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NHS Expenditure (Reduction)

Volume 506: debated on Tuesday 2 March 2010

I am delighted to see the Minister in his place. I do not mean to imply that not all Ministers have his qualities, but I know that he is a receptive and thinking Minister. I am grateful that he will respond to my suggestions, which are intended to be helpful to the future of the national health service, which we all know is vital to our constituents and beloved by the large proportion of staff who work in it and the patients who receive treatment.

The extra money that has been provided has seen dramatic improvements, especially in cancer care, cardiac care and the increasing scope and success of the various treatments that are now available. A crisis therefore looms. The NHS Confederation estimates funding cuts of £8 billion to £10 billion in the next two or three years, and £15 billion in the next five years. The King’s Fund has produced a useful document, “Windmill 2009: NHS response to the financial storm”, which opens with the words:

“The health service is about to enter a new era. After years of unprecedented growth, it faces the prospect of unprecedented austerity.”

I want to talk about ways of addressing that challenge without widespread cuts. A high proportion of NHS expenditure is on staff, so if there are cuts, they are likely to be in the number of staff, which would not be helpful as the numbers in some areas are already inadequate. By lucky coincidence, my medical colleague on the Health Committee, the hon. Member for Dartford (Dr. Stoate), started this debate on Friday last week, and I believe that the Minister responded to it. The hon. Gentleman made the point that it is estimated that increasing self-care of patients with minor ailments could save the NHS £2 billion.

I was joining the train at Kidderminster station at about the time when the ban on smoking in public places came in, and a member of staff who had drawn the short straw and was sweeping up the fag ends outside said, “We might be able to change policies, but it’s a job to change people.” That was extraordinarily perspicacious at that time, and it is absolutely true that it is extremely difficult to change people. We can easily write new policies, but we must change people and how they use the NHS.

The hon. Member for Dartford quoted the Proprietary Association of Great Britain, which has described five clear steps to ensure that self-care increases. Following on from that, a discussion paper that I found extremely useful was produced by the National Endowment for Science, Technology and the Arts. It is headed, “The Human Factor”, and has a sub-heading, “How transforming healthcare to involve the public can save money and save lives”. It was drawn to my attention recently, and was written by Laura Bunt and Michael Harris, and published by The Lab and NESTA.

In this short debate, I can only point the Minister to that discussion paper, and give a brief flavour of it. The authors considered long-term conditions in particular, and how to change the way people cope with such conditions by educating them. I am thinking particularly of diabetics who, if they know how to control their disease, need much less help. The paper recommends a mixture of redesigning care with user involvement and more effective prevention. User involvement is crucial, and the NHS constitution has picked that up.

One public responsibility on patients from the NHS constitution is this:

“You should recognise that you can make a significant contribution to your own and your family's good health and well-being and take some personal responsibility for it”.

If NESTA’s suggestions were taken up and led to a 10 per cent. reduction in the cost of treating long-term conditions, that could save £6.9 billion a year, which is not to be sneezed at.

I cannot resist giving one of my favourite quotations. I do not know whether you have read Sir Walter Scott recently, Mr. Jones—I have only just rediscovered him—but one of his last novels was “The Surgeon’s Daughter”. He was writing about the burgesses of a Scottish borough and said:

“There the mothers of the state never make a point of pouring, in the course of every revolving year, a certain quantity of doctor's stuff through the bowels of their beloved children. Every old woman…can prescribe a dose of salts, or spread a plaster; and it is only when a fever or a palsy renders matters serious, that the assistance of the doctor is invoked”

What a lesson for all of us. Has the national health service limited people’s ability to look after themselves and spoiled them with the help that they receive. We must change that so that they have the help of medical and nursing staff—the clinicians—only when they really need it.

My hon. Friend has rightly, responsibly and caringly brought an important subject to the Chamber. He is approaching the matter from the viewpoint of taking personal responsibility, as well as that of clinical strategies, but he seemed to dismiss early in his speech the possibility of cutting staff. Will he address the possibility of cutting management teams because Government policy, defensive insurance strategies and so on have driven up the cost and number of management teams in the health service far too much?

I thank the hon. Gentleman for his intervention, but I will not touch on that because this is such a short debate. In fact, very recently, reports in the papers have suggested that NHS trusts with more managers have performed better than the others. That must be taken into consideration.

I was drawn to this debate because of its interesting title, and the hon. Gentleman’s background. I want to make two brief points. First, is it not important that he and others are careful when using phrases such as “age of austerity” when it comes to the NHS, in case the wrong signal is given to front-line staff—nurses and others—who often work in hard-pressed circumstances and who need a continuing period of stability, building on the welcome investment to which he referred? Secondly, on his point about prevention, does that not underline the critical importance of community health initiatives, community nursing and nurses in our schools? Will he say a word or two about that?

