Healthcare Optimisation Plan: Kirklees

Rachael Maskell Excerpts

Tuesday 12th December 2017 Westminster Hall

[Rachael Maskell (York Central) (Lab/Co-op)]

It is pleasure to serve under your chairmanship, Mr Hollobone. I want to start by thanking my hon. Friend the Member for Dewsbury (Paula Sherriff) for making such a powerful case about why the health optimisation programme is failing the public, failing patients and failing all of us. Her contribution to today’s debate reminded me of the Adjournment debate that I brought to the Chamber on 28 February, which the Minister attended. My speech was parallel. That reinforces how urgent it is that this issue is addressed.

I am proud of so many things about York, but one thing I am really ashamed about is the way that it has gone about rationing healthcare. It was one of the first places to ration healthcare. When the Health and Social Care Act 2012 came in, it had to back-pedal, and then it stepped forward in 2016 in rationing healthcare, particularly surgery for patients who urgently needed it to be provided. There seem to be some key issues that we need to address that are not being addressed in the debate. I had a very helpful meeting with the Minister the other day, but there was little progress on the back of it. We need the Minister to make an intervention and not to say that it is a matter for CCGs to change their practices.

What is evolving is a massive postcode lottery across the country. My hon. Friend referred to a BMI of 30, which her CCG uses as an indicator to draw the line to provide access for surgery. I know that other CCGs use a BMI of 35. That absolutely demonstrates that this is not based on clinical evidence, but is about the financial expediency of CCGs. Therefore, it is absolutely crucial that we go back to clinical evidence when making decisions about patients. That is why we invest so heavily in our medical profession: to go through that training, to have the skills and the ability to do that. They are being completely undermined by these arbitrary figures that are being put into use for the basis of saving money. That is what this is all about, but they are not saving money, because people come back more poorly in future and require even greater resources. It may be save today, but it is spend more tomorrow. Surely that should not be the policy of any Government, let alone the one we have at a time when they keep claiming that there is not enough money.

It is absolutely crucial that the Minister intervenes because we are talking about a population with health inequality. All the demographics and the research show—I am particularly grateful for the University of York’s work on epidemiology—that there is a correlation between health inequality and social and economic inequality. The very people who are being denied surgery are the people who are most disadvantaged in society. There is a whole predication against those individuals. We know that there is a correlation with shorter life expectancy.

It is absolutely crucial that the Minister makes an intervention to improve the quality of life for these individuals. Therefore, although it seems that my hon. Friend’s CCG is attempting to do more than mine in the health optimisation programme, the problem is deeply concerning. This is not about health optimisation at all. I want to see the Minister step forward on a case of health optimisation. I absolutely agree that we have to address the obesity crisis in our country. Twenty five per cent of people are obese—that has an impact on the draw around diabetes and on other needs. I would welcome a health optimisation programme being in place in my CCG, but that is not what is happening. As I demonstrated to the Minister last week, patients in my constituency are being handed a letter that refers them to a website about some health programmes that may be far away—they are certainly not in our city because the local authority has cut them, such as the health walks. Therefore, individuals themselves have no choice about how to lose weight.

Looking at the issue of losing weight or smoking, I know as a clinician—as a former physiotherapist—those individuals need to be taken by the hand and walked through that journey, looking at all the markers around either their weight or their relationship with smoking. In the case of smoking, people need help to deal with an addiction. In the case of obesity or a high BMI, those issues need to be addressed.

I would welcome a health optimisation programme because that means that people will have a better life and they will probably not have the wear and tear on their joints. I welcome early intervention. We need to see that right through our school system, which is why I am worried about the massive fall in the number of health visitors, who could make those interventions at any early stage—as could school nurses, who have virtually disappeared—to enable people to have better, healthier lifestyles. I am particularly disappointed that the local authority withdrew the money from the NHS Health Checks, which enabled people to get their lives back on course from the age of 40 and have a healthier existence.

We fail people right through the system. At the point of crisis when they are in pain and needing surgical intervention, the system says to them, “No, you can’t access healthcare because of your behaviour over the years.” We have let people drift into that position. It is a completely failed system, which is causing individuals to be denied the surgery that they need. There is the complete nonsense of the amount of weight that people have to lose. People are told they have to lose 10%, but for somebody who is morbidly obese, 10% may take them down to the weight of somebody who is obese and who has to lose 10%. It is not a measure of a weight or a BMI figure at all. That is complete nonsense. Any clinician will absolutely recognise that this is a completely failed system. Therefore, I urge the Minister to make an intervention with the CCGs and to set the standards and the bar to enable clinicians to make the right decisions.

