Pharmacies and the NHS

Steve Baker Excerpts

Wednesday 20th November 2013 Westminster Hall

[Oliver Colvile (Plymouth, Sutton and Devonport) (Con)]

It is a pleasure to serve under your chairmanship this morning, Dr McCrea. I congratulate my hon. Friend the Member for Ipswich (Ben Gummer) on securing the debate. I have tried on one or two occasions to get a debate on pharmacy, and he has beaten me to it and introduced the debate very successfully. No doubt he has more pull with the Speaker’s Office than I do. I thank the Minister for attending, too.

I got involved in the pharmacy story when in the 1990s resale price maintenance on non-prescription medicines became a big issue. The chief executive of Asda—I do not think that he was a Member at the time—was very keen to get rid of RPM on non-prescription medicines because he felt the market should be much more open. Quite a debate has taken place over the years on how to liberalise the pharmacy market in a big way.

At that time, community pharmacists were concerned about whether their trade would be reduced and the effect on their livelihoods. We must recognise that community pharmacies play a significant role in the high street economy. People are regularly drawn into town and city centres to spend money and visit the community pharmacy at the same time. I have followed developments with interest. I congratulate and support pharmacists, who do an incredible job. As the right hon. Member for Rother Valley (Mr Barron) pointed out, they are the first point of contact for people who need help.

I understand the concern of my hon. Friend the Member for Ipswich about the lack of liberalisation in the market and the need for transparency. I am always one for a lot of transparency—more sunlight normally produces it. During the 1980s and 1990s, the Conservative Government made sure that town centre retail developments and new supermarkets were assessed, to find out the implications for other supermarkets and food retailers. Regulation of town centres has been going on for a while. That was also to do with the sequential test.

[Steve Baker (Wycombe) (Con)]

My hon. Friend reminds me that we often complain that our town centres are in decline; he may have given us the reason.

[Oliver Colvile]

I agree that supermarkets have had an impact, but my point is about trying to protect small businesses in town and city centres.

[Steve Baker]

That is not quite what I meant. I pointed out that our town centres have been regulated for a long time, and that they are now in decline. Perhaps we should liberalise more consistently, and should have done so for a long time.

[Oliver Colvile]

The bigger issue, frankly, is car parking in town centres. Outside town centres people do not pay charges for car parking, but they do in town centres: so where do they go? In my constituency, I suspect that they end up at the Marsh Mills Sainsbury’s or elsewhere.

Two other big issues affect the pharmacy profession, one of which is the criminalisation of dispensing errors. If pharmacists make a mistake, they can be prosecuted and potentially sent to prison, whereas GPs, for whom I have a great deal of time, do not suffer the same prospect. The Department of Health is looking at that, and I hope that it will come to a conclusion on how we can equalise the situation and ensure a more level playing field.

The other issue is the sharing of data between pharmacists and GPs. I raised the matter during a recent statement from the Secretary of State for Health on the whole business of how pharmacists could play a part in helping to relieve accident and emergency units. The Government are keen to ensure that more and better data sharing takes place. I have a slight concern in that my understanding is that the process would be run by the Department of Health, but I recently read in an article that the Department was suggesting that the responsibility would lie much more with the local commissioning boards. If the Minister can respond to that confusion, that will be helpful.

We need to ensure that pharmacies play a much better role. They need to be the first point of call for people seeking help from professionals, as that would help to relieve GPs. During the summer recess, I visited the Keyham healthy living pharmacy, which is a brilliant organisation in a deprived community. Life expectancy differs by 11 years between the suburbs of Plymouth and Devonport, which is where the Keyham pharmacy is located. The pharmacy offers not only flu vaccinations, but also smoking cessation services and other such things. It is a service that certainly needs to be available.

Finally, there is concern about how we can improve how people feel about pharmacies to ensure that they are used in a much better way. If pharmacies were used to deliver flu vaccinations, that would take some pressure off our accident and emergency units over the winter. We have discussed an important issue this morning, and I am delighted that you, Dr McCrea, have been in the Chair to ensure that we get some positive comments.

--- Later in debate ---

[Steve Baker (Wycombe) (Con)]

I congratulate my hon. Friend the Member for Ipswich (Ben Gummer) on provoking a stimulating debate, and one in which I have learned a great deal. In particular, he emphasised the local impact that pharmacies can have, while the right hon. Member for Rother Valley (Mr Barron) clearly explained some of the opportunities that can be seized through pharmacies.

In Lane End in my constituency, a pharmacy opened alongside a dispensing GP practice, but if I remember the circumstances correctly, the practice was forbidden from serving local people; we had an absurd situation in which the purpose of the regulation made my constituents’ lives less convenient and less easy, in the interests of somehow distributing profit fairly. The debate has brought in some of the wider aspects for society and some of the things that a heavily regulatory state has messed up.

The purpose of prices, profit and loss in a market society is to guide individuals and voluntary associations into best serving society. If pharmacists wish to open a pharmacy, they should simply be able to do so, if they can find a place to do it, can do so within the law and are selling lawful products. They should be able to get on with it and serve whomever comes through the door. Instead, we have the situation described by my hon. Friend—people have to fill in a 200-page application form and might subsequently find themselves subject to particular restrictions on whom they may or may not supply.

One of the issues with a market system is that business men are profit-maximising, which is both a problem and a benefit. The problem is that business men do not like competition much, because that is what drives down prices and therefore profit. That is the crux of the matter. The purpose of the Government is not to entrench in law and regulation the tendency of business men to seek rent—excess income through capturing the state—but that is just what is happening when competition is inhibited by restrictions placed on a dispensing practice simply because a neighbour has opened a pharmacy. Certainly, on the siting of pharmacies, the Minister should seek to abolish rules and controls wherever he can, because they are getting in the way.

[Ben Gummer]

In my address, I omitted to mention the whole range of practice payments paid to pharmacists simply for, in effect, being open. The problem is that the opening of a new pharmacy creates a liability for the NHS to pay those practice payments, no matter who does or does not go through its doors. That shows the rather extraordinary situation that we have ended up with in respect of how pharmacies are remunerated.

