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NHS Reorganisation

Volume 651: debated on Wednesday 12 December 2018

[Mike Gapes in the Chair]

I beg to move,

That this House has considered NHS reorganisation.

It is an honour to serve under your chairmanship, Mr Gapes. It is my pleasure to open this debate on our NHS as we near the end of the year marking its 70th birthday. In debating its reorganisation, we should not lose sight of what a great credit the NHS and its staff are to our country. Its foundation represents arguably the greatest achievement of this House. It is for precisely that reason that its reorganisation matters so greatly.

Let me set the context. Eight years of cuts and the biggest financial squeeze in its history have pushed the NHS to the brink. On all key performance measures, it is struggling to keep up with demand—A&E performance hit a record low this year, more than 4 million people are stuck on a waiting list, and cancer targets are repeatedly missed. In a speech last year, the chief executive of NHS England warned:

“On the current funding outlook, the NHS waiting list will rise to 5 million people by 2021. That is an extra 1 million people on the waiting list. One in 10 of us waiting for an operation. The highest number ever.”

As the NHS is pressurised to do more with less, it is imperative that Parliament properly scrutinises the ongoing process of its reorganisation. We should not allow the Government’s shambolic handling of the Brexit negotiations to distract us from reforms that are critical to the livelihoods of millions in this country.

I acknowledge that this subject is wide-ranging and complex, so I intend to focus on a few key issues: clinical commissioning groups; sustainability and transformation plans and partnerships; integrated care partnerships; health and social care integration; and healthcare infrastructure.

Let me start with the Health and Social Care Act 2012 and CCGs. Six years on from the coalition Government’s top-down reorganisation of the NHS, it is clear that that initiative has been as much of a disaster as Labour warned it would be. My hon. Friend the Member for Ellesmere Port and Neston (Justin Madders) rightly described those reforms as having put in place

“a siloed, market-based approach that created statutory barriers to integration.”—[Official Report, 6 September 2018; Vol. 646, c. 176WH.]

The 2012 Act removed regional health planning by abolishing strategic health authorities and creating a complex and fragmented system of clinical commissioning groups. Strategic health authorities helped co-ordinate the provision of healthcare across an area. Subsequent NHS reorganisations have often felt like partial attempts to reverse the damage done by the 2012 Act. It is therefore unsurprising that little effort has been made to keep the public informed of those changes.

I congratulate my hon. Friend on securing the debate. He touches on the reorganisation way back in 2012. Clinical commissioning groups were created, but they are not accountable to the public—we have problems trying to find out what their budgets are and so forth. We have the same problem with NHS England, which is another very difficult organisation to deal with. As a result of all this reorganisation, we have organisations that are not really accountable to the public, and the public do not get their voices heard.

My hon. Friend touched on staff salaries. If we worked it out, we would probably find that they have had an 8% real-terms cut in wages over the past seven or eight years, on top of which they have to pay car parking charges for the privilege of serving the public. Does he agree that that cannot be right?

I thank my hon. Friend for his intervention. I totally agree with him, and I will come to that point later.

The Health Secretary has not even put out a press release about his most recent set of NHS reforms. I wonder when that will happen. Despite not being locally accountable, CCGs hold more public money than local authorities. That lack of accountability is particularly concerning given the large sums CCGs handle and the potential for vested interests to benefit in ways that do not best serve local populations. For example, although GPs acting as both commissioners and providers of care are allowed to sit on local NHS boards, elected and accountable local officials are not. It is alarming that current arrangements allow for such potentially significant conflicts of interest while resisting local democratic oversight.

I turn to sustainability and transformation partnerships. Since the 2012 Act, we have seen the launch of 44 STPs, covering all aspects of NHS spending in England. That process has been characterised by Government secrecy, with little or no engagement with staff, patients, unions or the public before the publication of plans. Despite being asked by the Government to deliver changes to local health services, STPs were given no statutory status, and their meetings are held in private. In the majority of cases, councils have not been included at all, and a number have passed motions or issued statements condemning the process. Under this Government, changes have been initiated with no proper consultation or engagement locally with the public, patients or staff. Without accountability to local democracy, we cannot ensure that health and care systems are relevant to the people and places they are intended to serve.

