Primary Care: North Essex

Will Quince Excerpts

Tuesday 14th March 2017 Westminster Hall

[Mr Douglas Carswell (Clacton) (UKIP)]

I beg to move,

That this House has considered primary care in North Essex.

I am grateful for the opportunity to have this debate. We face a serious problem of primary care provision in our corner of Essex. To put it bluntly, there are not enough GPs. In my part of Essex, there are three local GP surgeries, which are not taking on any new patients at all. Those fortunate enough to be registered with a surgery often struggle to get an appointment.

Here are some of my constituents’ experiences, pulled out from my postbag in the past three weeks, to give a flavour of what they are having to put up with. An elderly lady from Little Clacton wrote to me a couple of weeks ago:

“On attending the practice, I realised that there was an average of three weeks waiting time to see a GP. … When I did finally get seen, the practice nurse said, and I quote, ‘You have to be at death’s door to get an urgent appointment on the NHS now.’”

This is a woman who has spent decades paying into the system, unable to see a doctor for three weeks.

Then there is a lovely lady from Kirby near Frinton who emailed me, saying:

“I’m writing to say how abysmal the doctor’s surgery is now. I waited two weeks for an appointment, only to be told to go to a different surgery if I wasn’t any better in two weeks.”

There is not much sign of customer service there, is there?

Finally, a man from Clacton wrote:

“I am my mother’s carer. I’m not a doctor. I just do my best and feel abandoned by my medical practice. I am having great trouble making appointments for my mother to see a doctor so that we can control her pain.”

Those are not isolated cases. My postbag is full of examples—it is fair to say that something is badly wrong with primary care in our part of Essex. What concerns me is that it was possible to see the problem coming. Back in September 2013, I led a delegation of GPs to see the Health Secretary to flag it up, precisely because GPs said the problems were going to happen.

To be fair to Ministers, we in this room all know—I hope people outside know it too—how disastrous the 2004 GP contracts were. They were certainly disastrous for those who are meant to be provided with primary care—but that is now more than a decade ago. We also recognise that a Minister cannot, as I think Nye Bevan put it, be held responsible for the “sound of every dropped bedpan” in every NHS surgery and waiting room. In fairness, I do not think we can blame Ministers for the failure of individual surgeries to get their appointment systems sorted out. But the question is, who does take responsibility? Who will answer to my constituents for these failings?

It is clear there has been a failure to provide the level of primary care that is needed in our part of Essex. What is less clear is who we hold to account. We have an alphabet soup of different agencies and quangos in charge, but none of them seem to be properly responsible. There is something called the CCG—the clinical commissioning group. It allocates the money and the patient is then expected to follow. The technocrats commission and the patient is expected to follow. Then there is the CQC—the Care Quality Commission. It inspects the GP surgeries. Would it not be better if surgeries had to satisfy customers and not simply comply with CQC assessments? Then, of course, there is NHS England, and in our part of Essex, something called ACE—Anglian Community Enterprise—which provides certain primary care services.

I have raised concerns with all those different branches of NHS officialdom on behalf of constituents and I have done so repeatedly. Promises are invariably made. I am told that we will get more GPs, that new contracts and a new kind of contract will be sorted out—always tomorrow. Not much ever actually seems to change on the ground.

Sometimes I am told, or it is implied—they do not dare tell me this any more because I react very strongly to it—that all of this is to be expected. There is, they say, an elderly population in our part of Essex. The profile of the patient group, I was once told, means that there is all this extra pressure.

Those sentiments are excuses for failure; they are not credible reasons. We should not be in the business of blaming people for being elderly. After all, if someone is elderly, it means they have paid more into the system. In what other walk of life or area of activity is a surfeit of customers regarded as a problem? In Clacton, it is possible—I speak as a father—to go shopping for the family 24 hours a day, seven days a week, so why is it not possible to see a GP on a Saturday if a child is ill?

At the root of the problem is a system of state rationing—it is probably one of the last vestiges of the mid-20th century system of state rationing—in which the patient is expected to stand in line and wait. The patient is made to follow the money. We need a system of primary care in which the money—for a taxpayer-funded service, free at the point of access—follows the patient.

Ministers are absolutely right to want to see surgeries open on a Saturday, at weekends and in the evenings. Heaven forbid, if we really had a system of primary care that responded to my constituents’ needs, there might even be GP surgeries in railway stations, where quite a large number of my constituents tend to congregate in the early morning and late evening. If we are to have a more accessible, customer-focused service, it means making the patient king. It is not something that can be done by top-down design or by ministerial decree. Good customer service comes from the need to please customers, not from on high.

GPs tell me that the burden they face could be alleviated in part if more people were willing to use and made better use of pharmacists. There is a lot of truth in that. Pharmacists are highly qualified and often very experienced, and we are right to look into that. I say this in the week when we have finally passed the legislation to get us out of the EU, but perhaps we could learn from some of our European neighbours who seem much better at making good use of pharmacists, particularly Italy and France. I gather that in Germany people do not have to depend on the equivalent of a GP acting as a gatekeeper in the way that we do in this country. I would be very grateful if the Minister could elaborate and talk about not just what we can do to alleviate the problems in our part of Essex but the far-reaching reform that is needed if we are to make sure that people who have spent all those years paying into the system can be seen by a doctor when they need to.

