Future of the NHS

Sarah Wollaston Excerpts

Monday 9th May 2011 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

I have no doubt that one of the main reasons I was elected to the House was that I promised to bring my clinical experience to bear on the health debate and to stand up for our NHS. I would therefore like to set aside party politics for a moment and give my personal take on the direction that I hope the proposed reforms will take and where we should go from here.

At the heart of the Bill lie issues of choice, competition and clinical commissioning. My right hon. Friend the Member for Charnwood (Mr Dorrell) set out clearly the huge funding challenges that face the NHS. We have always had rationing in the NHS, but we are squeamish about discussing it. In an ideal world with unlimited resources, unrestricted choice would of course be a good thing, but it is not deliverable. Because of the limited budget, we need to focus on getting the very best value while openly and honestly involving communities in how we do that fairly. If that happens locally, one person’s local commissioning becomes another person’s postcode lottery.

The central problem with unrestricted choice in the form of the “any willing provider” model is that it forces commissioners to act as bill payers and has the potential to undermine good commissioning. What is the point of commissioners designing high-quality, locally responsive clinical pathways that deliver good value for money for the whole community if patients have a free choice of any willing provider and commissioners have no choice but to write the cheques?

[Mr Umunna]

The hon. Lady has long experience of working in the sector. One of my concerns about the “any willing provider” model is how it will potentially disadvantage teaching hospitals. [Interruption.] The Minister of State, the right hon. Member for Chelmsford (Mr Burns), might want to listen to this, because one of the hospitals involved is St Thomas’s, which serves the House, and if he fell ill here he would probably go over there. One of my concerns is about how teaching hospitals will be able to compete with other providers given the extra burdens of training and supervising those who are learning to work in the NHS. Does the hon. Lady share that concern?

[Dr Wollaston]

Of course, one of the greatest burdens on many hospitals is that of the private finance initiative, and I will come to the issue of training later. I am not opposed to competition in the NHS, but it should not be an end in itself. It can have a role in improving some services—take, for example, the provision of mental health services and talking therapies, on which I am repeatedly told that the voluntary sector delivers better results. If I were facing a long wait for an MRI scan, for example, I would not mind if it was provided by the private sector as long as it was free to me at the point of use as part of the NHS.

The point is that competition should be used only where there is evidence that it can deliver real benefits for patients and value for money for the whole patient community. If competition becomes an end in itself, that can actually increase costs and risk fragmentation. For that reason, I hope that as the Bill moves forward, there will be fundamental changes to the role of Monitor. The NHS cannot operate like a regulated industry, and I believe that concern about the proposed role of Monitor is the impassable barrier to co-operation from the professions, without which we will not achieve the great success that we need from these reforms.

We must return to the original promise of the reforms, which was about clinical commissioning and a focus on outcomes rather than targets. For years, commissioning has failed because decision making in primary care trusts has not been clinically led. The NHS has been dogged by illogical care pathways, top-heavy management and a target-driven mentality, often completely divorced from any evidence base. The idea that clinicians should be put at the heart of decision making is still very sound, and it has become divisive only because of the stipulation that GPs should hold all the cards and be the sole commissioners.

Where clinical commissioning is already successful, that is achieved through a collaborative process with multi-disciplinary input. I hope that as a result of the Government’s welcome listening exercise, the call to broaden the membership of commissioning consortia will be heeded, along with the need for a more graduated and phased introduction so that consortia are authorised only when they are ready. The same should apply to foundation trusts. They should take on functions only when it is right for that to happen.

If commissioning consortia are to achieve the best results for their patients, they will need to focus on the integration of health and social care, as my right hon. Friend the Member for Charnwood said. I pay tribute to Torbay, which was at the forefront of moves that were widely applauded nationally and internationally, including by the King’s Fund, and that achieved real results for patients, driving down unnecessary admissions and improving outcomes. The integration of health and social care is complicated to achieve, so perhaps Monitor could have a relevant role in it—not arbitrating in disputes about competition law, but driving down costs and facilitating integration. We know that splitting tariffs, for example, could benefit community hospitals. Again, that is complex to achieve, so perhaps Monitor could also help in that regard.

