NHS (Contracts and Conditions)

Sarah Wollaston Excerpts

Monday 14th September 2015 Westminster Hall

[Helen Jones]

No. I need to make a little progress, because other people want to speak.

In Warrington, we have fewer GPs than we had in 2010—those are the Government’s own figures, not mine. Nationally, the number of unfilled GP posts quadrupled in the three years from 2010 to 2013. The Royal College of General Practitioners says there are severe shortages in some parts of the country and that in some areas—it quotes Kent, Yorkshire and the east midlands—we need at least 50% more GPs over the next five years just to cope with population increases. Now, when there are not enough GPs to ensure timely access to appointments on weekdays, it is difficult to see how the Government are going to extend GPs’ working hours without recruiting more staff.

Of course, the cost is also an issue. It is estimated that the costs of extending services beyond the current contract, with one in four surgeries opening late in the evening and at weekends, would be £749 million. That would rise to £1.2 billion if one in two practices were open longer. That is far in excess of the money currently in the GP challenge fund. If the Government intend to proceed without recruiting more staff, that will simply increase the pressures on the staff working already, leading to more burn-out, and it will be a downward spiral. We already know that many GPs are thinking of retiring early.

The Secretary of State has now turned his attention to not only GPs, but hospital doctors and consultants, who he says do not work weekends. Well, I have two consultants in my family, and that is news to me, because they certainly do work weekends. In fact, the Secretary of State so provoked hospital doctors that they took to Twitter under the #iminworkJeremy, posting pictures of themselves working at weekends, often after a 70-hour, five-day week.

Now, I reiterate that everybody accepts that out-of-hours care has to improve, but the Secretary of State needs to achieve that through consultation and by showing respect for the staff we already have. At the moment, he is guilty of muddled thinking; he has deliberately confused emergency care with elective care. Specialists in emergency care do work weekends; in fact, very few consultants opt out altogether—the figure is about 0.3%. Yet, the Government tell us that there are 6,000 extra deaths among people admitted at weekends. The Minister needs to publish the research on that and to go further, because correlation and causation are not the same thing.

[Dr Sarah Wollaston (Totnes) (Con)]

May I recommend that the hon. Lady read last week’s edition of the British Medical Journal, where the issue is set out very well by Professor Freemantle?

[Helen Jones]

Yes. I thank the hon. Lady for that useful suggestion. I will do so.

People who are admitted to hospitals at the weekend are much sicker than those admitted on weekdays, because we do not have elective admissions at the weekend.

--- Later in debate ---

[Dr Sarah Wollaston (Totnes) (Con)]

It is a pleasure to serve under your chairmanship, Ms Vaz, particularly as recently you were a fellow member of the Select Committee on Health. For the record, I am married to a full-time NHS forensic psychiatrist, although one might say that I do not have a dog in this fight, because he already works weekends.

It may help the House if I comment quickly on the background. I thank Professor Freemantle and his team for their excellent updating of the data following the last analysis of data in 2009-10. He and his colleagues carried out the exercise again based on data from 2013-14, and it may help if I put some of that in context. What he shows is that 1.8% of NHS patients will die within 30 days of admission. It is important that we look not only at the data relating to what happens within a few days, which he has also analysed, but at the longer-term data. He shows a very real effect: if someone is admitted to hospital on a Friday, there is a 2% increase in the risk that they will die within 30 days; if they are admitted on a Saturday, the increase is 10%; if they are admitted on a Sunday, the increase is 15%; and if they are admitted on a Monday, the increase is 5%. Those are relative, not absolute, statistics and are on a background rate of 1.8%, so it is important that we do not alarm people unduly with those data. However, they mean, very importantly, that around 11,000 more people die if they are admitted between a Friday and a Monday, relative to what we would expect had they been admitted on a Wednesday.

That is extremely important, and the Secretary of State is absolutely right to take that very seriously, but we need to look at it in its wider context. Is it simply because a different group of people are being admitted in the middle of the week than are being admitted at weekends? Is it because they are a sicker group of people? Both of those are true, which is why it was important that Professor Freemantle made adjustments for those kinds of data. He showed that even if we take account of the fact that there are genuinely sicker people coming into our hospitals at the weekend, the effect was still present, but it was reduced. There was a 7% increase on a Saturday and a 10% increase on a Sunday, so it was still important. As for people admitted to hospital for routine procedures, it was shown that the nearer it gets to the weekend, the more their chances of mortality increase.

