Future of the NHS

Richard Drax Excerpts

Thursday 20th July 2017 Commons Chamber

[Richard Drax (South Dorset) (Con)]

Before I start my speech, may I thank you, Mr Deputy Speaker, the Speaker and all the office staff, the police and everyone else who takes care of us here? I wish them all a very happy summer recess, when they all go off on their holidays. We are extremely grateful for all that is done.

First, I thank and praise all those who work in the NHS, especially those on the frontline. Secondly, it would be inappropriate of me not to pay tribute to our able and competent Front-Bench team, who face some extremely difficult challenges within the NHS. My speech today is in no way at all a criticism of the Government; it is purely based on my own observation and the observations of others, in part in Dorset but also from around the country. I hope Ministers will forgive and indulge me as I honour one of my election pledges and bring this matter to the Government’s attention.

As I said, in essence I am responding to my own observations and to those of the many people I have spoken to, who work either in or around the NHS. I, we and they are proud of our NHS, and rightly so. As Nigel Lawson, the former Chancellor, so memorably said, “It’s the nearest thing we have to a national religion”.

The NHS will be 70 years old next year; it is the world’s fifth largest employer, with 1.5 million employees; and it serves a population of the United Kingdom of more than 54 million people. The total budget for NHS England is a staggering £117 billion. The three founding principles of the NHS—that it is available to all, free at the point of delivery and based upon clinical need rather than the ability to pay—still stand. Last week, the US-based Commonwealth Fund health think-tank found the NHS to be the best, safest and most affordable healthcare system of the 11 countries it analysed, for the second time in a row. That is a record to be proud of.

However, the NHS is, to some degree, a victim of its own success. That same study placed the UK second from bottom for clinical outcomes. So what to do? Politicians take a scalpel to the NHS at their peril. The consequence is that only sticking plaster is used to meet changing circumstances. Medical advances, longer life-spans and soaring healthcare costs have outpaced resources, and the situation can only get worse.

A recent Public Accounts Committee report found that the financial performance of NHS bodies had deteriorated, with NHS trusts seeing their deficits almost treble to £2.6 billion in a single year, 2015-16. Plugging those deficits will not be easy. Addressing the shortage of nurses and GPs, coping with a strained adult social care system, responding to an overstretched A&E service and countering ambulance waiting times all require careful thought and perhaps further review.

I am a former soldier and we used to say in the Army that time on reconnaissance is never wasted, so a visit to the frontline—in my speech—is instructive. A senior doctor on my Dorset patch despairs at the “army of office staff” who leave every evening on the dot of 5 pm, while work in the hospital, which he emphasises has always been a seven-day service, rolls on. He believes that administrative staff could be cut by about 25% without affecting patient care.

That senior doctor says the so-called “bed bureaus” in most hospitals are a case in point. When a patient is admitted, doctors must book a bed through bed managers—there is one per shift, so three per day—who, in turn, inform the ward sisters, who were themselves once responsible for the beds on their wards. In fact, the bed managers are often very senior nurses who have been promoted out of their clinical roles into well-paid managerial jobs. Formerly, such senior nurses were an invaluable source of knowledge and training for junior nurses, but it now seems there is a risk that their hard-earned skills will be wasted in administrative roles.

To be fair, the NHS says that managers have been cut by 18% since 2010. However, in the view of the senior doctor I am referring to, there is still ample opportunity better to share back-office functions across regions, especially in commissioning services, purchasing and postgraduate medical education for doctors. For those who are unaware, newly qualified doctors apply to a regional deanery for further training in foundation years 1, 2 and 3. That deanery remains responsible for their rotations until they choose their clinical specialty, three years after qualifying. Therefore, my doctor source asks, why are there education managers, deputy education managers and deputy assistant education managers in most hospitals he has worked in? In addition, he points out that nurses are efficiently certified and accredited by their own system, so they do not need in-house education managers, either.

The pressure on social care has also had a significant impact on acute hospitals, says this doctor. Like hospital administrative staff, care home staff are available to assess prospective new residents only during office hours, leaving A&E departments—often with elderly patients who are not strictly emergencies—to languish until Monday morning. Occupational therapists are also unavailable until Monday morning, meaning patients cannot be sent home because their homes cannot be certified as safe. In addition, A&E departments are frequently overwhelmed by patients suffering from mental health issues.