For consortia to succeed, not only do we need to focus on the make-up of their boards, but they must be geographically logical and, I am afraid, cater for geographically defined populations. Giving a free choice to register with any consortium risks encouraging consortia to cherry-pick their patients. One striking feature of the Bill is its sheer scope. All junior doctors will remember the fiasco of MTAS—the medical training application service. We currently have a successful model of deaneries in this country. I hope that we can retain them as the Bill goes forward, because they have a vital role to play in encouraging quality. Of course they are not perfect, and they need to look at regional variants, but we should keep our deaneries.

Speaking of quality, at present, PCTs play a vital role in maintaining what is called the performers list, on which all GPs have to be registered in order to practise in an area. As we move forward, we need to clarify who will take over that role. That is particularly important because we have a crisis with many doctors coming here, particularly from the European Union, who do not speak adequate English, as we saw in the case of Dr Ubani. We need to ensure that the person responsible for the performers list can get rid of this nonsense, so that all doctors not only have the necessary qualifications, clinical skills and experience, but have good spoken English.

I welcome this listening exercise, which I believe is genuine, and I hope that the Opposition will engage with it constructively. The public’s affection for the NHS is well justified. At its best, the NHS is outstanding. Where that is the case, it is not competition that has delivered those good results, but a relentless focus on what is right for patients. We need to do the same in this House.

Medical Students

Sarah Wollaston Excerpts

Tuesday 3rd May 2011 Westminster Hall

[Mr Smith]

I am grateful to have the support of my colleague. I might describe her constituency as covering the other third of Oxford university. Her support on that point is very welcome. I was about to say that people are already asking what the situation will be, and obviously the sooner they can have certainty, the better.

The BMA has joined other bodies in consulting on the issue, and I understand there is some expectation that agreement will be reached. However, one big outstanding question is whether the new proposed bursary arrangements will cover tuition fees in the same way as they are covered now, with the Department of Health paying the fees for years 5 and 6 of an undergraduate course. If the bursary does not cover fees—it seems extraordinary that Ministers have not yet made the Government’s position on that clear—medical students would obviously face still higher costs and debt.

As my colleague and friend the hon. Member for Oxford West and Abingdon (Nicola Blackwood), whose constituency represents the other third of Oxford university, says, mounting urgency on that matter arises because would-be applicants worry about how the arrangements will work for 2012-13. I press the Minister to give an undertaking that tuition fees for medical students will be covered at least as well as they are now.

[Dr Sarah Wollaston (Totnes) (Con)]

The other point that needs to be made is that many of these courses are for six years, not just five. We need to take into account the cost of living expenses and the fact that many medical students have to take out commercial loans in addition to student loans, which makes the matter especially significant. I declare an interest as the mother of a medical student on a six-year course.

[Mr Smith]

The hon. Lady will know all about the matter. That was a very well made point. I will come to the subject of commercial loans later.

I also want to press the Minister on the position of graduate-entry medical students. That is an even more important route of entry than the 10% of total numbers that they represent suggests. The BMA has pointed out to me that its 2009-10 medical student finance survey shows that a higher proportion of students from poorer socio-economic groups enter medicine through graduate-entry courses than do so through undergraduate courses. Oxford university medical sciences division has pointed out to me that the best graduate-entry students are extremely strong and do exceptionally well. That route into medicine is important both for excellence and widening access.

Health and Social Care Bill

Sarah Wollaston Excerpts

Monday 31st January 2011 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

It is easy to see why politicians continuously want to fix the NHS. The perspective from the green Benches is very different from the perspective one gets as a GP—I say that having worked in the health service for 24 years. My surgeries and postbag, and I am sure those of other Members, are full of stories of delays, frustrations and sometimes really poor practice. The trouble is that not enough people write to their MP to tell them how sensitively or compassionately they have been treated, or how the NHS saved their life. They do feel those things, however, and they do appreciate the NHS. That is why they are understandably wary of any changes, proposed by whatever Government.

Here are the things in the Bill that I welcome. I really welcome clinical leadership. We should be in no doubt about this: there is clear evidence that commissioning works best when there is clinical leadership backed up by excellent management. The Bill will go some way to pushing us towards true clinical leadership in all parts of the NHS.

The provisions will also result in an information revolution. That will involve information about not only whether someone’s treatment worked but what the experience was like—a kind of TripAdvisor for the NHS. We all know that, with information, daylight is the best disinfectant. If people know that their performance is going to be compared with that of others, that is likely to drive up performance in the NHS.

