North-east London STP

Stella Creasy Excerpts

Friday 16th December 2016 Commons Chamber

[Mike Gapes (Ilford South) (Lab/Co-op)]

Changes to our national health service are being planned all over the country, which are going to have profound implications for the quality of health, the availability of both primary and secondary services and for the size and location of our hospitals. There has been justified criticism of the secrecy with which this process of producing so-called sustainability and transformation plans has been carried out. The Department of Health has produced a five year forward view and a very large number of plans. I want to focus on the north-east London sustainability and transformation plan draft, which was published on 21 October, and on the eight delivery plans supposedly to implement it.

[Stella Creasy (Walthamstow) (Lab/Co-op)]

I want to put on record my personal gratitude to my hon. Friend on behalf of all the residents of Walthamstow, because we know that these plans are not going to be subject to parliamentary scrutiny. The fact that my hon. Friend has secured this debate today might be the only opportunity we have in Parliament to look at something that will fundamentally transform their local healthcare services.

[Mike Gapes]

I am grateful to my hon. Friend, who spends a great deal of time, as I do, campaigning with her local council to improve the NHS locally. Throughout our sub-region of north-east London, we are all concerned about what we are facing.

The King’s Fund reported in November that the speed of development of these plans means that

“patients and the public have been largely absent”

from the process and that NHS England has instructed that freedom of information requests should be “actively rejected”. Locally in north-east London a freedom of information request for the financial and working detail of the STP was rejected in November on the basis that:

“Disclosure would be likely to inhibit the ability of public authority staff…to express themselves openly...and explore extreme options…Deliberation needs to be made in a ‘safe space’ to develop ideas and to reach decisions away from external interference which may occur if there is premature public or media involvement.”

My local council, Redbridge Council, has been concerned that it has not been adequately involved in the process. It has made it clear that it will act in the interests of our local community and that Redbridge will not be signing off or endorsing the STP unless we are satisfied that it is in the interests of Redbridge residents

I understand that the STP programme boards are not required to hold meetings in public, and no agenda or minutes are published. The secrecy surrounding this process has not been helpful in building public trust and has caused suspicion within communities all over the country—I speak particularly from local experience—as to the intentions of the proposals.  In many respects what could be a reasonable response in the circumstances to the crisis we face in terms of future funding, the ageing population and other challenges to the NHS, is being undermined because of process issues. The NHS needs to learn from these experiences about how better to engage with the public and key stakeholders, including elected local representatives.

We are fortunate in Redbridge and north-east London because there are good working relationships within the NHS and local government, and there is already a model of collaborative working.  However, the problem with the STP is that it brings a top-down process into this situation and potentially undermines the joint-working that has been voluntarily established over recent years.

Redbridge along with neighbouring authorities will be strongly arguing that the developing STP governance structures should not stifle or negatively impact the local work that is happening. Redbridge and its partners in Barking and Dagenham and in Havering have over a number of years been developing cross-borough, collaborative approaches on the integration of health and social care. Redbridge is arguing that STP governance needs to ensure that this subsidiarity to the local level is taken as a model for the future, and is not undermined by the STP approach. We need to ensure democratic accountability if we are to get public buy-in, and we do not have that at present. Public engagement needs to be enhanced and improved.

The north-east London October STP draft is subtitled “transformation underpinned by system thinking and local action”. It says, however, that

“the system partners may not be able to work together collaboratively to deliver the plans.”

Today we have seen news about the reality we face in our NHS: large numbers of hospitals with dangerously high bed-occupancy levels and little or no flexibility. The CQC’s chief executive recently talked about hospitals being dangerously full. On 26 November, a leaked memo from NHS England revealed that hospitals were being banned from declaring so-called “black alerts” and told to prepare for the winter crisis by passing on scheduled surgery to private hospitals and discharging thousands of patients to get bed occupancy down from a national average of 89% to 85%. 

However, north-east London’s population is massively increasing. The report states that the population of north-east London boroughs will increase by 18% over the next 15 years—equivalent to a new city—and yet there is no plan for an additional hospital to cope with that change. In fact, page 20 of the draft policy states that building an additional hospital is “not practical or realistic.” Indeed, the situation is worse than that. Not only is there no extra hospital, there is the planned closure of the A&E at King George hospital in my constituency. The plan is to stop overnight ambulances sometime next year, with a total closure in 2019. The STP is calling for that not only because it would meet some savings and restructuring requirements, but also because there are unsustainable costs. The previous Health Secretary announced in 2011 that the A&E at King George would close in “around two years”. That has not happened because it was deemed unsafe and because there is insufficient capacity at Queen’s hospital in Romford or at Whipps Cross university hospital in Waltham Forest to cope with the increased demand.