The under-16s pose a particular problem, certainly in Dorset, because the office hours of the children’s mental health assessment service are from 9 to 5, Monday to Friday. Most young patients present at night, when stress, depression or suicidal thoughts tend to rear their ugly heads. An A&E doctor is unable even to prescribe a sedative. Instead, dedicated nurses must be found to watch the young patient constantly until Monday morning, when a child psychiatrist can see them.

In addition, the NHS internal market, which has been with us since John Major’s Government, has also had unintended consequences. Procuring goods and services across a region, rather than restricting individual commissions to each small trust, would save millions, says this doctor. So what can be done? Clearly, the current situation is unsustainable in the longer term. The right hon. Member for Birkenhead (Frank Field), if I may paraphrase him, has said that the NHS is so rapacious that it could probably never be satisfied. However, there must be another solution.

Healthcare spending is protected relative to other public services, but increasing demand and costs surely demand we think a little more out of the box. As I have mentioned, hospital deficits reached £2.6 billion in 2015-16, negating the benefits of any funding increases. Projections from the Office for Budget Responsibility suggest that spending on healthcare could rise from 7.4% of GDP in 2015 to 8.8% in 2030-31, which is the equivalent of a real increase in spending of £100 billion.

The Office for National Statistics predicts that the proportion of people aged 65 and over will increase from the current level of 18% to 26.1% in 2066, with over-85s tripling to 7.1% over the same period. A study by the King’s Fund found that financial pressures have affected access to services and quality of patient care, while the Care Quality Commission’s latest report concluded that the quality of care provided across England varies considerably.

When compared with member countries of the Organisation for Economic Co-operation and Development, the UK spends less per capita than France, Germany, Sweden and the Netherlands. We also perform poorly on many acute care indicators, with worse outcomes for stroke victims, heart attacks, and cancer survival over five and 10 years. With more people, better and more expensive technology and greater expectations, the pressures will continue to grow.

A significant new House of Lords report, “The Long-term Sustainability of the NHS and Adult Social Care”, describes a “culture of short-termism” across successive Governments. Interestingly, the report calls for a new political consensus on the future of the health and care system via

“cross-party talks and a robust national conversation.”

I do not entirely agree, but I will come on to that later.

The report concludes:

“Short-term funding fixes will not suffice. Neither will tinkering around the edges of service delivery.”

It made three recommendations: that there should be radical service transformation, with more integrated health and care services in primary and community settings; that there should be long-term, stable, predictable and adequate funding for the NHS and adult social care; and that there should be immediate and sustained action on adult social care, with urgent funding to alleviate the crisis in NHS hospitals. It is not just the Lords who have an opinion; these are coming in thick and fast from across the political spectrum, including from the King’s Fund, the Barker commission, the Nuffield Trust, the Health Foundation, the Public Accounts Committee, the Care Quality Commission and a number of parliamentary Select Committees.

To be fair, a good start has been made. The Health and Social Care Act 2012 abolished primary care trusts, to be replaced by 44 clinical commissioning groups, responsible for commissioning the majority of NHS services. Since 2015, those in turn have developed local sustainability and transformation plans, as part of the NHS five year forward view. The STPs are blueprints for better integration of GP, community health, mental health, cancer care and hospital services, focusing on more joined-up working with home care and care homes. The Government are to be congratulated on all of that. I am delighted and touched that this week Dorset’s STP has been awarded more than £100 million by the Government. Dorset is also one of eight areas nationally to announce an accountable care system, which will fast-track these improvements, especially taking the strain off A&E departments and making GP appointments easier to get. It will share in a £450 million pot. The STPs are, say NHS England,

“a starting point for local conversations”.

We all hope so. Dorset’s CCG is currently poring over responses to its public consultation which closed in February. Some of its proposals, including moving A&E services from Poole to Bournemouth, and losing community hospital beds on Portland and at Wareham, I find difficult to accept.