I thank the right hon. Gentleman, who made many points in a short time. I cannot hope to address them all. On stability, I absolutely agree. I do not believe that anyone will try to reorganise the health service crucially in the near future, for which we will all be grateful.

Prevention is a huge subject, and I am afraid that I am taking that as read, because it is obvious that spending more money on prevention saves money in the long term. The huge problem is moving money out of acute care into prevention, but I am sure that the Minister will be well aware of that.

I have spoken about patients and the public, and what they should be doing to improve how they look after themselves. Now, I want to speak about the staff. I am the first to praise staff for their tremendous, hard work, but we must be realistic and ensure that they realise the problems afoot. I remind the Minister of the NHS Confederation’s paper, “Dealing with the downturn”, which was published in June 2009. It is useful because it lists first many bad ideas from history that do not work.

If waiting lists are allowed to grow, quality is diluted. Indiscriminate cuts in expenditure can focus on cost rather than on value, and pay could get out of line, training might be cut or we could fail to protect curative services. Those measures have all been tried and have failed. They are doubtful things such as centralising support functions, mergers, structural change or reducing staff. The document contains a useful quote about price competition, which states that

“this does not fit with patient choice. The risk is that providers can exploit this to obtain increases in prices – particularly when they have a monopoly. It can also lead to ‘a race to the bottom’ which reduces price and quality.”

I believe that that has been one of the reasons behind the poor quality of out-of-hours care in some places.

Let me move on to the more positive points in this document. There are several pages of suggestions of ways to do things differently in order to improve how services work and improve patient safety and quality of care. Some of those things will save money, such as the productive ward, which I am sure the Minister knows all about. I have seen that initiative in several hospitals that I have visited, and it is a scheme whereby all staff, from health care workers to the sister to the cleaners, get together on a regular basis and talk about how they are doing things. That can lead to obvious alterations, such as moving all the things that are necessary to set up an intravenous drip to one place, so that staff do not have to dash from place to place picking things up. That leads to improvements in ways of feeding patients, and can reduce wastage of time over meals. It can lead to nurses doing the nursing rather than lots of admin, so that they can spend more time with the patient.

The document mentions the difficult matter of treatment prohibitions. However, as the National Institute for Health and Clinical Excellence has told us, relatively few treatments in use have no proof of effectiveness, so we cannot save billions of pounds by cutting out useless treatments. There is a mention of limiting the NHS package, which in my language is health care rationing. However, as is pointed out, that would require public debate and it would be difficult to sell to the public unless all other ways of saving had been exhausted.

Productive wards are an initiative from the NHS Institute for Innovation and Improvement, which sadly seems to have rather a low profile. That organisation was responsible for the better care, better value indicators, the first tranche of which came out several years ago, and I believe that there have been further tranches. The indicators compare the performance of the NHS with the performance figures for the top 25 per cent. regarding that treatment or method of carrying out a service. The productive opportunity from those indicators is, I am told, £3 billion—something worth looking for.

The King’s Fund “Windmill” report makes specific recommendations for the Department of Health, regulators, strategic health authorities, commissioners and providers, and there are two interesting appendices. Appendix B apparently fell off the back of a lorry; it is a leaked Department of Health memo with a long list of possibilities for the emergency strategy committee to consider. That is encouraging as it shows that people at the Department of Health are using their brains and getting their staff to work on those sorts of things. Appendix C is a useful classified summary of the various approaches taken to reducing costs, improving efficiency and perhaps increasing income.

In addition to the papers from the King’s Fund, NESTA and the NHS Confederation, I have had a host of letters over the past few days from organisations making suggestions. Action on Smoking and Health—ASH—points out the cost-effectiveness of measures taken to reduce smoking, which can be highly effective. The Royal College of Nursing mentions the huge benefits and cost savings from community nurses, particularly specialist nurses, who can save a vast amount of time and money. There were suggestions for isolated drug economies, and suggestions from the Alzheimer’s Society.

I will return to my initial point: we must first change people by making them more informed and responsible for their own health care, not only for minor ailments but for long-term conditions. We must then change the workings of the NHS and give staff at all levels the chance to suggest innovation and better ways of working. I am conscious that I have not spoken much about prevention; there is no time for that, although it is a crucial matter.

I conclude with something that Disraeli said towards the end of his first spell as leader of the country:

“There can be no economy where there is no efficiency”.