STPs’ lack of accountability is even more significant given their role in administering spending reductions. Analysis by the Nuffield Trust found that some STPs are targeting up to 30% reductions in areas of hospital activity, including out-patient care, A&E attendances and emergency in-patient care, over the next four years. Those reductions are being planned in the face of steady growth in all areas of hospital activity. Too often, such initiatives encourage short-term savings, to the long-term detriment and overall cost of the NHS.

We should not forget that hard-working frontline staff bear the brunt of these pressures. It is sadly unsurprising that hospitals report growing shortages of doctors, nurses, midwives and therapists, while these bureaucratic bodies flourish.

My hon. Friend is quite right. One of the things that would help, particularly among women, is reintroducing the education maintenance allowance so we can bring forward student nurses and so forth. I will give a very quick example—I know you have been a bit lenient, Mr Gapes. In Coventry, a certain facility is starting to be moved to Birmingham. That is 16 miles away, so people are going to have to travel quite a distance. We still have difficulties getting through to NHS England, which arbitrarily comes along and says, “This is going to happen.” It looks as though it might happen unless we can find some alternative. Does my hon. Friend agree that that is no way to run a national health service?

Order. I remind hon. Members that they should not make lengthy speeches in interventions. I would be grateful if all Members bear that in mind in future. I will not be very kind if I get the sense that we are getting three or four speeches from one Member.

Thank you, Mr Gapes. I thank my hon. Friend for his intervention. I agree with him to some extent, but I think his microphone was not working, and it was very difficult to hear what he was saying. That needs to be looked at.

The Warrington and Cheshire STP is completely unworkable. It has the second largest footprint of the 44 STPs, covering 2.5 million people, 12 CCGs and 20 NHS provider organisations. There are so many bodies involved that the STP has been almost impossible to co-ordinate. It required £755 million in capital funding to be deliverable. Against a backdrop of cuts to NHS capital budgets it is unsurprising that the STP has made little progress.

Integrated care providers represent the latest iteration of the changes. Although ICPs could drastically change health and social care provision if adopted, their implementation is taking place without a vote or a debate. The details setting out what an ICP will do were published during the summer recess, with very little publicity. An ICP can be awarded a contract to deliver a general practice for up to 10 years. Significantly, these contracts can also be awarded to private companies. One of the criteria used to assess bids will be

“whether they are able to deliver value for money,”

moving away from an emphasis on quality and choice. Does the Minister believe that these changes should be made without parliamentary consent?

Mr Gapes, forgive me for using these confusing and seemingly never-ending abbreviations. The communication of the changes has been another major flaw in the process. Indeed, I echo the criticisms in the seventh report of the Health and Social Care Committee, published earlier this year, which noted:

“Understanding of these changes has been hampered by poor communication and a confusing acronym spaghetti of changing titles and terminology, poorly understood even by those working within the system. This has fuelled a climate of suspicion about the underlying purpose of the proposals and missed opportunities to build goodwill for the co-design of local systems that work more effectively in the best interests of those who depend on services.”

This unnecessary use of abbreviations and complex terminology has shut out the public and excluded them from the debate over the future of the NHS. The Government have a clear a responsibility to make the debate around NHS reorganisation far more accountable and accessible to the public.

Moving on to health and social care integration, there is broad consensus that if the NHS is to maintain levels of service provision while making the efficiency gains demanded of it, the integration of services across health and social care is vital. Demands on the NHS are becoming increasingly complex, and long-term integrated care has the potential to transform the lives of millions of patients, as well as improving the patient experience. It has huge potential to save money by cutting down on costly emergency hospital admissions and delayed discharges. However, a recent report on health and social care funding by the Institute of Fiscal Studies revealed:

“Social care is facing high growth in demand pressures, which are projected to rise by around £18 billion by 2033-34, at an annual rate of 3.9%.”

This is not something that can be done on the cheap.