[Steve Baker]

My hon. Friend is absolutely right and I am extremely grateful to him for bringing that up. We pretend that we live in a capitalist society—I have said this in the House before—but if our system is capitalism, I am not a capitalist. We have an absurd hybrid system, in which the state constantly intervenes in order to give people rents. It is peculiar that we call it a free market society.

The purpose of our all being here, of course, is to improve our constituents’ lives. When I say such things, my intention is to ensure that my constituents—all our constituents—have better access to pharmacies. In the House, we have a real consensus about an increase in the services offered by pharmacists being of benefit to all our constituents. What I want is for the Government to get out of the way, not to use taxpayers’ money to provide the payments that my hon. Friend mentioned and to allow pharmacists to get on and best serve the public in a way that is in the public’s best interests—a way that can be discovered only through experimentation and entrepreneurship.

On pricing, I want to make the point that in this country we are not good at haggling. We should haggle over prices and drive them down. The hon. Member for Strangford (Jim Shannon) talked about the scandal of some simple and inexpensive medicines that ought to cost pennies, but cost very much more. What I see at work there could be something that I witnessed when I was a contractor working with Government: Departments are not good at driving down prices. They tend to accept the price that they are given—“Oh, that must be the market price.” No—they should set the market price by demanding that they are charged less and, if suppliers do not provide the goods at a lower price, they should go elsewhere.

That brings me to generics and parallel imports, a subject touched on earlier. We ought to be making sure that the big pharmaceutical firms do not hold the NHS over a barrel. I have heard some of their arguments, and of course producing a new drug is an expensive business, but we should not be held over a barrel. In a market society, people should be held to account to drive down costs and drive up quality.

Johnson & Johnson, based in my constituency, has a wonderful credo, which was written when the basis of a free society was under threat in an earlier time. That credo sets out the principles on which the industry should be founded, and one such should be: no legal privileges, wherever possible.

[Oliver Colvile]

During the all-party group inquiry, we looked at that issue. One suggestion for easy identification of who was exporting and importing pharmaceutical products in this country was to look at VAT returns—when I ran a small business and was VAT registered, I had to fill in a piece of paper that recorded what level of EU trade I had ended up doing. I approached the Treasury on the matter, but it was not willing to participate and help, but that seems to me to be a way in which we could identify who the offenders are. We had some difficulty in identifying the offenders.

[Steve Baker]

My hon. Friend has identified what might be a missed opportunity because an enormous effort is going into preventing that fraud. With the opportunities that electronic communication offers today, it should be possible to use some of that information in other contexts. With that in mind, I will turn to the internet.

Clearly, everyone wants to ensure that prescribing takes place properly, but when people have been prescribed medicines it should be possible for them to buy over the internet in appropriate circumstances. I am particularly aware that homeopaths have had great difficulty with the internet because of the need for people to present physically to buy a medicine.

We cannot have it both ways on homeopathy—either the medicines are relatively harmless and can be treated with scorn by the medical profession, in which case they should be freely available on the internet, or they are dangerous and should be tightly regulated. Homeopaths’ experience suggests that people can take responsibility for themselves and buy products on the internet.

[Ben Gummer]

My hon. Friend touches on an interesting issue. Given the fact that the Government are going to great lengths to try to get GPs to do more consultations on the internet and Skype—great news for many of my constituents, especially those in busy jobs with difficult hours—it seems obvious to extend such innovation to the dispensing of pharmaceuticals.

[Steve Baker]

My hon. Friend is right. In the 21st century, we should be waking up to the opportunities to use technology to drive down costs and drive up service. People are so busy today, so why can they not have consultations in their offices with Skype, and why can pharmacists not prescribe to offices with Skype? The solution to these problems is for the Government to abolish whatever rules and controls they can and wherever they can, and to liberalise when abolition is not possible.

[Mr Barron]

The majority of patented goods that the national health service buys are a recognition not just of cost, but of the pharmaceutical industry’s worth to the British economy—including exports, manufacturing base and so on. We export around £7 billion of pharmaceutical goods a year. Might a free market endanger that?

[Steve Baker]

We may be in danger of straying into philosophically deep water about what free markets do and do not do. Clearly, because of the moral imperatives of health care, we cannot have an unimpeded market. We have made political decisions to ensure that no one goes without health care. That has consequences, and we should accept them.

The way to deploy scarce resources in the service of the public is to allow the price system, as well as profit and loss, to run as freely as possible. When we talk about something’s worth, price is too often ascribed to things that are not subject to market transactions. Only through exchange can it be established how people value things. I do not want to go on for too long, so I will leave that to another debate, perhaps the one on the Budget.

I want to encourage the Government to liberalise and to look more closely at what can be done to enable pharmacists to set up wherever they need to in order to serve the public best.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 22nd October 2013 Commons Chamber

[Jane Ellison]

If my hon. Friend will allow me, we will perhaps need a separate conversation. I am happy to meet her afterwards to discuss the matter she has raised.

[Steve Baker (Wycombe) (Con)]

16. What steps he is taking to ensure that the NHS becomes a more patient-led organisation.

[The Secretary of State for Health (Mr Jeremy Hunt)]

The big shift we need to make is to turn the NHS into a patient-led organisation. Two measures that will help that are: independent inspections by a new chief inspector that put the patient experience at their heart; and asking every NHS in-patient if they would recommend their treatment to a friend or member of their family.

[Steve Baker]

I am encouraged by that answer. Long ago, the medical establishment was held to account by what were essentially patient-led co-operatives, and today more and more voices are asking for more patient engagement. Will the Secretary of State consider a paper brought forward by Civitas and Anton Howes calling for the incremental implementation of patient-led commissioning to close this gap?

[Mr Hunt]

No one campaigns harder than my hon. Friend on the issue of putting patients first in his constituency and throughout the NHS. CCGs have a legal obligation to involve patients in decisions about services and about them personally. The ideas in the paper he mentions are interesting, and I respect them, but given that we have brand-new commissioners and inspectors going out this year, I think we should see how the current reforms work first.