Inevitably, some of the CCG’s remit must be to find savings. Various suggestions have been made in the past: the Carter review in 2016 found that £5 billion could be saved through shared procurement and back office support; the Naylor review in 2017 concluded that better management of the NHS estate could generate £5 billion and provide land for 26,000 new homes; and the Wachter review suggested that better IT systems would help. Whatever savings are made can then be reinvested in the NHS’s most precious asset of all, those on the frontline, where there are genuine concerns.

A House of Lords report described the lack of an appropriately skilled, well trained and committed workforce as the

“biggest internal threat to the sustainability of the NHS”.

A shortfall of some 10,000 GPs across the UK is predicted by 2020. At the same time, hundreds of GP practices are in danger of closing because 75% of their doctors are aged over 55. Nurses are wooed now with flexible hours and school-friendly schedules, but the abolition of the nursing bursary earlier this year has seen the number of applicants applying to start nursing degrees this October fall by 23%. I know from my own research into ambulance waiting times that the ambulance trust covering my constituency is having trouble both recruiting and retaining staff.

We all agree, in all parts of this House, that the NHS is a unique national treasure, to be protected, sustained and nurtured, but it cannot remain a sacred cow, untouchable at any cost. So why do we not hand this problem to an independent panel, totally divorced from politicians, and ask it to see how we can make better use of the £117 billion that we spend? From what I have heard and seen, I simply cannot believe there is not a better way of running our beloved NHS. The will from those in all parts of the House is there, so let’s be bold, take politics out of it, simplify the way the NHS is run and channel more resources to the frontline.

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

It is a great pleasure to join you in the House for the last debate before the summer break, Mr Deputy Speaker.

I congratulate my hon. Friend the Member for South Dorset (Richard Drax) on securing this debate and commend his timing, as it is two days after we laid the Department of Health and NHS entities’ 2017 accounts before Parliament. He will note from what I am sure will be his diligent scrutiny of those accounts that provider deficits have been much reduced in the year that has just ended compared with the figure he cited for the previous year. That is a tribute to the focus of managers and trust leaders on securing the financial balance that the NHS as a whole has delivered over the past year.

To put all that in context, this is a time when more people than ever are using the health service. In 2016-17, some 23.4 million people attended A&E departments in England—2.9 million more than in 2010. The overwhelming majority of patients continue to be seen within four hours, and the NHS overall sees more than 1,800 more patients within the four-hour standard every day compared with 2010. In the previous year, the NHS carried out 11.6 million operations—some 1.9 million more than in 2010. That provides the context of the achievement and the treatments that have been given to patients throughout the land.

I am pleased that my hon. Friend recognised the excellent care that the NHS provides, which has been demonstrated for the second year running by the Commonwealth Fund report: in its international study published last week, the UK was ranked as the No. 1 health system in a comparison of 11 countries. That is a testament to NHS staff. The patients who benefit from those treatments rate their experience of care highly. The adult in-patient survey, which was released in May, shows that the majority of patients report that their overall experience was good, with 85% rating it as at least seven out of 10—a slight improvement on the previous year.

Looking to the future, which is the subject of the debate, the Government are committed to increasing the NHS budget to ensure that patients get the high-quality care they need. By 2020-21, NHS spending will increase by £8 billion in real terms from the 2015-16 baseline. That will deliver an increase in real funding per head of the population for every year of this Parliament. Nevertheless, my hon. Friend is right to point out that whatever funding we provide, it is important that we spend it to achieve the best possible outcomes for patients.

It is essential that we ensure that the NHS continues to make the most effective use of its resources to deliver high-quality patient care, so I recognise what I think was my hon. Friend’s motivation in securing this debate and raising this subject before the House rises for the summer recess. We all agree that it is important to target NHS funding to frontline services, which is why we are investing in the workforce and there are already more than 33,800 extra clinical staff, including almost 11,700 more doctors and almost 13,000 more nurses on our wards since May 2010.

NHS management is an important element of ensuring an efficient NHS, but of course we are keen to ensure that an increasing proportion of NHS funding goes to patient-facing services. Between 2010-11 and 2016-17, the proportion of the NHS pay bill spent on managers declined from 6.5% to 5.8%, which I am sure my hon. Friend will welcome. We are also reducing the number of people involved in management, which he called for. Between May 2010 and March 2017, the number of managers and senior managers in NHS providers and support organisations reduced from some 37,000 to around 31,000—I think that is similar to the effective percentage to which my hon. Friend referred. We are also looking to manage the rate of pay of senior managers, again to ensure that as much as possible is focused on the frontline.