For patients, the lack of integration of health and social care can be a maddening experience. I am sure many Members have heard complaints from constituents about having to constantly repeat their story to any number of different health and social care professionals. In my constituency, a community-led healthcare non-governmental organisation passed on the following patient comment, which sums up the problem well:

“When I get on a plane, there is a lounge, passport control, security, air traffic controllers—lots of separate organisations. But what I experience is a trip from A to B. In health and social care what most people experience is A to Z, B to Z etc. having to repeat their stories each time.”

This confusion is the outcome to be expected from the unnecessary complexity and fragmentation that has characterised NHS reorganisation for several years. The fear is that the next NHS reorganisation will not take into account or optimise the 80% of individuals’ wellbeing impacted by the wider determinants of health—housing, employment and connectedness to the local community.

In my constituency, Warrington Together offers a potential way forward as a locally appropriate, collaborative model of care. Its rationale is a return to the principles of the NHS when it was established in 1948: a single taxpayer-funded organisation working to a single integrated plan; promoting healthy lifestyles; utilising doctors and hospitals, as well as community care, social care and mental healthcare; and striving to keep an entire population well in the most efficient way possible, with enhanced stewardship by those who are locally democratically elected.

Warrington Together offers the opportunity to stimulate a social movement to ensure that changes to healthcare are more accountable to the local population. It has established a third sector health and social care alliance, which is an umbrella group made up of 12 local voluntary health and care providers, who can act with one voice and be contracted as a single entity. That will enable a broad range of providers to come together, offering such diverse care as housing and home repairs, mental health support, and links to local leisure and cultural opportunities. While that is not without its challenges, it represents something we should try to achieve on a national scale: involving local stakeholders to provide integrated health and social care services.

My last topic is healthcare infrastructure. NHS reorganisations need to be informed by infrastructure needs. Buildings need to be more efficient and cost-effective. It is estimated that one third of GP surgeries are conversions of former Victorian terraces, 1960s bungalows or former offices. They are often unfit for purpose and cause significant waste. Innovative and modern infrastructure helps to reduce energy and utilities costs to our NHS, while also protecting our environment. The less money we spend on the maintenance of outdated NHS infrastructure, the more money we can spend on long-term care.

I have a number of questions for the Minister to answer. How can he justify the creation of ICPs without a parliamentary vote or debate? Does he acknowledge that ICPs are moving away from an emphasis on quality and choice by allowing bids to be assessed based on whether they are able to deliver value for money? How can he explain the Government’s decision to keep accountable, elected local officials out of the NHS’s decision-making process? Without accountability to local democracy, how can he ensure that health and social care systems are relevant to the people and places they are intended to serve? Will he now acknowledge that the Health and Social Care Act 2012 has been a disaster for the NHS, creating a fragmented and overcomplicated system that fails to meet patients’ needs?

The 2012 reforms have been likened by one commentator to

“a football team reorganised in such a way that the defenders, midfielders and forwards have to contract formally with one another for a certain number of tackles, saves, passes and goals, according to a general plan laid out by the manager, even though all the money comes from the same source: the club, and ultimately the fans. To make things more complicated, on match days, fans are encouraged to swap their tickets for another game, at another stadium, with other teams.”

Is that not an effective summary of these reforms? Finally, does the Minister agree that the unnecessary use of abbreviations and complex terminology has functioned to shut out the public and exclude them from the debate over the future of the NHS?

It is a pleasure to serve under your chairmanship, Mr Gapes; I love saying that, particularly to our current Chair. I thank my hon. Friend the Member for Warrington South (Faisal Rashid) for securing this important debate.

I am here today to put on record the wild west of the NHS in south-west London, which will be well known to the Minister. It is a branch of the NHS that has spent the past two decades desperately trying to close the A&E and maternity unit at St Helier hospital on the border of my constituency and move those services to leafy, wealthy Belmont in Sutton. I will describe the geography for any hon. Members unfamiliar with my constituency. St Helier hospital is based in the deprived area of Rose Hill. Further south is the Royal Marsden in the wealthy area of Belmont, and seven miles west is Epsom hospital. The local CCGs are proposing to move all their acute services to just one of those sites.