[Will Quince (Colchester) (Con)]

I recognise the issues that my hon. Friend rightly raises. Does he agree that a direct result is the considerable pressure placed on the general hospital in Colchester, which serves his constituents and mine, and that the foolhardy decision to consult on the closure of minor injuries units and the walk-in centre in Colchester should be dropped immediately, because it is such a ridiculous idea? It will just put additional pressure on Colchester general hospital.

[Mr Carswell]

My hon. Friend, as so often, is absolutely spot on. His judgment is impeccable. The failure to provide people with the primary care they need when they need it means that more people then tend to go to A&E departments. The people who run the ambulance service tell me that that then causes a bottleneck in A&E, which has a knock-on effect on ambulance response times. Many of the problems we are grappling with are a consequence of the failure to provide accessible, customer-focused primary care where it is needed.

The consultation on the minor injuries unit and walk-in centre is irresponsible. I share the view that it would clearly be absurd to shut that facility. A lot of angst and worry could be addressed if the option was ruled out now, and I hope it is.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. I congratulate the hon. Member for Clacton (Mr Carswell) both on obtaining the debate and on the lucid way he put forward his case. I thank my hon. Friends the Members for Colchester (Will Quince) and for Harwich and North Essex (Mr Jenkin) for their points, which I will try to answer.

There is an issue with the number of GPs in the CCG in that part of north Essex. I will talk a little about why that is the case and what we can do about it. It is very hard to make progress on a number of the issues that were raised without fixing that problem. We are short of GPs across the country, but we are particularly short in the North East Essex CCG. Let me give some numbers for context. There are 40 GP practices and a little over 210 GPs within the CCG, which covers 330,000 people. The CCG estimates that it is 28 GPs short. I spoke to it this afternoon, and I was told that if any GP wants to get a job in Clacton, it will not be a difficult process. Indeed, the figures for Clacton and the coast are marginally worse than those I have just given.

That is somewhat mitigated by the fact that the CCG has more nurses than the UK average. That might well be to do with the walk-in centres and minor injury units, which are nurse-orientated. I will come on to talk about how we can work in a slightly different way—this was implied by the remarks of the hon. Member for Clacton—by making use of other disciplines, such as pharmacists, physios, allied health professionals of different sorts and mental health professionals. The CCG now has 10 full-time pharmacists, and there is a plan to increase that number considerably between now and 2020. Frankly, it is easier to recruit pharmacists than GPs, but we need GPs too.

I will spend a little time talking about the reasons for that. I spoke to the CCG about them in some detail today. As the hon. Gentleman mentioned, Clacton has an older population, which causes problems, and there may be contractual issues relating to that, although the GP contract allows extra money for areas of deprivation and those with ageing populations. There are no training GP practices in Clacton, which puts it at a disadvantage, as GPs are likely less to go there as part of their training and then stay. It is also true that Clacton has a higher than average age demographic of GPs, so there is a higher tendency for them to retire, which exacerbates the situation. I concede that there is a problem, and I will talk about some of the things being doing about it. The hon. Gentleman used the phrase “jam tomorrow”, and I am afraid that some of it might sound a bit like that.

I want to draw attention to some of the things that the CCG in north Essex does well. We often talk about issues to do with locations—bricks and mortar—whether minor injury units or hospitals, but all MPs, including me, should properly evaluate our CCGs on the full set of published metrics. We have done an awful lot on transparency. I will just mention some of the things that the CCG does well. The hon. Gentleman’s CCG is well above the national average for cancer diagnosis in stage 1, for dementia care planning, for organising health checks for patients with learning disabilities, and for organising care packages for people with mental health episodes. I say that to put its issues in context. It is clearly true that there are difficulties with access and, to a lesser extent, with getting on lists in the first place.

The hon. Gentleman rightly made the point that we should be following the patient. We do a lot of work across the NHS and with every CCG to poll patients to ascertain how satisfied they are with the level of service they have received. North East Essex CCG received something like 82% patient satisfaction—lower than the national average. It is thought that the figures for Clacton are likely to be lower than the CCG average as a whole, so I will not hide behind that number.

In terms of what we are going to do about it, I will start by talking about some national initiatives—the comment about STPs related to that—and the need to invest more in primary care. There are two national initiatives that I want to mention. First, there is the GP five-year forward view. I know it sounds like jargon, but it redresses the persistent underinvestment in primary care over the past decade or so. Between now and 2020, there will be a 14% real increase in primary care across the country, which will manifest itself in the workforce and in different ways of working. That is real money; it is accepted by the British Medical Association’s general practitioners committee. It is very welcome, and frankly it has been a long time coming.

If we were designing an NHS today, with the sort of patient environment we have now, we would not design it around acute hospitals, as was done in 1948. We would design it much more around long-term conditions—diabetes, dementia, heart disease and so forth—which account for 70% of the NHS’s total cost and mean that much more can be done in the community. That is our very clear direction of travel.

[Will Quince]

Although I very much welcome those plans and the steps the Minister is hoping to take in relation to primary care, there is still very serious pressure on Colchester general hospital. I welcome last week’s Budget announcement of £100 million for triage services in accident and emergency units. Will the Minister give serious consideration to making Colchester general hospital a pilot for that, which would help to alleviate some of that pressure?

[David Mowat]

My hon. Friend may be relieved to hear that Colchester general hospital is not in my portfolio, but I will speak to my ministerial colleagues about it being a pilot and write to him.