We had a discussion with our CCG in York and with the Minister about the programme. Obviously, we addressed the inadequacy of the healthcare optimisation programme, but we also talked about particular groups of patients who are denied treatment. Some people are on drug therapy that causes them to gain weight and are being denied the surgery they need. I gave examples of people with polycystitis, which has a particular impact on women, who are denied fertility treatment and the free surgery that would enable them to receive that treatment, because their condition is causing them to put on weight. That shows that the programme is discriminatory not only on grounds of economic status, but against women.

We have to look at the issue in the round. What we are trying to achieve? If we are trying to improve people’s health, let us put in the measures to achieve that, but let us ultimately move to a place where the right people in the system are making the decisions. Surgeons will not proceed with or recommend surgery if it puts someone’s life at risk. They know those parameters. That is what they are trained for, and they need to assess each patient in turn. I have had patients who have needed only an arthroscopy—an operation given under local, not general, anaesthetic—who have been denied surgery. We need to ensure that the surgeon makes the decision. No disrespect to GPs, but they are not specialists, and that should be a specialist’s call. I therefore urge the Minister to move clinical decision making to the right place in the health service and to ensure that surgeons, who have a responsibility to their patients, are able to put things in place.

Finally, I call on the Minister to look at NHS finances, which we know really drive the equation. We have had a bit of an exchange about that previously, too. We cannot ignore the driving factor. The Vale of York CCG in my area has done everything—it has put in the most draconian rationing system there is—but its finances do not add up. We have to be cognisant of what has happened at King’s College Hospital and the real concerns there, but CCGs up and down the country are wrestling with their finances. Public health is being cut massively by local authorities as they become risk averse, trusts themselves are in a desperate state as they gear up for a winter crisis, and the social care system is not working. We have real financial pressure.

In York, we have a capped expenditure process that limits CCGs’ choices. We need to be able to release the money to address the need. The NHS is not being fed the money it needs, and it is therefore in crisis. We cannot keep saying that it has to do more and there has been personal failure. This is becoming a national crisis, which is deeply concerning because, as my hon. Friend the Member for Dewsbury said, lives are at risk as a result. We cannot go to that place.

This is about funding. It was always going to be about funding. I remember having an exchange with Andrew Lansley about the funding formula back in 2011, when he was introducing the Health and Social Care Bill and I was head of health at Unite, to highlight this risk. I therefore feel it on my conscience. I raised these very concerns about the failed funding formula and the way that finances in the NHS work against each other rather than together. That is what creates these issues, so we can avoid them not only by ensuring that there is enough money in the system, but by ensuring that the relationship is right and the funding formula works in the right way.

In my exchange last week with the Minister, we talked about individuals in the system being able to put their hand up, in the light of the massive inequality they face and the big no on money, and say, “By the way, can I have an individual funding request? I don’t like the decision that’s been made, so I’m going to challenge what my doctor”—let us face it, doctors have stature in society—“has said and say, ‘Actually, I want to have an individual funding request.’” Making that point to a GP is a massive step, and it shifts the risk in a system that is there to care for people on to the individual patient—the smallest person in the whole health system. Patients have to say, against the weight of the system, “You got it wrong over my healthcare, and I want you to review that and put the money in,” when there is no money in the pot. That is a complete nonsense of the process. We therefore need to shift the debate back to putting the right funding into the NHS so that patients are not discriminated against and clinicians can make the choices they are trained to make.

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

It is a pleasure, as always, to serve under your chairmanship, Mr Hollobone. I am conscious that there is the possibility of a vote coming rather earlier than we had anticipated; in which case, I will try to ensure I do not use up all the available time. I congratulate the hon. Member for Dewsbury (Paula Sherriff)—Dewsbury, Mirfield, Denby Dale and Kirkburton, but I will use Dewsbury for shorthand—on securing the debate and securing the support of the hon. Member for York Central (Rachael Maskell), who made a compelling case today. She referred to our recent meetings on this subject and previous debates on it in the Chamber, demonstrating her clear commitment to the cause.