Accident and Emergency Departments

Steve Baker Excerpts

Tuesday 10th September 2013 Commons Chamber

[Mr Hunt]

I thank the right hon. Gentleman for the interest and support that he shows for his local hospital. Of course, Mid Staffs has an extremely troubled history and it would be a derogation of my duties if I did not try to sort out the problems there once and for all, but we will not make any changes that have knock-on effects on neighbouring trusts without proper assessment and making sure that provisions are in place so that they can cope with any additional pressures. The final decision about what is going to be done has not been made, but I reassure the right hon. Gentleman on that point.

[Steve Baker (Wycombe) (Con)]

The A and E crisis in Wycombe results from the closure of the department under the previous Government. Although I would love to lay the blame squarely on Labour, is not the truth that, over the life of the NHS, clinical practice and management have changed substantially? Will my right hon. Friend consider producing a White Paper that takes a holistic view of emergency and out-of-hours care so that we can have an A and E service that is fit for the 21st century?

Hospital Mortality Rates

Steve Baker Excerpts

Tuesday 16th July 2013 Commons Chamber

[Mr Hunt]

Perhaps the hon. Gentleman would like to acknowledge that more money has gone to the front line as a result of the reorganisation that this Government have introduced. We have 8,000 more clinical staff now than when the Labour Government were in office.

[Steve Baker (Wycombe) (Con)]

Walter Coles died because he was forgotten. Edward Maitland died because he was fed solid food. I could name others; those are just two of the patients who have died unnecessarily. And yet high mortality rates made it on to the board’s agenda in Buckinghamshire only because of a trigger relating to concern for reputational risk. The board had no robust risk management practices in place, and there were no plans to introduce any. Furthermore, certain key elements relating to changes in urgent care were missing. In setting out to champion patients, will my right hon. Friend set out how it will be possible to remove an entire board, or any members of a board who are not performing well?

[Mr Hunt]

Absolutely. I congratulate my hon. Friend on his extraordinary campaigning on behalf of his constituents. It is very difficult for a local Member to take on his own hospital when he finds failings, but he does it with great bravery. Yes, we need to ensure that the way we judge hospitals is not just about meeting waiting time and A and E targets, important though they are; it must also be about safety, about compassionate care and about governance. Other things matter as well. That is what we are changing.

Accident and Emergency Waiting Times

Steve Baker Excerpts

Wednesday 5th June 2013 Commons Chamber

[Mr Stephen Dorrell (Charnwood) (Con)]

I welcome the fact that we are debating increased evidence of service pressures in the national health service. Having attended health debates in the House of Commons for quite a few years, I can say that there is a depressingly familiar tone to this debate. May I tell the right hon. Member for Leigh (Andy Burnham) that if we want to develop party points in the House and convince the electorate that there is something in it, it is not a bad idea to begin by establishing where the real differences exist between the Government and the Opposition? If we look at the evidence for why we have experienced increased service difficulty in the health service, we see that it is not the differences between the Government and the Opposition that are striking but the fact that there is a shared analysis. However, there is an apparent unwillingness to apply that analysis and work it through in the necessary large-scale service change that we require.

As for the roots of increased service pressures in the health service, I agree with quite of lot of what my right hon. Friend the Secretary of State said about the GP contract, but that is not why those pressures exist. Their true roots go back to the time in which the right hon. Member for Leigh was Secretary of State. In 2009, David Nicholson said that demand would go on rising in the health service, and that given the state of public finances we had to find ways of meeting that demand without continuing to make calls on the taxpayer on the scale that we had grown used to over the first 60 years in the history of the health service.

[Steve Baker (Wycombe) (Con)]

In Wycombe, ever since our A and E was closed under the previous Government, people have wanted nothing more than to get it back. It is clear that medicine has changed and that they will not do so, but does my right hon. Friend agree that there has been a long-standing failure to explain those pressures to the public?

[Mr Dorrell]

I absolutely agree with my hon. Friend. We cannot blame people in the country for not understanding the need for change in the health service if politicians never explain why that need has arisen. I quite often quote Enoch Powell—not someone who wins a consensus across the House—who as Health Minister went to the equivalent of the NHS Confederation conference, which is now under way in Liverpool, to explain the need for the change in the service model in mental health. He said in his speech that

“Hospitals are not like pyramids, built to impress some remote posterity”.

That is the case that we need to begin to explain.

Accountability and Transparency in the NHS

Steve Baker Excerpts

Thursday 14th March 2013 Commons Chamber

[Steve Baker (Wycombe) (Con)]

My constituent Edward Maitland was a frail man who could not eat solid food following tongue surgery. He was admitted to Wycombe hospital from his warden-controlled accommodation suffering from dehydration, shortness of breath and weight loss, things from which he should have recovered. His son, a paramedic, clearly explained on his father’s admission that Mr Maitland could not eat solid food and he also provided liquids. About three weeks later Edward Maitland had died from aspiration pneumonia. At the post-mortem, Weetabix was found in his lungs.

Of course, the investigation was taken extremely seriously and the documentation is, up to a point, very professional. Under “root cause”, it states:

“The investigation found that there is no evidence to support robust communication between nursing and medical staff…No SBAR”—

situation, background, assessment and recommendations—

“documentation was used in EMC or in handover to Ward 6B this would have highlighted the patient’s nutritional needs.”

It proceeds to make some “recommendations”, but I want to highlight the “lessons learned”:

“To care for all patients with a holistic approach and the multi-disciplinary team must focus on all health concerns.

Better communications between all staff members, this should be ongoing and involve all the different professionals who may need to collaborate the care delivery plan. This collaboration and communication should involve the patient, family and the healthcare staff.”

Unfortunately, that is bread-and-butter, typical stuff—and managerial gibberish.

What I learned is that two words would have saved the life of Edward Maitland: “no solids”, written on the records at the end of his bed, on his wristband, and above his bed. The situation in his case is very simple. A man died who ought not to have died. He should not have died in these circumstances.