Despite our excellent and hard-working staff, all the hospitals in north-east London are in crisis. With pressure for early discharges, but inadequate social care and community support, we have large-scale bed blocking and delayed discharges. Sick patients then get readmitted because they cannot get GP appointments due to the pressures that exist in that sector. The STP sees out-of-hospital and integrated community care as the way forward. However, Dame Julie Moore, who in 2014 chaired a commission on hospital care for frail elderly people, said:

“As much as it suits us all to have one nice neat solution to the problem of our growing, ageing population… the truth is that as a catch-all answer it is simply wishful thinking. Integrated community care is a good thing… but this can never be a substitution for hospital care.”

We still need hospitals and acute care. Plans to transform care in the community are good, but that requires a transformation of primary care, which needs resourcing. The STP projects a 30% shortfall in nurses by 2021, and we know that many GPs plan to retire over the next few years. Both are difficult issues.

Problems also exist in the potential financial situation, and one such issue is the estates strategy. The STP delivery plan highlights sites such as Goodmayes hospital, which is a large mental health hospital, and King George hospital as places where land could be sold. Contractual issues and other matters mean that that is probably an optimistic approach.

[Stella Creasy]

My hon. Friend is making an incredibly powerful case about why we must involve the public in some incredibly difficult decisions. We know that the financial situation we are facing is particularly dire. He has just mentioned the sites at Goodmayes, but in addition Whipps Cross has a large private finance initiative debt, where it is paying out a huge amount of money. No wonder the suggestion is being made that we need £578 million to bridge the gap.

[Mike Gapes]

My hon. Friend has given the figure I was about to cite. The STP executive summary states:

“Our total financial challenge in a ‘do nothing’ scenario would be £578m by 2021. Achieving ambitious ‘business as usual’ cost improvements as we have done in the past would still leave us with a funding gap of £336m by 2021.”

Those are eye-watering figures. The claim is made that

“we have identified a range of opportunities and interventions to help reduce the gap significantly”.

However, the £240 million gap between the “business as usual” case model and the actual predicted figure requires a series of other measures, including significant funding from the sustainability and transformation fund, reductions and changes in specialised commissioning, and what is called

“potential support for excess Public Finance Initiative (PFI) costs.”

That covers Whipps Cross hospital, Queen’s hospital, Romford, and, to some extent, King George hospital. “Potential”, what a lovely word. So this is not real and it is not even planned—it is just “potential”.

These plans are based on unrealistic, heroic, Soviet-style assumptions. This is a truly Stakhanovite model of over-estimation of potential, yet the STP still proposes it can transform a deficit of £578 million in 2021 into a potential surplus of £37 million—and improve the services. That will not happen. The plans are also predicated on totally unrealistic assumptions about savings from closing the A&E services at King George hospital, and there is a lack of clarity as to when this will happen and how much we are talking about. I have been told that tens of millions would be invested in the sites at Queen’s and Whipps Cross, but I have been told that at least £75 million is needed to do that, and there is no sign of where this capital is coming from in the Department of Health. So wards are being closed in one hospital and then millions are being invested in rebuilding wards or constructing wards at other hospitals, for no real net gain.

There is also a problem about what process will be involved in this closure at King George hospital. I am conscious that I do not have limitless time, but let me say that my local Redbridge Council is very concerned about this, because King George is supposed to be transformed from an acute hospital into an urgent care centre and so the local community needs to be involved. Redbridge is requesting that it should be involved, and I note that it has recently been agreed that it will be involved on the transformation board. However, Redbridge wants an independent chair of that board, because it is important to involve a person of public trust so that there is no controversy. There needs to be a transparent, open process as we discuss the options for the future of King George hospital, so that we can challenge the business case and take account of the fact that the assumptions on which this model is based are 10 years old. They go back to the misnamed “Fit for the Future” plans of 2006. The population growth that we have had and the growth that is yet to come, the young population that we have in the area and the movement in population means we have to look at these issues with great doubt and concern.

We need to assess the implications of all those issues. As Redbridge says, it wants to know how the reconfiguration to an urgent care centre assists primary care, community health services, adult social care, public health, and public health prevention and education. An opportunity exists in the changes, but we need public engagement in those changes, and we do not have that at the moment.

There will be enormous pressure on my local council because of budget problems, and I am worried about the situation. I am glad that the STP highlights the social care challenge, but it needs to be taken seriously by the Government if we are truly to have an effective health and social care system. The statement in this House yesterday did not offer a solution to my borough. It did not answer the challenge that boroughs such as Redbridge are facing. These boroughs are already ahead of the game in the integration of health and adult social services and are working with neighbours to take up the challenge by being a pilot for the development of an accountable care system.