This is about accountability. Over the past 20 years a staggering £50 million has been wasted on almost identical consultations to reach the obvious conclusion: acute health services must be placed in the area where people are most deprived and most in need, and have the greatest health issues. They must be placed at St Helier hospital’s current site. It does not matter how many brands or names the local NHS gives these proposals or how many marketing consultants are hired. Moving these health services would be catastrophic for my constituents, and catastrophic for south-west London.

What my local NHS fails to consider is this: if St Helier hospital loses acute services, my constituents will not turn to Belmont. The Minister will know Lavender, Cricket Green, Figges Marsh and Mitcham town centre. They will turn north to St George’s or east to Croydon, both hospitals that are already under extraordinary pressure. I told the Prime Minister only today of the case of my constituent who had to queue outside St George’s hospital last Monday because the A&E was simply full. Two weeks ago, St George’s was on black alert. It had no beds. The managers had to cancel all meetings and walk around wards, attempting to get people discharged. Those pressures exist even before the winter bad weather starts and before the flu epidemic that we are anticipating.

I could not possibly have emphasised any more strongly to my local NHS that its statistics and suggestions that people will move from London and parts of my constituency to Belmont are simply not going to happen. In all the years I have been fighting this, nobody in the NHS has ever said anything publicly to support my view, until the week before last. I could not believe it when the chair of St George’s NHS trust wrote a letter that argued:

“There is no formal requirement to take account of the impact”

of its proposals on other providers.

Let me make this clear. Moving acute hospital services from St Helier to Sutton could bring St George’s hospital to the point of collapse, yet those consulting on these proposals were not even taking the inevitable impact on other hospitals into account. Is there a code of guidance on consultation in the NHS? It does not seem that people in south-west London have read it. Take last year, when the same consultation was run, this time by the hospital trust itself, and was called “public engagement”. To the public, the trust portrays a neutral stance and says a suitable site will be selected across south-west London for its services. To the stakeholders in Sutton, it confesses its desire to move the services to their wealthy area. To me, it pretends that the consultation will genuinely seek the views of the public, before it happens to ignore the fact that the consultation receives six times as many negative responses as positive ones.

I was not surprised, given that—this is hard to believe—Epsom and St Helier University Hospitals Trust delivered the consultation document to most parts of Sutton and most parts of Epsom, but not a single street in my constituency; and that is called a consultation. I ask the Minister whether he thinks it is appropriate for an NHS body to run a consultation or an engagement and simply exclude part of the catchment area. Better to deliver no leaflets at all than not to include everybody.

Fast-forward to the latest attempt, where flawed consultation documents are created so that boxes can be ticked and the process can move along more and more quickly. The latest versions argue that Belmont is the deprived area locally, but, staggeringly, the same documents suggest that Pollards Hill is outside the catchment area for the Epsom and St Helier trust—something that will come as news to Wide Way, the largest GP surgery in Pollards Hill, which sends 35% of its patients to St Helier hospital. The trust claims to be neutral about sites, but when I secured £267 million from the Department of Health and the Treasury under both the Labour Government and the coalition Government to rebuild St Helier, guess what happened? The local NHS sent the money back; it did not want to use it.

It seems that every step forward comes up with a new consultation involving closed meetings that unswervingly fails to take account of health inequalities, which I understand is a legal requirement for the NHS. The trust ignores access to the site, public transport and percentage of car ownership, and we make no progress. For me, the last 20 years as the MP for Mitcham and Morden has been like being in the film “Groundhog Day”. Every month there is something, and we can absolutely rely on the fact that every July some bit of the south-west London NHS will want to come up with a consultation to move acute services from St Helier hospital. I simply want to put a stop to it. I want the staff at St Helier to know they have a future, and I want my constituents not to be worried about how they will access an A&E.

I thank the hon. Member for Warrington South (Faisal Rashid) for bringing the debate. It is a pleasure to follow the hon. Member for Mitcham and Morden (Siobhain McDonagh). The Minister will not be able to answer all my questions because, as everyone knows, health is devolved to Northern Ireland. However, I will illustrate the issues with NHS reorganisation with some stories from the Province. The Minister has a close parliamentary aide from Northern Ireland, so he knows a wee bit about Northern Ireland.