I have the hard task of saying, therefore, that I look to the courts, and the Francis report helps me. Recommendation 13 of the report, on fundamental standards, refers to:

“Fundamental standards of minimum quality and safety, where non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations.”

Elsewhere, the report discusses at some length—I do not have time to go into detail—a regulatory gap in relation to the Health and Safety Executive:

“It should be recognised that there are cases which are so serious that criminal sanction is required, even where the facts fall short of establishing a charge of individual or corporate manslaughter. The argument that the existence of a criminal sanction inhibits candour and cooperation is not persuasive. Such sanctions have not prevented improvements in other fields of activity.”

I took legal advice. I approached a retired circuit judge in my constituency, who in turn approached a firm of lawyers. I am most grateful for the guidance of Kate McMahon, of Edmonds Marshall McMahon, who has provided me with considerable free legal advice in relation to this case. The firm specialises in private criminal prosecutions. She has explained that, at least at the preliminary stage, there may be a corporate manslaughter case to answer, and liability for gross negligence manslaughter may well be attributable to one or more employees of the hospital.

I do not want people to be prosecuted unnecessarily, or to see taxpayers’ money wasted, but I do want accountability, and I believe that in the end the courts provide that crucial accountability. Edward Maitland’s son Gary now has this advice, and I have left it to him to decide whether to approach the police. I have briefed the police superintendent in Wycombe on the circumstances. I believe that the courts should be the ultimate way of sanctioning the NHS. Francis agrees, and I hope he will provide a policy in this area.

There should be more democratic control. I am delighted—

[Frank Dobson]

Does the hon. Gentleman not agree that one characteristic of involving lawyers is that there is a lot of money around, and it goes to them? Would it not be better spent trying to ensure that performance standards are enhanced, rather than employing lawyers to have a go at the people who got it wrong?

[Steve Baker]

Of course I would rather that the money was spent on standards and performance and not on prosecutions, because I would rather the problems did not occur. I do not wish to lecture the right hon. Gentleman, and I feel sure he did not quite mean it this way, but if we do not intend to apply the law of corporate and individual gross negligence manslaughter, let us repeal it, or amend it so that it does not apply to the NHS. I have to say to the right hon. Gentleman that it does apply to the NHS and that in certain cases, as Francis has said, things are so bad it should be applied.

I ask the Government to look at democratic control. I am delighted that the Secretary of State is reforming the Care Quality Commission, but how can we make sure that there is more direct accountability, perhaps to the health and well-being boards, and the overview and scrutiny committees? How can we give them the power to sanction or perhaps even, through due process, dismiss a board or a chief executive?

I think here of Paul Ryan, a man with vascular disease who had lost one leg already when he found himself sick. He had four days of GP visits and spent nine hours in accident and emergency on a Friday. He was then sent home, having had an MRI scan, after which he was expecting to lose his leg on the Monday. He was told to expect a phone call, but no phone call came. The Ryans eventually called 999 and were told that it was better to get a GP. The GP arrived and called an ambulance. It took two hours for that to arrive and Paul Ryan died in the ambulance with his wife on the way to hospital.

[Mr Cash]

Does my hon. Friend agree that accountability does reside also with the Secretary of State, as set out in the national health service legislation? That is essential in relation to our functions in this House and those of this Secretary of State and former Secretaries of State.

[Steve Baker]

I am grateful to my hon. Friend for his point, although it has been examined at length, so I do not want to go down that rabbit hole with him—I hope he will forgive me.

The post-mortem on Mr Ryan indicated that he probably would have suffered the same fate in any event, but the system let the Ryans down—Mrs Lyn Ryan made that point to me and to the local newspaper. Unfortunately, the case plays right into the fears of the public in Wycombe, because we lost our accident and emergency facility in 2005 and we recently lost our emergency medical centre. We have just had two similar repeat occurrences of the minor injuries unit failing to refer people across the car park into the excellent cardiology and stroke units. We have seen an enormous range of little problems, for example, an 85-year-old lady with dementia was sent home in a taxi at 2 am in just her hospital gown. This cannot go on, and the public’s concerns are justified. The trust is being investigated by Sir Bruce Keogh and although I have heard good reasons why its mortality levels are justified—they relate to running hospice care, in particular—this must be taken as an opportunity to improve things.

Finally, I wish to make a point on transparency. Yesterday, I spoke to Anne Eden, the chief executive of the trust. I am not going to put on the record the entire content of the conversation, but when I told her that I intended to raise this issue of corporate manslaughter on the radio this morning, I was told, in terms, “To protect the reputation of the Buckinghamshire trust, legal action would be sought.” This is a matter of public interest being raised by a Member of Parliament in good faith, but I have had to—[Interruption.] To be fair to her, she was talking about the radio. But I have had to rely on privilege to protect myself from being sued on this matter. It is not acceptable that such a matter should have to come to a Member of Parliament, simply to rely on privilege. The situation reinforces something I have experienced again and again since becoming an MP: second-hand rumours and half-truths about the state of health care in Buckinghamshire. I have encountered: people stymied; people thinking it is helpful to give half a rumour to a friend to repeat to me so that I can know how bad things are; and people’s frustration at not being able to do anything. I know that Buckinghamshire Healthcare NHS Trust is obviously close to your heart, Mr Speaker. I know that it expects to satisfy Sir Bruce Keogh, but it is really time for proper accountability and that must include the courts.

Accident and Emergency Departments

Steve Baker Excerpts

Thursday 7th February 2013 Commons Chamber

[Angie Bray]

I certainly think that a petition of that size cannot be easily ignored. However, as we pointed out when we encouraged people to take part in what was a massive and time-consuming process, I suspect that, technically and legally, the authority is obliged to register only the responses to the consultation.