Yet with all that transformation, Redbridge still faces a huge social care challenge. That is made worse by a triple whammy of public sector funding reductions to local government—my borough has lost 40% of its income since 2010—chronic underfunding of adult social care by the Government and the fact that Redbridge does not get a fair funding level in the first place. There is, potentially, a major problem. We face a shortfall of about £4 million in social care and the 1% extra on council tax raises less than £1 million. The responses that we have heard from the Government in recent days have been inadequate—indeed they have been worse even than the silence from the Chancellor in the autumn statement. They offer no real solutions to the growing crisis that will impact on some of the most vulnerable in our society.

I conclude with this plea: please will the Government look at the situation in north-east London and will the Minister meet me to discuss the fact that this plan is unrealistic, incredible, unachievable and will lead to disaster?

--- Later in debate ---

[Stella Creasy]

It is good to hear the Minister say that she wants to see local people involved in these plans. Will she therefore commit not just to a conversation but a consultation with teeth to give people confidence that the very difficult decisions that we all know have to be made about changing the NHS can be done with their consent, and not simply given to them as a fait accompli?

[Nicola Blackwood]

Perhaps if the hon. Lady lets me continue with my speech, she will hear a little more about how the process will go forward.

The geographies have been determined not by central bodies, but by what local areas have decided makes the most sense to them. In the case of the constituency of the hon. Member for Ilford South, that has involved five providers, seven CCGs and eight local authorities covering the whole of north-east London. Each area has also identified a senior leader, who has agreed to chair and lead the STP process on behalf of their peers. In north-east London it is Jane Milligan, the chief officer of Tower Hamlets CCG, who is co-ordinating the development of the plan.

I was concerned to hear what the hon. Gentleman said about local authorities not feeling as involved as they should. It is important to emphasise that local authorities must play a role in developing these plans. Reflecting the social care needs of an area, which councils are obviously best placed to represent, will be key to the success of the NHS in the coming years, so they must be closely involved.

The plans offer the NHS an opportunity to think strategically and open up the public discussion about how we will meet the challenges facing the NHS in terms of demand and rising costs. It is inevitable that debate will become heated; it is simply a reflection of how important local NHS services are for us all. By planning across multiple organisations—both commissioners and providers—STP footprints can seek to address in an holistic way the health needs of an area and all the people within it in a way that we have never had the opportunity to have before.

We all know that the NHS faces tough choices about how we will design future services to meet rising demand, rising costs, and more chronic and complex illnesses. Choices have often previously been postponed again and again because they were too hard and because the discussions are too uncomfortable. I do not think anyone in the Chamber would think it is fair or safe for our local populations for us to keep putting them off in this way.

In north-east London, as elsewhere, that has meant having an honest conversation about the best way forward for services that are unsustainable as well as how to integrate services to give patients a clearer route through the system. All those conversations will help ensure that patients maintain access to high-quality care.

As I understand it, the north-east London October STP draft looks at these challenges in a number of different ways. The hon. Gentleman has described some of them. It also proposes embracing integrated services, from urgent and emergency care to mental health care and support as well as public health, which is important to me as the Minister for Public Health. The STP is also exploring how to improve patient outcomes through community-based care and preventive measures, which must be important if we are to manage demand. For example, the proposals include utilising initiatives to provide adequate housing in the area, and using new models of care to give health education. It also highlights three enablers for change for the area—workforce, digital enablement and infrastructure—and investigates how to improve its position with each.

I share the view of the hon. Gentleman and the hon. Lady that the public, key stakeholders and elected representatives should be closely involved in the development of STPs. With the plans now published, preparation for STP implementation must begin in the new year. Now is the time for STP leaders to reach out actively and engage patients and the wider public, and I expect nothing less. That means having frank, engaging and iterative conversations across areas, as well as some potentially difficult conversations about what the NHS could and should look like. Simon Stevens and Jim Mackey—the heads of NHS England and NHS Improvement—have written an open letter to STP leaders making that expectation absolutely clear. The letter reiterated that now is the time for local engagement to help develop the proposals and for those involved to make it clear that these plans must have a real benefit to patients.

I should also be clear that, nationally, all reconfigurations must meet the four tests mandated by the Government to NHS England in 2010, which require all local reconfiguration plans to demonstrate support from GP commissioners, strong public and patient engagement, clarity on the clinical evidence base, and support for patient choice. We would not expect any proposal to move forward that has not met all four tests. Patients must be at the heart of the NHS, and no plan can be successful unless they are fully engaged.

I close by saying that the hon. Gentleman has raised some very serious questions around details of his local STP plan and the quality of public consultation. I will ask the Minister responsible for community health—the Under-Secretary of State for Health, my hon. Friend the Member for Warrington South (David Mowat)—to meet him and the hon. Lady to discuss the details to ensure that they are properly ironed out and that the public consultation and discussion are of the highest possible quality.

Question put and agreed to.