It is no secret that the NHS faces significant challenges. All the Opposition Members who spoke referred to some of the financial pressures currently acknowledged as affecting the NHS. However, I do not think they quite recognised that the NHS’s own five year forward view identified some significant challenges that need to be addressed in relation to the way in which the nation supports the healthcare of the population as a whole. Throwing money at it inexorably is not always the right solution. Some difficult choices have to be made about the way in which the public lead their lives. What we can do, through a combination of public health support, advice and education, to encourage the public to lead healthier lives is an important responsibility of Government. It is important for individuals to help to ensure that they lead long, independent lives in as healthy a condition as possible.

[Rachael Maskell]

The five year forward view was put in place long after people established lifestyles either of being overweight or of smoking. To penalise them after the event was not the intention of the five year forward view. That strategy is about improving people’s health, whereas this programme is about causing health to deteriorate.

[Mr Dunne]

I do not accept that. It is important that we use all the tools at our disposal to encourage the public to lead healthy lives where possible. These measures form part of the suite of measures that are necessary to bring that about.

The Government have backed the five year forward view. Opposition Members raised the issue of finances. We have committed to a real-terms increase in funding through the spending review period. Most recently, in the Budget only last month, we committed an additional £2.8 billion on top of the £8 billion real-terms increase by 2020. We are providing significant extra resource, but we recognise that different areas of the country will face different challenges and so will develop different approaches to how they use their resources most effectively in patients’ interests. That will inevitably involve making difficult decisions. It is right that we trust local NHS organisations, clinically led, to make those decisions, rather than second-guessing them centrally.

Having said that, we have set certain expectations of the system, one of which is that blanket bans on treatments are completely unacceptable and incompatible with the NHS constitution. That is why I refute the challenge from Opposition Members to say whether or not we are imposing rationing on the NHS. The local management responsible for the NHS in their areas have to respect the constitution and should not introduce blanket bans, but they do have to look at ways to provide care for their populations in a manner that lives within the budgets they have been provided with.

[Mr Dunne]

The hon. Lady made that point in her remarks, and I will try to address it. She can pick me up on that again.

[Rachael Maskell]

To put this into the context of how it is working in reality, patients who do not meet the thresholds are automatically put through a system, and therefore it is completely in breach of the NHS constitution. There is no individual input about the clinical needs of a patient.

[Mr Dunne]

I will come on to that. We are talking primarily about what is happening in North Kirklees and Greater Huddersfield CCG areas, which have not yet implemented this policy. I will explain why I do not think that that should be the case.

On the healthcare optimisation plan, I take the gentle chiding from the hon. Member for Ellesmere Port and Neston (Justin Madders) about the way in which the NHS describes proposals. I have some sympathy with what he says about the way in which language is used, but this is a plan to encourage greater public health among the population of North Kirklees and Greater Huddersfield CCG areas, for which they are responsible. I talked to the CCGs in preparation for the debate and was advised that they do not see this as a blanket ban on treatment. I have emphasised to them that they should not do so and that there should not be a blanket ban on treatment.

I will describe the proposals, as I understand them. They have been developed by the CCGs since autumn 2016, and the objective is that patients who are overweight with a body mass index of 30 or above will have 12 months to lose at least 10% of their overall weight or to reduce their BMI to less than 30, while patients who smoke will be encouraged to take up to six months to quit smoking before undergoing routine surgery. Those who quit smoking for four weeks or achieve their target weight loss will be able to be referred for surgery under the policy.

The development of the plan coincided with the UK’s childhood obesity strategy and the proposed introduction of the soft drinks industry levy, reflecting the Government’s commitment to tackling the major public health problems affecting large sections of society. The hon. Member for Dewsbury and the hon. Member for York Central recognised the need to address the obesity crisis in this country. I am grateful for their support and that of the Opposition spokesman, the hon. Member for Ellesmere Port and Neston. I think we are united in recognising that something has to be done about this. I hope they support the proposals that the Government have made for the obesity strategy and the considerable progress we have made in reducing smoking since 2010. Hon. Members have made the point that the policy should not be at the expense of treatment if treatment is urgent or, if there is no treatment, it might lead to degradation of the health condition of the patient subject to the policy.

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[Mr Dunne]

As the hon. Gentleman knows, CCGs are subject to appraisal and are accountable to NHS England, which is accountable to Ministers. It is not for Ministers to direct individual CCGs as to how they should enact their policies, but there is a route through which we can provide some encouragement to NHS England to ensure that these policies reflect its national position. That is what we will do.