Beyond what I have described, my role has been to make my objections, and those of my constituents, fully known to and understood by as wide an audience as possible in Government. After doing the rounds of meetings with the previous team at the Department of Health, I held meetings with the new ministerial team and the Health Secretary after last autumn’s reshuffle. I followed that up with a meeting with the Prime Minister, whom I left in no doubt that this issue was of the utmost importance to my constituents.

We all believe that the closure plan must be reviewed. None of us can believe that it is anything other than reckless. We wonder how the A and E departments that are left standing will be able to cope with all the extra pressure that will result from the closure programme. I explained to the Prime Minister in detail why the extra travel time to A and E departments further afield would be unacceptable. He listened carefully, asked a number of detailed questions, and told me that he would certainly discuss the issue this with Health Ministers.

Much of our campaigning has focused on the baffling way in which NHS North West London has chosen to present the proposals as a virtual fait accompli, without adequately explaining quite how they will work in practice. We are told that new “urgent care centres” will cater for everyone’s needs, but we have also learnt that there is a lengthy list of conditions, and that there are a number of possible problems with which they will not actually deal.

[Steve Baker (Wycombe) (Con)]

It is, in a sense, reassuring to hear that my hon. Friend is experiencing exactly the same problems as we are experiencing in Buckinghamshire. It is always made to sound so good, and then it is so awful. I hope that the Minister will be able to explain how things can change, so that instead of standing here complaining on behalf of our constituents we can actually make a difference.

[Angie Bray]

I entirely agree. The issue of trust is so important, but I suspect that we shall have to do a lot of work if we are to build that trust.

What I have just said about urgent care centres will not be at all reassuring for my many constituents who use the local A and Es. We must not forget that Ealing hospital’s A and E sees at least 100,000 people every year. Nobody is suggesting that we do not need to make long-term improvements to our health service and the way services are delivered, but we need better guarantees that the planned changes will provide an acceptable replacement for what we have at present.

It is unreasonable to expect my constituents to support the closure of their local much-cherished A and Es without any certainty that what they are told will be put in place will materialise. In the meantime, there is the practical question that everybody is asking: if the A and Es are closing at four hospitals, what will happen to the queues at the A and Es that are left open?

No one is under the impression that everything is rosy and that the way health care is delivered in north-west London is absolutely perfect. Clearly, in the longer term we will need to encourage more people to sign up to local GPs rather than depending on A and Es for all their health care needs, but that requires time and organisation. We cannot just close the A and E and expect people to cope. Looking forward, we clearly need to make sensible decisions on how we fund health care provision locally, to ensure money is available to meet all the rising costs associated with people living longer, new medicines coming on-stream and new costly treatments, but we have to take people with us as we approach change.

Understandably, people have an emotional attachment to their local hospitals and they need to be persuaded of the case for change. Given that the health reforms are about to put GPs in charge of local health provision, why are we not waiting to see what decisions they think would be appropriate, rather than pushing these decisions through now? The whole approach has been too rushed. Local GPs have hardly been queuing up, in public at least, to support these proposals. The impression my constituents have been left with is that the consultation was little more than an attempt to channel their views towards the preferred option, in what was a box-ticking exercise by NHS North West London.

There are too many questions left unanswered, and too much of the information provided in the consultation was too questionable. For all these reasons, I can only hope that if NHS North West London decides on 19 February to proceed as it currently intends, the Secretary of State will ensure that that is reviewed in its entirety. My constituents are deeply concerned.

Hospital Services (South London)

Steve Baker Excerpts

Tuesday 22nd January 2013 Westminster Hall

[Clive Efford]

The point made by my hon. Friend is self-evident, but if I may, I will not be drawn down the road, because I want to get the next point on record.

Lamenting the fact that local commissioners have not been listened to, Helen Tattersfield says in her article:

“No argument has any weight, however, against the needs of a failing trust, foundation trusts and potential private companies eager to expand their areas of influence, and NHS managers convinced of the merits of their model of fewer larger hospitals. Those of us who have spent hours acquiring the skills supposedly to lead commissioning have been shown that, in fact, decision-making and influence remains where it always was: with central managers, computer-derived models and reasoning that takes no account whatsoever of human behaviour in real life. We are little more than window-dressing for central planning geared to the needs of large foundation trusts, and open to the interests of the private sector.”

That comment alone just about sums up where we are.

I will finish soon to allow the hon. Member for Beckenham to speak, but I just want to ask the Minister whether she will consider a review of proposed A and E closures across London. We are seeing a piecemeal, salami-slicing of A and E services, which is putting the safety of Londoners at risk. As we know, we have seen a 50% increase in people waiting in ambulances for 30 minutes or more outside A and Es to gain access, and we have seen a 26% increase in those waiting for 45 minutes. We know that they are under pressure, so before we see any closures, that review must take place.

We can pray in aid what the Lord Chancellor and Secretary of State for Justice said. The headline on the relevant article read: “Hunt faces Cabinet split over A and E closure after Justice Secretary blasts plans as ‘sticking two fingers up’ to patients”. We also have the right hon. Member for Sutton and Cheam (Paul Burstow)—the former Minister of State, Department of Health—who lamented, when he was still a Minister, the proposed closure of St Helier:

“This is a flawed conclusion from a flawed process. There is still a lot of water to flow under the bridge before final decisions are made. The panel have ignored the pressure on all the A and Es and maternity units in south west London.”

We can pray those people in aid to defend our A and Es, and the Government should go back and look again.

To make one last point, we have seen the closure of an A and E, despite the promises of local Conservatives. The Leader of the House of Commons, when he was shadow Secretary of State, was going to save the A and E at Queen Mary’s, Sidcup, but it never came about. Under “A Picture of Health”, there was a proposal to have overnight stay, elective surgery at that hospital. It was promised to my constituents, who welcomed it and wanted to see it. I ask the Minister to reconsider removing that planned service from that hospital, because it was beginning to work and people welcomed it. It will be a serious cut to the quality of health care.

[Steve Baker (Wycombe) (Con)]

Will the hon. Gentleman give way?

[Clive Efford]

No, I will not, because I want to allow the hon. Member for Beckenham to speak. It will be a serious cut to local services, and we should not allow that cut to go ahead.