To go back to my earlier point, the Secretary of State is absolutely right to take this issue seriously. This is not just an effect in Britain; it is observed internationally, but it matters. Yes, those people are sicker, and yes, a different group of people is coming in, but there is also the issue of what we should do about it. We must not give the impression that all those 11,000 deaths are preventable. We have to be very careful not to rush into action that leads to a levelling down, rather than a levelling up. We want to bring the data up as far as we can, but when hospitals have done a deep analysis of the deaths that have occurred within 30 days of people being admitted at weekends, it is sometimes very difficult to say what could have happened differently.

We need to look at this issue, but it is not just about consultant presence. Senior supervision at weekends is undoubtedly part of it and is very important, but other issues are at stake. Is there access to diagnostic tests? We need to look beyond this being just about consultants; it is about nursing staff, too. We have to be careful not to shift resources into trying to sort out one part of the issue—consultant presence—because if that means a continuation of a worrying trend of shifting resources out of primary care, we could inadvertently end up with a sicker group of people coming into hospitals at weekends. In other words, we have to be very careful about the balance and potential unintended consequences of what we do.

Undoubtedly, at the root of all this—this issue would face whoever was sitting behind the Secretary of State’s desk—are the issues of financing and resources for the NHS. I hope, as we come closer to the spending announcements, that as much as possible of the £8 billion announced will be front-loaded, so that some of these issues can be addressed. Resourcing and how we spread it across the wider NHS lies at the heart of this question, and it is important that we do not focus entirely on hospitals.

I want to talk more widely about the seven-day NHS. I hope that the Secretary of State will look carefully at what that is for. Is it about trying to reduce that excess weekend mortality? Yes, it should be about that. Should it be about reducing avoidable, unnecessary admissions to hospital? Absolutely. We know that people do not want to be in hospital. It is a dangerous place for someone to be if they do not need to be there, particularly if they are frail and elderly and would be better looked after in the community, so yes—let us reduce avoidable admissions.

Should the seven-day NHS be about accessing the kind of specialist advice that makes a real difference to people’s lives? I am very conscious that this House debated on Friday whether people should have the right to medical assistance in ending their life. It was a controversial debate. I think the House made the right decision, but there was absolute consensus within that debate about the need for greater access to specialist palliative care advice. I would include that kind of thing in a seven-day NHS, because people’s quality of life at the end of their life has an extraordinary impact not only on them, but on their whole family. Seven-day services should be about addressing quality, and I would love the Minister to comment further on how we can bring about sustainable funding for specialist palliative care. That is absolutely part of what we should be doing on seven-day services.

However, there is another aspect, which is more difficult. When resources are very restricted, should we prioritise access to primary care out of hours for people who would prefer to be seen at the weekend than mid-week? I am sure we all understand that—in our busy lives, it is sometimes difficult to take time off work—but it might not be the priority when resources are tight. I speak as someone who, before I came to this House, was a clinician in rural Dartmoor in a two whole-time-equivalent practice. It was a very rural setting, and if we were to try to provide an 8-till-8 service on Saturdays and Sundays for routine GP appointments—if we were, as this is sometimes presented to the public, to enable people to see their doctor at any time—the cost would be enormous. There are extra costs involved in manning surgeries at those times, and there are also issues to do with staff availability.

I visited several practices in my area over the summer recess, and I see there genuine concern about not only the GP workforce, but the wider primary and community care workforce. We have to be very careful. If we prioritise issues such as making it possible to have a routine appointment from 8 till 8 on Saturdays and Sundays—much as I can see merit in that—it will take resources away from the other things on that list of four. We should focus on other priorities on this stage and be clear that there are other risks, such as undermining other out-of-hours services.

I would like the Secretary of State to be very clear about what he means by a seven-day NHS when it comes to primary care, and about how we will make those fair funding decisions and divide the cake, so that we get the very best for people. We absolutely have to address the excess mortality, but we have to look at the reasons behind the data to be realistic about what we can achieve. We have to make sure that we bring the quality up and that we do not inadvertently end up bringing it down by having sicker people coming into hospital, which is one of the drivers of the data that we are trying to address.

Many Members want to speak, and I, along with colleagues, have the opportunity to question the Secretary of State at the Health Committee tomorrow, so I will draw my remarks to an end. However, I hope that those points can be addressed.