I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this debate on what will be one of the most challenging issues for the health service over the coming decade. I understand that the Health Committee is looking at this subject, and I look forward to the evidence that it produces.

As the hon. Gentleman said, over the past 12 years funding for the NHS has increased substantially and is now—as we promised—broadly on a par with the rest of Europe. The NHS has expanded and improved beyond any recognition, and as a consequence we now have a more capable and resilient service. Patient care has improved significantly, far fewer people now die from heart disease and cancer, and waiting times are the shortest they have ever been. Despite what some newspapers claim, patient satisfaction rates are extremely high.

Those improvements have been recognised internationally. Last November, the Commonwealth Fund survey of primary care services ranked the UK first in almost every area. There has been a transformation in the NHS, which has moved from being pretty poor to being good, although it must still go further before it is great. If we want a great health service, we must continue to invest in it and ensure that we deliver improved care beyond that which we are delivering now.

As the hon. Gentleman said, the time of rapidly increasing budgets is coming to an end. The stimulus package that we and Governments around the world have put in place has avoided a second depression, but the cost of that will mean tighter budgets in years to come. I do not for a moment accept the argument that a crisis is coming, and neither do I believe that a great storm is coming. There is, however, a demand for good management and efficiency, and a need to ensure a clear focus on the priorities.

Should any manager happen to overhear the debate—saying something in the Commons is almost like trying to smuggle a message out—the message that came out in the Mid-Staffordshire inquiry and in the problems with out-of-hours doctors and a range of issues is this: the first priority for any manager in the health service is patient safety and the quality of care for patients. Managers must be aware of issues to do with finance and targets, but the priority must be to ensure patient safety and patient care.

Does the Minister accept that there could be a crisis if decisions were wrongly taken to slash and cut public services such as the health service in a devastating way? We should certainly avoid that policy. One way in which we could move forward is by addressing the amount of funding that is spent on NHS management.

I do not want to get sidetracked into a discussion about what is or is not management. A lot of figures are bandied about, which I sometimes worry about. Sometimes they refer not to managers but to staff who are necessary to ensure that a patient knows when their appointment is and can get there, and that the health service is properly administered. More than ever in the coming years, we need good-quality management and sometimes we have not had that in the past in the NHS, which is why we are mounting a programme to improve the quality of management in the health service.

As this is the season for giving way, I will intervene at this stage. I apologise, Mr. Jones, for not being here for the first 10 minutes of the debate. I am mortified that I was not here for my leader’s speech. The Government are to be congratulated on the amount of money that they have provided to the NHS and on the transformation that the Minister has spoken about, but will he acknowledge that there is a danger in being over-ambitious and trying to create rather remote hospitals as centres of excellence and in being too ambitious about how much we can move patients away from hospitals to polyclinics? When it comes to planning appropriate savings and improvements in health provision, managers and, indeed, Health Ministers should not be too ambitious about how such changes to management can be provided. That is a great controversy, as the Minister knows, in London and in south London as well.

Polyclinics in London—GP-led health centres in other parts of the country are a slightly different type of NHS institution—are providing a great opening for people. They offer extended hours and deliver the services that patients want. We have to accept that the NHS will not be frozen just as it is now. What we have to see, particularly in the years to come, is a resolute focus on quality and improving patient care within reasonable budgets. We need to ensure that managers in the health service are focused on that, which means innovation and change. Change will come to the health service, and the changes that we want to see will improve the quality of patient care.

We want to ensure that managers know that there is not a crisis. My right hon. Friend the Member for Oxford, East (Mr. Smith) is right: sending the wrong message at this stage would be very dangerous. The NHS budgets are increasing this year by 5.5 per cent. and next year by 5.5 per cent., if the Government remain in power at least. We have said in the pre-Budget report that we are committed to protecting front-line NHS spending for the following two years, growing it in line with inflation.

However, the demand for health care from an ageing population, new technology and ever higher patient expectations mean growing pressures on the NHS budget. That is clear, so along with commitments on spending, we have set out the quality and productivity challenge that the NHS faces. In four years’ time, the NHS needs to be making efficiency savings of between £15 billion and £20 billion a year. Importantly, those are not cuts. Let me make that clear. The money will not be taken out of the NHS by the Treasury. After all, we are not Thatcherites. Importantly, those funds will be kept within NHS budgets. Our aim is that every penny of those savings will remain within the budgets, allowing us to realise our vision of continuing to improve the quality of care for all. Essentially, we envisage no cuts in NHS front-line funding.