Vascular Services (Wycombe Hospital)

Steve Baker Excerpts

Monday 14th January 2013 Commons Chamber

[Steve Baker (Wycombe) (Con)]

I am most grateful to you for that, Mr Speaker. I am also grateful to my hon. Friend the Minister for being here at this hour to discuss vascular services in Wycombe hospital, as I know he has thought carefully about the subject. It is a subject that will be of interest to your constituents, Mr Speaker, so I am glad to see you in the Chair, and to my right hon. and learned Friend the Member for Beaconsfield (Mr Grieve), a number of whose constituents campaign vigorously on the issue, so I am glad to see him here supporting this case. The nub of the issue is that we in Wycombe have been told repeatedly that it is in our interests for hospital services to be centralised away. There is today a clear momentum to centralise vascular services for the Thames Valley in Oxford, yet Wycombe enjoys better results and Oxford has been subject to a range of criticisms, as I shall set out.

We need to look at the historical context to understand why the opposition to what is happening is so vociferous. Wycombe hospital is in a position perhaps typical of a generation of district general hospitals: we lost our accident and emergency unit; we lost consultant-led maternity, retaining a midwife-led unit as a concession; we lost paediatrics; and in 2012 the emergency medical centre—the EMC—was downgraded to a minor injuries unit, repeating much of the local outcry about the loss of the accident and emergency unit. At each stage, campaigners expressed fears that the withdrawal of services would lead eventually to the closure of the hospital. At each stage, those fears were vigorously stoked by dissenting voices among the affected medical staff. At each stage, the NHS management no less vigorously denied that such an outcome could ever occur, and after each stage the NHS management went on to propose further service withdrawals. It is no wonder so many local people fear closure.

In Wycombe, we do have the Buckinghamshire units for cardiology and stroke, which treat two of the biggest killers, but, scandalously, the minor injuries unit recently failed to admit a lady who arrived with suspected heart trouble—the Minister will recall taking my question in the House on that occasion. It is now being suggested by some clinicians, specifically those within the vascular unit at Wycombe, that losing vascular services at the hospital could threaten those excellent services we have left.

I feel sure that the Minister will appreciate the excruciating sensitivity of this issue. The long, grinding decline of our hospital has sown anger, despair and cynicism, not least because the public have come to appreciate that NHS consultations seem to be exercises in manufacturing consent—or perhaps the appearance of consent—rather than providing democratic accountability and control.

The recent “Better Healthcare in Bucks” consultation on the downgrade of the EMC mentioned vascular services, supporting the view that vascular should remain in Wycombe until a review in 2014. We are now approaching that review and a series of leaked documents has shown two important points: first, vascular care in Wycombe is superior to that in Oxford; and, secondly, the transfer of vascular services to Oxford is essentially a done deal.

Let us consider how vascular services have changed, because I know that it has affected many of my hon. Friends and Opposition Members. Diseases of the arteries and veins used to be treated by surgery only, but problems are now reached via other blood vessels using techniques known as interventional radiology. Vascular surgeons and interventional radiologists support cardiology, cardiac surgery, stroke and other disciplines. The new vascular specialty was approved by Parliament in March 2012. Vascular is now listed as a specialty on the General Medical Council website, although the approved curriculum and assessment system was not available today. There is also a Vascular Society.

According to the authors of a report on the centralisation of vascular services in Oxford,

“the advent of separate specialty status for vascular surgery together with speciality commissioning plans for 2013 onwards…will reduce the number of hospitals providing vascular surgery to about 50 in England and Wales”

from 150, and

“commissioners will not purchase arterial interventions except from arterial centres.”

I think that is why the issue has affected so many of my colleagues.

[Eric Ollerenshaw (Lancaster and Fleetwood) (Con)]

I congratulate my hon. Friend on securing this important debate. In north Lancashire, the situation is similar. It is perhaps not the policy that is the problem but the implementation of it, because if it is implemented some of my constituents, particularly in rural areas, will face transport times of more than one and a half hours. The national target for improvement is just one hour, which is why, unfortunately, I have to support my local hospital, the Royal Lancaster infirmary, which has reached the point of considering taking the implementation of the policy to judicial review.

[Steve Baker]

My hon. Friend raises an important point about transport, which will be an issue for many of our constituents, not least because they will not have cars.

People in need of vascular care will include those with abdominal aortic aneurysms, a life-threatening weakness of the main artery that must be repaired, and those who have had strokes or mini-strokes—transient ischaemic attacks. After a stroke, drugs are administered immediately, but they need to be followed up with a procedure to clear the carotid artery, called a carotid endarterectomy or, mercifully, a CEA. Other people requiring care will include those with poor blood supply, including smokers and diabetics, who might endure serious complications that might even lead to amputation.

Wycombe hospital provides the full range of services. It is proposed to move them all to Oxford university hospitals on the basis that the present arrangements are “not sustainable”, but I have yet to see evidence that supports that assertion. Leaked documents suggest that Oxford provides worse outcomes and is struggling to be ready.

[Tim Farron (Westmorland and Lonsdale) (LD)]

I am extremely grateful to my hon. Friend for giving way and congratulate him on securing the debate. Further to the point raised by my hon. Friend the Member for Lancaster and Fleetwood (Eric Ollerenshaw), in the north-west the number of units will go down from four to three. Folks in Morecambe bay will no longer be able to go to Lancaster but will have to go to Carlisle, Blackburn or Preston. Does my hon. Friend the Member for Wycombe (Steve Baker) agree that the majority of vascular surgery these days is not elective but acute, following road traffic trauma and incidents such as coronary emergencies? We are talking not about elective surgery but about acute emergency provision, so it is vital that the services are close at hand.

[Steve Baker]

My hon. Friend is possibly inviting me to stray beyond my expertise, but perhaps the Minister can deal with that point. The concern in Wycombe is about elective treatment of aneurysms, and particularly the treatment that goes with stroke services. The key concern is that it is an excellent service that will be degraded if it is moved to Oxford, according to the clinical evidence.