It is important that we recognise that leadership is as important in the NHS as it is in any organisation—we must ensure that we have high-quality leadership across organisations. I for one am keen not to bash the managers in a somewhat traditional manner, but to recognise that high-quality leadership in our NHS organisations is important in driving high-quality performance for patients. That is why I have been working with the leadership academy in Health Education England to ensure that we have two things: a pipeline of talent so that we can identify quality individuals at the beginning of their careers in the NHS and track them as they pursue their careers, identifying the leaders of tomorrow, in a similar system to that with which my hon. Friend will be familiar from his service in the military; and some consideration of how we can get more clinicians involved in leadership roles in their organisations. Clearly, we have directors of nursing and medical directors in all provider trusts, but too few go on to take up the most senior leadership positions as chief executives.

[Richard Drax]

I am listening carefully to the Minister. Would it be naive to say that what we want to see is matron, in the form of Hattie Jacques, back on the wards and to hand far more administrative work, if that is the right phrase, back to clinicians, with whom it originally lay?

[Mr Dunne]

I am not keen to hand administrative work to clinicians, but I recognise that there is a role for ensuring that senior clinicians are present and in charge of activity in wards. That is the experience I am seeing as I visit acute hospitals around the country: senior members of staff, normally coming out of nursing staff —so they are a matron or other senior nursing officer—are responsible for what happens on their ward.

My hon. Friend says that an independent review might be appropriate, and I say gently to him that we think that the right way to drive improvement across the NHS and help position it for the challenges of the future is to back the plans prepared by the leadership of NHS England with colleagues from across the system through the five year forward view. This is the NHS’s own plan for change and it lays out how the NHS can transform services and improve standards of care while building a more responsive modern health service. We are backing this plan, enabling the NHS to deliver Government objectives including seven-day services and improved access to cancer treatments and mental health services. We agree that the answer to the challenges faced by the NHS lies in modernising services and keeping people well and independent for longer.

The NHS is using the sustainability and transformation partnerships mentioned by my hon. Friend to deliver that vision through transformation across local areas. These are clinically led, locally driven and can deliver real improvements for patients. The five year forward view also announced the development of new care models and we are already seeing the results.

My hon. Friend referred to the announcement yesterday about the first allocation of capital funding for the most advanced STP areas, including Dorset, which covers his constituency. It is fortuitous that the largest single beneficiary of capital through the STP allocation was Dorset, and what a great day for him to secure this debate and give an albeit somewhat guarded welcome to that significant capital injection. I am aware that he has a number of issues with how that money will be spent.

[Richard Drax]

It was totally unguarded. I am extremely grateful, as I am sure all clinicians and all those who work in the NHS in Dorset will be.

[Mr Dunne]

That applause is on the record, and I am delighted that my hon. Friend takes that view.

We see this investment as backing the exemplar STP plans that have been published thus far, and we hope that other areas, whose plans are in less good shape, will be encouraged to look at those that have succeeded to see what they can do to follow their example for the next phase of the roll out in the coming years.

I will conclude with a couple of comments about how we drive efficiency through the NHS and make best use of resources. My hon. Friend referred to the Carter and the Naylor reviews. Carter is driving heavily towards using best practice and removing variability across the NHS, whether in clinical practice or in financial performance, in areas such as procurement. Alongside that, Naylor is looking at how we drive out inefficiency from back-office functions, from estates and from the facilities management element of running such a substantial network of hospitals and facilities across the country. There is scope to do more. That will appeal to my hon. Friend’s desire to put more resources on the frontline. We are looking at encouraging organisations to share back-office facilities—as he called for—to bring down cost and drive up efficiency and operational productivity, which is the right way to go.

I conclude by confirming that we are making good progress in small steps. We need to continue to make progress to try to raise the depth of the tread of the steps that we are taking to ensure that the NHS is fit to serve the health needs of this population for the future.

Question put and agreed to.