, shall we say, fluctuating mood, perhaps a bit more so since I have been in this place, so I feel that I have first-hand experience through my family and myself of how prevalent the problems are.
I know from my professional experience that the nature of this topic means that it is something one does not forget. I recall clerking in a patient who was a survivor of Auschwitz—I remember the tattoo quite clearly—and the following day, that person hanged himself. I remember the relative of a senior member of the Ministry of Defence at the time breaking down in front of us, which was a quite shocking incident for me as a medical student.
Finally, I remember a case—I only remembered this as I listened to the hon. Member for Strangford (Jim Shannon)—of somebody who had been a victim of the troubles in Northern Ireland and had been relocated to where I was working under the witness protection scheme. That gentleman had experienced guns being held at his temple, in his mouth and so on, and I was in a position to be able to help him.
The nature of this subject means that it tends to throw up cases that are quite memorable and emotive. I feel strongly about it. Locally, I have done my bit. I have met Rethink Mental Illness and the first hustings I attended during the 2010 general election campaign was run locally by a mental health charity. Broadmoor hospital is in my constituency, at Crowthorne. I have visited there and I would encourage everybody to visit Broadmoor hospital. It is a very interesting place to visit with recidivism rates that are, I imagine, the envy of the prison system.
I have done my bit to try to raise the profile of the discussion and debate around mental health services, because this is a significant area of concern. About 800,000 people have dementia in this country at the moment and that number will rise—it will double. That is because of ageing and lifestyle, depending on whether it is Alzheimer’s or vascular dementia. The estimated cost of mental health is £89 billion by 2026, although perhaps that figure is out of date as I heard the shadow Secretary of State give a larger figure. Half of that is due to loss of earnings in the work place. The significance of this topic cannot be overstated.
Unfortunately, more than half of people with anxiety disorders do not interact with the service and about a third of those with depression do not interact with it. The services we have cannot deal with the demands being placed on them, so God only knows what it will be like when everyone starts turning up to see me as a GP or, now I am here, as an MP. I fear that this will need some realism on the part of the current health team and any future health team that might come from the Opposition side in terms of rationing and prioritisation of resources. For example, I read that we are now giving fertility treatment to everybody. I am sorry, but if I were to prioritise where my funding was going, I know it would go to mental health before it went to fertility treatment. I know that is a difficult thing for people to accept if they have fertility problems but we have to make decisions and I know where my priorities lie.
Let me address GP commissioning and some concerns that I want to raise with Front Benchers. There is some unease in my profession about the commissioning of psychiatric services—more so than for diabetes, hypertension or any cardiac service. In a recent poll that I saw, about 70% expressed significant concerns about this issue. I want to flag this up because most GPs do not get a lot of psychiatric experience when they are training. I happened to do a post in which I worked with depression and dementia as a junior but quite a few do not. That needs to be borne in mind. Perhaps we need to look at training in the way that my hon. Friend the Member for Totnes (Dr Wollaston) mentioned earlier. The commissioning of mental health services is complex and difficult, and we need to be cautious. I have been broadly supportive of the Government regarding commissioning but psychiatric services are different.
Another matter that I want to raise is about the police. I heard the earlier comments about the police force and I know that the police are not terribly enthusiastic about getting involved in acute psychiatric crises, but let me tell hon. Members an anecdote. A good friend of mine attended a psychiatric hospital at which someone had been brought in by the police. Six policemen had brought in that person, who was in a violent state of mind, and there was one female psychiatrist there. The six policemen had stab vests on and she was wearing a blouse. Somebody has to do that work and I am slightly concerned about who will do it if the police want to get out of it because the psychiatrists on the front line do not have the same protections that the police have.
On the Human Rights Act, let me highlight that whereas when people come on to the parliamentary estate they have their bags checked, psychiatrists cannot check the bags of a patient they are about to assess even if that patient has displayed violent intent. So someone could come in with a bag with knives and guns in it and the psychiatrist cannot investigate that bag or have it searched because of the patient’s human rights. I would very much like the Front Bench team to look at that and get back to me.
I want to take this opportunity to ask a few questions and re-emphasise that the knowledge base of GPs in this area needs to be improved, particularly for commissioning. I should like to know what the Government propose to do in this area. On the issue of choice, it is all very well wanting patients to be able to exercise choice but if they are not capable of doing so because they are profoundly depressed, demented or psychotic how on earth can they exercise that choice? Is the Minister confident that patients will get the care they need? I welcome the £400 million for talking therapies, but I should like to know where that money is being spent. What is the breakdown of the expenditure of that money? Is the Minister confident that it is being spent in appropriate areas? Anecdotally, I am hearing that it is not making much difference on the front line.
What can be done about the Human Rights Act and the example I have given? We should look at this. Perhaps it is an issue for colleagues in another Ministry, but I would appreciate a response about this.
Finally, let me raise a local issue. The Royal Military Academy at Sandhurst is in my constituency—or at least the parade ground and the buildings are. The residential accommodation is in the constituency of my right hon. Friend the Secretary of State for Education. The problem on the Surrey-Berkshire borders is that there is a difference in the mental health care provision from each trust. There is a perverse situation in which people registered at the Royal Military Academy, whether personnel or family members, receive different levels of care. I would appreciate a written response on this from the Minister or from the Ministry of Defence. We may be able to address that with commissioning groups, but it is important, particularly given the comments by some of my colleagues, with reference to our armed forces.
Finally, may I congratulate everyone in the mental health sphere and anyone who is delivering care. They do so in often challenging circumstances. Doctors, nurses and so on need all the support that they can get in a service that will be increasingly important to us in future.
Oral Answers to Questions
Phillip Lee Excerpts(12 years, 3 months ago)
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Dr Phillip Lee (Bracknell) (Con)
6. What the average cost has been of a consultation at an NHS walk-in centre since 2008.
The Minister of State, Department of Health (Paul Burstow)
The average cost of an attendance at an NHS walk-in centre was £36 in 2008-09; £42 in 2009-10; and £39 in 2010-11.
Dr Lee
I thank the Minister for his detailed answer. Does he agree that in the future new commissioning groups, such as those that will serve my constituency in Bracknell, might choose not to fund walk-in centres—whether ones already established or those in the future—based on clinical justification terms? I, for one, remain to be convinced—indeed, I am far from convinced—of the long-term financial justification for, or clinical benefit of, walk-in centres.
Paul Burstow
There is not a nationally mandated programme of walk-in centres; rather, it will be for local commissioners to make decisions based on the evidence and their evaluation, and ensuring that they fulfil their contractual obligations.