I am grateful to Dr Annet Gamell, chief clinical officer of the Chiltern clinical commissioning group. She has given me a clear explanation of the position in Buckinghamshire, which is that things are waiting on the outcome of the review in 2014. Once a new theatre is open at Oxford, it is proposed that all complex elective vascular surgery will go there. It is planned that outpatient and diagnostic services will remain at Wycombe. CEA services would be subject to review in 2014, and I understand from Dr Gammell that the group would support moving CEAs to Oxford only if results indicated that patients would benefit from it. The Chiltern clinical commissioning group would take into account the impact of such moves on other services. Dr Gammell points out that if it is agreed to transfer CEAs to Oxford, there would be another local consultation, but on the basis of recent experience it is not clear to me what end that consultation would serve. The decision would have been made and it is clear that there is vast momentum to take services in that direction, despite the clinical evidence.

The key performance indicators for the south central cardio-vascular network show that in the first two quarters of the 2012-13 reporting year, Wycombe performed 17 aneurysm repairs and Oxford 16. Wycombe carried out 31 carotid endarterectomies to Oxford’s 47. Almost half of patient records at Oxford did not provide the dates of patients’ symptoms. Eighty per cent. of CEA patients at Wycombe received the procedure within two weeks of referral. At Oxford, the figure was just 23%, although patients seem to have received their treatment within 48 hours of symptoms. At Wycombe, 58% of patients were treated within 48 hours. Oxford achieved a ratio of total vascular interventions to amputations of 4.55:1, whereas at Wycombe the ratio in the period was 8:1, which shows a considerably greater degree of success in maintaining people’s limbs in very difficult circumstances.

The clear clinical evidence in that period is that Wycombe outperforms Oxford, and it does so with fewer clinical staff. All this is not mentioned in the “Oxford University Hospitals Review of Phase 1 of the Centralisation of Vascular services”, which has been sent to me under cover of a letter dated 12 August from the chief executive of NHS Berkshire. It was among a number of documents leaked to me. The report describes the resignation of a vascular consultant, Mr Peter Rutter, following significant difficulties associated with the move from Wexham Park to Oxford. Those difficulties including antiquated theatre instruments, poor quality theatre lighting and patient safety issues.

Mr Rutter observed:

“Vascular surgery is not very important in Oxford and would take 5 years to bring up to standard.”

He also said that vascular had no champion at Oxford, which is confirmed in other documents. Other remarks in the review include, for example,

“Many outlying district general hospitals have better endovascular facilities”,

“Oxford is not a modern endovascular hospital”

and

“Oxford has no culture of multidisciplinary working”,

which is essential when vascular supports those other specialties. Furthermore,

“Little thought had been given to the effect on Interventional Radiology in DGHs”

and very worryingly, an

“Oxford senior surgeon threatened to make Bucks vascular surgeons redundant unless they toed the line.”

A comment in the review implies that Wycombe’s excellent interventional radiologists would join Oxford University Hospitals only if CEA and bypass surgery stayed at Wycombe, which has been rejected. Presumably, these valuable experts who make the excellent service possible will resign and go elsewhere.

In summarising, the review explains that the impression had been given that OUH had not properly thought through the implications of centralisation. In discussing theatre upgrades, it concludes that

“there remain concerns about the quality of lighting, ventilation, anaesthetic facilities and sterility.”

I am only a humble aerospace and software engineer, but it seems to me that these are fairly basic concerns. Despite all this, the review clearly states:

“It will not be possible for carotid surgery to remain in Wycombe as CE and CAS will not be commissioned from Wycombe beyond 2013.”

Surely this is a matter for the commissioners.

The reviewers are clear that it is not viable for Wycombe to keep carotid surgery and bypass, but they do not state the evidence for their assertion beyond the new status of vascular as its own specialty. Before making recommendations, the review says:

“OUH practices Vascular Surgery more like a DGH than an important Teaching Hospital. Several of the surrounding DGHs, currently being centralised into Oxford, probably provide a better endovascular service.

Vascular surgery at OUH seems to be safe but has not developed in the way that it has in other hospitals in the United Kingdom. It seems to be positioned about ten to fifteen years behind the best.”

Notwithstanding the evidence of superior performance at Wycombe and shortcomings at Oxford, the review insists that vascular services must transfer, ultimately on the basis that it is inevitable that vascular services will be co-located alongside Oxford’s major trauma unit. That is a blatant rejection of the principle that is constantly used to justify centralising services away: clear clinical evidence. All the time that Wycombe provides better care and the team can provide it sustainably, in its opinion, and while local commissioners are prepared to buy it, why surrender to Oxford’s desire to be the Thames valley super-hospital, whatever the cost to patients?

Any responsible Member would admit that the trend in health care is towards specialisation. When my hon. Friend the Member for Bracknell (Dr Lee) was describing his Thames valley super-hospital proposal in Marlow, he said that any politician who claimed that they could restore A and E to a district general hospital would be a liar. I am grateful that I have not fallen into that trap, but it illustrates a point. Politicians are accountable to their electorates and businesmen are accountable to their customers, but managers and clinicians in the NHS who follow rules and guidelines seem to account seriously only to one another and, significantly, to do so on the basis of who carries the greatest authority through prestige.

In the midst of all that, senior NHS executives keep circulating. Stewart George and Fred Hucker—irrespective of their individual merits—who chaired the Bucks and Oxfordshire PCTs, became joint chairmen of the cluster. Mr George is now moving to the CCG, and Mr Hucker to Buckinghamshire hospitals trust. A new era of openness, accountability and genuine public involvement seems unlikely, and continuity seems a dreary inevitability, but all that ought not to be.

Vascular services in the Thames valley appear to be not so much sleepwalking into disaster as positively driving towards it. Vascular services in Wycombe are not some ditch and gatepost operation to be salvaged by the great Oxford University hospitals, as Wycombe outperforms them with a smaller team. In this regard, it is the John Radcliffe that needs saving.