The provisions will allow for that early scan that can make all the difference in an early diagnosis of cancer. When GPs can commission very good early diagnostics much more quickly, we will see a difference. The changes will also give GPs much greater flexibility to respond to their own area. In Devon, for example, community hospitals are really important, but they might not be so important in inner cities. The provisions should also give better choice to services such as mental health, and bring in opportunities for the voluntary sector. I recently met a group of carers for patients suffering from mental health difficulties, and they told me that they wanted better access to talking therapies. Rather than the support that has traditionally been supplied to them, they want better access to other kinds of support. I also really welcome putting public health back where it belongs, with local authorities.

Our spending now matches the European average, and I genuinely congratulate the Labour party on that, but I am afraid that that has also been a wasted opportunity. It is unforgivable that so much of that money was squandered, and that we have seen flat-line productivity. For that level of spending, patients should be able to expect the kind of services that people receive in France or Germany. I am sure that we have all heard instances of people coming back from a holiday on the continent with a minor condition, having had a scan and treatment within a week. We should be able to deliver that here. Health care workers should not have to spend three weeks chasing down a patient’s results. I am sure that we have all heard instances of that, as well.

The challenge is to improve aspects of the NHS, to look at the detail, to listen to patients and professionals and to ensure that we get this right. In Torbay, they have been getting it right for some time. It has been part of a national pilot of integrated care. Baywide, a not-for-profit company of local GPs, commissions health and social care from a pooled budget.

[Sarah Newton]

My hon. Friend mentions GPs working together on a not-for-profit basis. Does she share my huge disappointment at some of the terribly derogatory comments made by Opposition colleagues about GPs’ motivation, comparing them to the worst kind of bankers in the City? Is it not disappointing that they are so disrespectful to GPs?

[Dr Wollaston]

I agree with my hon. Friend. We have heard some terrible slurs about GPs profiteering and lining their own pockets. I am absolutely confident that that is not what we are going to see.

Torbay has been highly successful because it has pooled budgets and it can design integrated care. That saves lives and money. No one should be in any doubt that improving the quality of care, and thereby the quality of life, for those with complex, long-term conditions is the key to improving health care and cutting costs.

[Andrew George]

My hon. Friend talks about the role of GPs in cutting costs. I would be interested to hear whether, from her experience, she believes that the introduction of price competition—in which a maximum tariff would be set, below which there could be competition —will be helpful, or does she believe, as many authorities and other bodies do, that it is likely to put quality at risk?

[Dr Wollaston]

I am very confident, because I have discussed that question with the Secretary of State, who has assured me that the reforms are about competition not on price, but on quality. All doctors know that if they get it right the first time, they provide not only better care, but better value care.

GPs and PCTs throughout Devon are rolling up their sleeves and getting on with the job in hand, but to deliver the undoubted benefits of integrated care, they need to be able to work closely with colleagues in hospital, as well as with people in the community, to design those logical pathways. As I just mentioned, the Secretary of State has reassured me on the question of price versus quality competition, but it would help to spell out explicitly in the Bill that that will be protected. Professionals are understandably scared, and I hope the Minister will make the position absolutely clear in his winding-up speech.

Commissioners will not feel liberated if they are liberated from the Secretary of State but shackled to Monitor. Fundamental to the outcome of the reforms will be the powers of Monitor. I should like those powers to be carefully constrained in the Bill, so that it does not take on an unintended role. Focusing on quality and not on cost would help to bring all the professionals back into thinking that this is a positive step forward, because that remains a concern.

[Mr Graham Stuart]

My hon. Friend rightly emphasises quality ahead of cost, but surely both should be considered. In a time of constrained budgets, it is entirely right that commissioners use a service of comparable quality, which can deliver for patients at a lower cost, when they can find one, precisely so that they have additional funds available to look after other patients.

[Dr Wollaston]

I am confident that commissioners will consider the impact of those decisions across the health care spectrum, which is very important.

In the limited time I have left, I should like to ask the Secretary of State to consider how we will monitor the quality of primary care. Who will be responsible for performers’ lists, audit, and identifying poorly performing doctors? As I understand it, all GP contracts will be held with the NHS commissioning board. What powers will GPs within consortia have to deal with those whom they feel are underperforming if they have no control over their contracts? What will be done about the ongoing, disgraceful situation regarding doctors from the EU with poor English skills, over whom we have few powers to protect patients until there has been a problem?

Professionals are also concerned about the make-up of consortia. Will they have the flexibility to include consultants and other specialists—

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. Time is up.