On where the process is, in October the two CCGs presented details of the proposed plans to Kirklees Council’s health and social care scrutiny committee. The committee requested that the CCGs undertake a further six weeks of engagements, especially with hard-to-reach communities in the area of the hon. Member for Dewsbury. The CCGs have assured me that they are committed to that further engagement with the local community to ensure that the plan is fit for purpose, so there is a continuing opportunity to reflect on the revised iteration of the proposals. I am also advised that the CCGs have not yet made firm decisions on the plans. Instead, as a result of the engagement with local stakeholders, they are considering four options, and variations on the four options, for implementing the proposed plan, including not proceeding with the programme, which remains on the table.

Those options include: first, a phased approach, beginning with applying the programme initially only to patients who smoke and subsequently rolling it out further to obese patients if appropriate; secondly, only implementing the plan for smokers; thirdly, introducing health optimisation periods across clinical thresholds and pathways, in line with NICE guidance; or fourthly, moving away from implementation of the plan as previously defined and focusing on a strengthened education campaign to reinforce the benefits to patients of stopping smoking and losing weight. Those options remain on the table and there will be a further period of engagement. A decision on which option will be taken forward is due to be made by the CCGs in January, and further engagement on the implementation of the recommended approach will then take place later in the new year.

I said earlier that the plan is not a blanket ban on treatment. Instead, the intention is to encourage patients who are obese or who smoke to lose weight and/or quit smoking. There is evidence that that will have benefits, in terms of both surgical outcomes, as I have said, as well as reduced risk for general medical conditions, and there are clearly also benefits to patients’ general health in the long term. Hon. Members can be assured that the CCGs are providing support to the patients on weight loss and smoking cessation, and have agreed to invest £133,000 a year in such services to account for any health optimisation-related increase in uptake.

The hon. Member for Dewsbury asked how we will assure that the plan is in accordance with national guidelines. As she would expect, NHS England has been closely reviewing this and similar proposals where they have been made to ensure that there is robust supporting clinical evidence and appropriate safeguards. The Government expect NHS England to ensure that the responsible CCG is not breaching its statutory responsibility to provide services that meet the needs of the local population. I can confirm to hon. Members that NHS England has had ongoing discussions with both CCGs about the health optimisation plan and will continue to do so to ensure that it works in the best interest of patients. That is the right approach, in terms of both protecting patients and both encouraging the population to put themselves in a condition to maximise the benefits from surgical procedures, without allowing CCGs to introduce an inappropriate blanket ban.

NHS England carries out regular assurance of CCGs and holds them to account through the CCG improvement and assessment framework to ensure that they are fulfilling their statutory requirements, and NHS England can and will intervene if a CCG is failing to discharge its key responsibilities. NHS England’s regional teams also have regular discussions with CCGs about their commissioning activities and plans.

It is important in a debate like this, in which there are allegations of there being a postcode lottery, that we recognise that it is down to clinicians at a local level, through their CCG bodies, to make decisions that affect their local population, rather than, as has happened in the past, central diktat from Whitehall. Those may lead to perverse consequences and a less relevant healthcare capacity and treatments for patients on the ground.

[Rachael Maskell]

The Minister is being very generous with his time. Is it not important in a national health service that we use the very best clinical evidence on how to produce the best outcomes for all patients? Falsely drawn boundaries should not have any relevance to the kind of treatment people receive.

[Mr Dunne]

The hon. Lady will recognise that there are different health challenges in different areas, reflecting patients’ differing needs. Encouraging the public to stop smoking and to reduce their weight is, as she acknowledged, an ambition that is shared by Members across the House and across clinical leads.

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[Rachael Maskell]

Will the Minister give way?

[Mr Dunne]

I will not let the hon. Lady intervene again because, amazingly, I am about to run out of time, despite what I said at the beginning. I have taken a lot of interventions.

I conclude by assuring hon. Members that we are paying close attention to what is happening in Kirklees and Greater Huddersfield, and York Central. Other areas of the country may be considering similar proposals, and we need to ensure that it is done in a responsible manner, whereby clinicians stay at the heart of making referrals where appropriate and retain that discretion. We will not get to the situation that the hon. Member for Dewsbury described in her opening remarks, in which she said that people’s lives will be put at risk by policies such as this. That is not the case.