Let me ask the Minister some specific questions. Is the Chiltern CCG able to insist that it will purchase vascular surgery from the Bucks health care trust at Wycombe despite national guidelines? What are the roles and authority of the NHS Commissioning Board, the local health and wellbeing board and the south central vascular network? Crucially, has the elevation of vascular surgery out of general surgery and into a specialisation of its own led to such things as turf wars, demarcation disputes and office politics? What formal influence are locally elected representatives—councillors and MPs—supposed to have?

Wycombe has had its own hospital since 1875. The current hospital was not founded by the NHS; it was built in 1923 with donations from local people, which were mostly given in pennies, as a memorial to the men we lost in the great war. The public are therefore right to be incandescent with rage at changes that appear to be driven by remote sectional interests, not local patient care.

Recently, my right hon. Friend the Secretary of State said:

“I need to say this to all managers: you will be held responsible for the care in your establishments. You wouldn’t expect to keep your job if you lost control of your finances. Well don’t expect to keep it if you lose control of your care.”

What is needed is real accountability. Let us get health under the control of the people who pay for it and start by keeping vascular at Wycombe for all the time that that remains in patients’ best interests.

--- Later in debate ---

[Dr Poulter]

Yes. I assure my hon. Friend that when a referral is made by a local overview and scrutiny panel the Secretary of State will look at it and decide whether to refer it to the independent reconfiguration panel. That is often the decision that is made in these cases, but it lies initially with the Secretary of State, who will then have to consider whether to refer it. I am happy to write to my hon. Friend further to outline these steps if that would be helpful.

It is worth highlighting the national parameters that are being set for the delivery of good vascular surgery by the NHS Commissioning Board, which takes over full responsibility for commissioning from April this year. The board published a draft national service specification for vascular surgery for consultation. The consultation commenced in December 2012 and will conclude on 25 January 2013. It identifies the service model, work force and infrastructure required of a vascular centre. It says:

“There are two service models emerging which enable sustainable delivery of the required infrastructure, patient volumes, and improved clinical outcomes. Both models are based on the concept of a network of providers working together to deliver comprehensive patient care pathways centralising where necessary and continuing to provide some services in local settings…One provider network model has only two levels of care: all elective and emergency arterial vascular care centralised in a single centre with outpatient assessment, diagnostics and vascular consultations undertaken in the centre and local hospitals.

The alternative network model has three levels of care: all elective and emergency arterial care provided in a single centre linked to some neighbouring hospitals which would provide non arterial vascular care and with outpatient assessment, diagnostics and vascular consultations undertaken in these and other local hospitals. All Trusts that provide a vascular service must belong to a vascular provider network.”

In essence, this is about making sure that we deliver high-quality vascular care. There are two or three circumstances in which someone would require vascular care. First, there is emergency care—for example, when there is a road traffic accident, or when someone has a leaking aortic aneurysm, which is a very severe and potentially life-threatening emergency. We know from medical data that such service provided in an emergency is much better provided in a specialist centre—an acute setting such as the John Radcliffe, which would be the hub and the central focus. There is also good evidence that trauma care in any setting, including the requirement for neurological specialists potentially to be involved, is better served in a specialist trauma centre. A specialist centre provides better care in emergencies.

At the same time, it is clear from those models that there can also be a strong role for other hospitals as satellites of the central hub at the John Radcliffe. My hon. Friend clearly made the case for the high-quality outcomes at Wycombe hospital for carotid endarterectomies and other vascular services. I would suggest that there is a role for challenging local commissioners if they wished to remove some elective procedures from Wycombe when there is a case that they can still be delivered in a high-quality manner and to a good standard for patients.

[Steve Baker]

I apologise for intervening on the Minister when there is so little time left, but I can see the campaigners leaping up and down and saying that the clinical evidence in this case is that Wycombe is doing better than Oxford on aneuryism repair.

[Dr Poulter]

The evidence on the outcomes of patients from many trials does stack up over a period of time. Generally speaking, all surgeons need to do a minimum number of procedures in order to maintain regular competency, and to maintain continually high and good outcomes for patients when carrying out aneuryism repair. That is the reason for the service reconfiguration. The argument can be made, as my hon. Friend has done, that Wycombe should continue to provide those services, but we know that the national data and best evidence point to the fact that the services are best provided at specialist centres.

However, there is a good case for my hon. Friend to take forward to the local commissioners about ensuring that more of those elective procedures and elective amputations remain local, and I am sure that he will do that. I am sure that he will also want to talk to his local health scrutiny committee to ensure that it refers cases to the Secretary of State for review, if required. I thank him once again for raising the matter in the debate.

Question put and agreed to.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 27th November 2012 Commons Chamber

[Norman Lamb]

The specialised commissioning groups will receive advice at their December board meetings and are expected to finalise their advice on the clinical and cost-effectiveness of Kalydeco early in the new year. The aim is to provide consistent national advice on the use of the drug for a sub-group of patients with cystic fibrosis.

[Steve Baker (Wycombe) (Con)]

Aylesbury constituent Mrs Evans-Woodward is a young woman who has had five heart attacks. One evening her husband drove her to Wycombe’s heart attack unit with a racing pulse, but she was turned away to the minor injuries unit, which again turned her away to the accident and emergency unit in Stoke Mandeville, before suggesting that she sit outside and call an ambulance, which she duly did—all of this with a racing pulse of 180. This is not good enough. It is an appalling prioritisation of bureaucracy over simple human care and compassion. Does it not show that the NHS needs to become much more accountable to patients?

[Dr Poulter]

My hon. Friend is absolutely right, and I am very sorry to hear of the case he outlined. Clearly the care that his constituent received was more than substandard. If a patient needs immediate treatment, they should always receive it. This Government are quite rightly ensuring that we embed good care in everything we do. We have beefed up the role of the Care Quality Commission to improve the inspection of care quality throughout the NHS and the care sector. We are also introducing a friends and family test to pick up on examples of bad care, so that the NHS can properly learn from them locally and so that these things do not happen.