Public Health White Paper

Sarah Wollaston Excerpts

Tuesday 30th November 2010 Commons Chamber

[Mr Lansley]

I have had discussions with environmental health officers and they are enthusiastic about the opportunity for much greater synergy between their work and public health responsibilities. They see their role as integral to the achievement of public health. Indeed, some of the greatest public health improvements of the past were initiated in local government and through responsibilities that are currently within environmental health legislation, so I am looking to the health and well-being boards to bring these responsibilities together more effectively.

[Dr Sarah Wollaston (Totnes) (Con)]

Is my right hon. Friend aware that about 30,000 people a year in this country die as a result of alcohol, and that Department of Health modelling has shown that if we were to increase the minimum price per unit to 50p we would save over 2,000 lives a year? Will he look at the proposals published in the British Medical Journal to have variable rates of VAT so we can increase the price without penalising the on-licence trade?

[Mr Lansley]

My hon. Friend will know that the Chancellor of the Exchequer made an announcement today about the level of duty on beers, in particular. We have made it clear, in the coalition agreement and since, that we will act to ban the below-cost selling of alcohol. I think that that will make a significant difference. We will also in due course publish an alcohol strategy, through which we will examine a range of ways in which we can not only enforce the current legislation more effectively, but create an environment in which we progressively reduce the abuse of alcohol. It is very important for us to understand that we must distinguish between our relationship with tobacco, whose use we want to minimise—we want to encourage people never to use tobacco—and our relationship with alcohol, where we are seeking its responsible use, rather than seeking to penalise people who engage in responsible drinking.

NHS Reorganisation

Sarah Wollaston Excerpts

Wednesday 17th November 2010 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

Does the right hon. Gentleman realise that not all GPs will have to be involved with commissioning? Does he welcome the efforts of the Royal College of General Practitioners to introduce real clinical leadership and tuition for those GPs interested in taking up commissioning, helping them to provide this service?

[John Healey]

It is a very good thing that the Royal College of General Practitioners is trying to bring the skills of many GPs up to speed because this is a big job for which GPs are not trained and not equipped, and which many do not want to do.

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 7th September 2010 Commons Chamber

[Mr Lansley]

I have had very helpful and productive conversations with the Health Minister in Northern Ireland, but I have to say that they did not include that particular subject. Of course, decisions on the availability of medicines in Northern Ireland are a devolved matter, but I should be perfectly happy to take account of those issues when we next talk.

[Dr Sarah Wollaston (Totnes) (Con)]

One year on from the implementation of the European working time directive, there is evidence that patient care is suffering. Handovers have been inadequate in some cases, and junior doctors’ training time has been reduced. Will my right hon. Friend reassure me that he will take action to allow some acute specialities to opt out of the European working time directive?

[Mr Lansley]

Yes. I am very clear that, together with my right hon. Friend the Secretary of State for Business, Innovation and Skills, we need to take the European working time directive back to the European Union. We need to discuss it again. We need to go to the European Union with the intention of maintaining the opt-out and of giving ourselves, not least in the health context, the flexibility that we lack, so that junior doctors, in particular, have the capacity to undertake the training that they need. It is not that we want to go back to the past, when there were excessive hours—100-hour weeks and so on—but we want junior doctors to be confident that they will get the training that they require in the period allocated for training.

NHS White Paper

Sarah Wollaston Excerpts

Monday 12th July 2010 Commons Chamber

[Mr Lansley]

I would encourage the hon. Gentleman to go and talk to GPs in Warwickshire whom I have talked to, and to talk to those at Walsgrave about the freedoms that they want to enjoy.

I wish to make it absolutely clear to the hon. Gentleman that there is great consistency between what we said in opposition and what I am announcing today, but that there are some major improvements. Frankly, they have come about because of the conversations that I have had with my colleagues from the Liberal Democrat party. Not least, those conversations have enabled us to focus on the fact that instead of leaving what was a diminishing, residual role for primary care trusts, which withered on the vine, it is better and stronger for us to create a strategic responsibility for local authorities on public health and on joining up health and social care. That will allow us to remove the bureaucracy associated with PCTs, and it is more coherent and stronger than the proposals that we had in opposition.

[Dr Sarah Wollaston (Totnes) (Con)]

My right hon. Friend recognises how toxic many targets were in the NHS, but they were not all bad. There were some that ensured that standards were maintained—for example the two-week wait for cancer referrals. How will he ensure that standards are maintained when targets are abolished?