In previous times of financial challenge, patients have borne the brunt through longer waiting times, reduced availability of drugs and treatments and, ultimately, poor-quality care. Managers lacking in imagination made slash-and-burn cuts. That approach is indefensible when the scope for improving quality and productivity in the system today is still great. Patients should not pay the price of poor managers who are unable to handle budgets. The Mid-Staffordshire lesson is a lesson for every manager in the system.

We need imaginative managers who will focus on the quality of care. I make no bones about it—I will name and shame managers who are making slash-and-burn cuts across the health service. Just in the last couple of weeks, I saw a press release from Gloucester hospital that deeply concerned me. I wrote to the managers at Gloucester hospital, expressing concern. They have said that the economic situation means that they have to slash a load of beds—a couple of hundred beds. That is nonsense. Thankfully, they have now decided that that sort of slash-and-burn announcement is unnecessary and needs to be looked at with care. It is a product of a lack of imagination by managers, and managers need to be very careful when they go down that route.

No, I will not, if the hon. Gentleman will forgive me. I have only a few minutes left.

The vision of high-quality care for all is one of local clinical leadership, of empowered patients shaping their own health care, of prevention being as important as treatment, as the hon. Member for Wyre Forest said, and of unstinting demand for higher-quality care. We must not for one second consider stepping away from that. Improving quality can also reduce costs. Our record on reducing health care-associated infections demonstrates that. We have made great strides, reducing MRSA by 74 per cent. and clostridium difficile by 37 per cent. That has not only improved care and saved lives, but saved the NHS £240 million.

There are many areas with the potential to improve quality and increase productivity. In the time allowed, I shall give a few examples. Enabling all hospitals to meet the staff productivity currently delivered by the best could deliver annual savings of up to £3.5 billion. The hon. Gentleman talked about the productive ward programme. As a result of that, nurses in London were able to spend an extra 500,000 hours—500,000 hours—with patients, because they themselves have worked out ways in which they can improve the quality of what they do in productive wards to give that time to patients. We are talking about the equivalent of an extra 255 full-time nurses, costing about £7.5 million. So far, the productive ward has been introduced for only 12 per cent. of London’s wards, but the ideas that underpin the productive ward programme have also been applied in mental health wards and operating theatres and in the delivery of community services.

Pilots of productive community services have already produced promising results and suggest potential reductions of time spent: on travel by more than one fifth; on administration of referrals by more than 80 per cent.; on finding stock and supplies by two thirds; and on dealing with interruptions by more than half. That has led to an increase in time spent on direct patient care and, not surprisingly, staff morale has gone up by more than 90 per cent. That is the type of measure that can change the quality of care and save money. Reformed community services and transforming the care of those with long-term conditions, delivering integrated, efficient and people-centred care, has the potential to improve the quality of millions of people’s lives and to save up to £2.7 billion in the process.

The next area of our focus is improving health as well as treating sickness. That has the potential to save the NHS further billions of pounds. For example, screening by pulse palpation to improve detection of atrial fibrillation improves the quality of care by reducing the risk of stroke, and it avoids the costs associated with stroke and its complications, particularly through emergency hospital admissions.

The Government have made clear their intention to drive down the costs of management, back-office support and procurement across the public services. The NHS wants to find ways in which that can be done sensibly, rewarding good-quality management but also ensuring that innovation in management and administration is acknowledged in the health service and rewarded, too. All too often, managers who are innovative in how they run things and who deliver higher-quality care for patients are forgotten, because that is just the administrative side, not the flashy, operating theatre, medical style of care, but they too are contributing to the quality of health care. We need to acknowledge where good management has reduced costs and improved the quality of care through administrative changes, rather than just medical changes.

All this cannot be administered from Whitehall. Instead, we need to empower clinicians and their patients. It is through innovation, through looking for new ways to do things, assessing them and, most importantly, spreading them throughout the health service—the NHS is great at innovation, but it does not spread it—that we can ensure that we unlock productivity gains. To support that, we have published the best examples of quality and productivity improvement on the NHS Evidence website. That has already been seen by more than 10,000 visitors to the site.

The hon. Member for Wyre Forest highlighted the debate that we had the other day on self-care. That is an important debate and one that we need to take further, but we also need to give people more access to information about the care of their own health, both through the internet and through interactive television, which presents a great opportunity. Let us say that someone has a problem such as asthma. Interactive television can be useful for someone who is not perhaps as technology-literate as younger people often are.

We face a great challenge, but we can overcome it by improving the quality of care, reducing the costs at the same time and delivering within NHS budgets, while recognising that the highest priority of the NHS must always be patient safety and ensuring that we improve the quality of patient care.