[Mr Lansley]

I am grateful to my hon. Friend, who is absolutely right. That is why, as I said in my statement, not only will we be clear about what we are trying to achieve—for example, where cancer is concerned, one and five-year survival rates at least as good as the European average and hopefully as good as any in Europe—but we will require the NHS to look towards clinically led, evidence-based quality standards that enable those working in the NHS to be clear about what constitutes quality. That will enable us to deliver those outcomes.

Supporting Carers

Sarah Wollaston Excerpts

Thursday 1st July 2010 Westminster Hall

[Dr Sarah Wollaston (Totnes) (Con)]

I am grateful for the opportunity to speak in this important debate. After 24 years as a doctor, I do not need to be told how important carers are, and I pay tribute to the many whom I have met in my experience as a doctor—they really are extraordinary people.

I would like to focus on young carers in particular, and to draw hon. Members’ attention to the fact that the average age of a young carer is 12, which is extraordinarily low. The 2001 census showed that there were 175,000 young carers in the UK, 13,000 of whom cared for more than 50 hours a week. Those young carers provide not only help with cooking, cleaning and shopping, but often very intimate and personal care, and emotional support to parents with severe mental illness. Organisations such as Barnardo’s need our thanks for their work, particularly in helping young carers to cope and in identifying them before they find themselves in crisis.

My constituency takes in much of Torbay, where there are 350 identified young carers. Those children suffer low attainment at school, which is partly due to their poor attendance as a result of their caring work. They are also particularly prone to living in poverty. I would like to draw the Minister’s attention to a particular subset of young carers: the 20% of the children and young people in the Torbay area who are carers as a result of alcohol and drug abuse, and associated mental illness. Those who have been identified are the tip of the iceberg. Some fear coming forward for help because they worry that they might be taken into care. Those children have no access to the carer’s allowance. They are particularly prone to living in poverty and to going on to misuse drugs and alcohol themselves, and also at risk of domestic violence.

My interest is in prevention as well as cure. We know that drinking adversely affects up to 1.3 million children in the UK, and that group especially needs our help. Police forces estimate that 40% of all child abuse cases and 62% of incidences of domestic violence are directly related to alcohol. I would like the Minister to look again at the evidence on what works to reduce alcohol-related crime and violence, and therefore the number of children becoming young carers. The evidence shows that that is about pricing and availability, so I hope that there will be support for the Health Committee and NICE, which is clearly on the side of minimum pricing as the way forward.

I pay tribute to the caring organisations in my constituency. A fortnight ago, I was privileged to attend the opening of the Brixham carers centre. Brixham is particularly fortunate as it is also home to Brixham Does Care, which supports 150 carers and has 150 volunteers. Those organisations asked me to raise with the Minister the time that volunteers’ Criminal Records Bureau checks take. Only this morning I was told that some checks submitted in April were still pending. We need to look closely at how we reduce the barriers to volunteering, because volunteers are a lifeline for carers. I welcome the review of the vetting and barring procedure that has been announced by the Home Secretary, but I would like the Minister to look at the time that the checks take.

Respite care is another concern of carers in my constituency. Will the Minister consider the issues facing the John Parkes unit, which provides respite care for some of the most severely disabled children in my constituency and is used by many of my constituents?

Mid Staffordshire NHS Foundation Trust

Sarah Wollaston Excerpts

Wednesday 9th June 2010 Commons Chamber

[Mr Lansley]

I am grateful to my hon. Friend. First, the Francis inquiry will go on to understand why one of those hospital SMRs, from 2003, indicated the nature of a potential problem. The SMRs are not a sufficient measure of quality across the board. The National Quality Board has already undertaken some work on how we can ensure that hospital SMRs are consistent and meaningful, and beyond that how we can identify the early-warning signs and act on them. As one of the things we derive from that, I shall be working with the quality board and across the NHS to ensure that we act on warning signs, including looking at potential risks either across the system or in relation to individual trusts.

[Dr Sarah Wollaston (Totnes) (Con)]

Will the inquiry cover the sheer volume of bureaucratic paperwork that nursing staff have to complete, which seriously gets in the way of their fulfilling their clinical responsibilities?

[Mr Lansley]

I am grateful to my hon. Friend. The answer is yes.