I thank the House of Commons Library for the help it always gives us. Sometimes its information is enormously helpful, and today is one of those days. I have listened with great interest to the contributions so far; it is clear that, no matter the make-up of the constituency—whether Strangford in Northern Ireland, Mitcham and Morden, Warrington South or constituencies in Glasgow, Cardiff or wherever—there are issues. The NHS is struggling UK-wide, and either the pressure goes or its ability to treat will go. We are caught betwixt those two.

I welcome the Government’s commitment to spending £20 billion extra on the NHS, which is a credit to them. My constituency is on the seaside, and lots of people head that way to retire; I suspect things are the same in many constituencies. Our elderly population is growing, and the future demand on healthcare will be enormous. That is why the £20 billion that the Government have set aside is so helpful—because it gives a golden opportunity to plan ahead. The hon. Member for Warrington South was clear about where that should go.

The Library briefing—I am sure that the Minister has had chance to read it; I know that other Members have—contains six simple lessons from the Nuffield Trust, which are very helpful.

“Lesson 1: Avoid the temptations of a grand plan”.

This refers to the complex and heterogeneous nature of healthcare. We all know that it is complex; that is the very nature of healthcare. There are no one-size-fits-all policies that can address the issues. There has to be more than that.

“Lesson 2: Listen to the public—and don’t pretend you will if you won’t”.

As elected representatives, we know how these things work. When constituents come to us and tell us a problem, we listen intently and respond accordingly. This debate will hopefully be an occasion when we can do just that.

“Lesson 3: Don’t treat the workforce as an afterthought”.

It is very important that the workforce are part of a focused reorganisation plan. With the input of the workforce, there is a way forward.

“Lesson 4: Make sure the funding follows the plan”.

If funding commitments are made, they should be in there.

“Lesson 5: Don’t overrate structural reorganisation”.

In other words, it will not be sufficient to add more to the system that is operating on its own without building that structure up.

“Lesson 6: You need a plan your staff can follow”.

Create a policy and strategy that staff can get behind and support. The best way of doing that is to make sure that staff are involved in the creation of the plan, with staff values reflected in targets. All those things are vastly important, and I know that the Minister, who is a compassionate man and understands the issues well, will be able to respond even to the very generic terms that I put that in.

For Hansard and for the record, I will highlight an issue that I know is important across the whole of the United Kingdom of Great Britain and Northern Ireland: GP out-of-hours services. I emphasise the importance of that service, but we have particular problems with it in my constituency of Strangford. Part of any strategy or plan for NHS reorganisation should look at that.

My local health board is the South Eastern Health and Social Care Trust—clearly, not the responsibility of the Minister—which covers my entire constituency. On selected days just last month, the GP out-of-hours service in the main town in my constituency, Newtownards, had to close because it was understaffed, and there are particular reasons for that. People could either follow the advice and go to the nearest South Eastern Trust facility in Downpatrick, some 40 minutes away from Ards—for those who dare to live in Portavogie in the Ards peninsula, not that far from me, it is an hour and 20 minutes—or they could go to the A&E department, which was standing room only. The choice puts massive undue burden on an already drowning service.

I suggest to the Minister—as I have suggested at home; I think it would be helpful—that, whenever GPs commit themselves to operating an out-of-hours service, there may need to be another method of addressing the issues of those who use the service. For instance, why not have a staff nurse to treat minor ailments, taking pressure off the GPs? There are ways of doing things. There does not always have to be a GP there. GPs are predominantly overburdened; they certainly are in my constituency, and I suspect they are everywhere else as well.

I will give the example of my parliamentary aide from just last week, which I believe, unfortunately, is the tip of the iceberg. Her daughter, who has just turned three, is treated in an asthma clinic. She had an extremely high temperature that would not come down to the normal range and which had been going on for nearly two weeks. Her little body fought so hard to control the infection that it was going through that her breathing rate was double what it should have been. The out-of-hours service was rung, and four hours later the call was returned—a long time when the mother and family are getting panicky. The child was lifted out of sleep and brought to a waiting room full of other children who were equally unwell.

Had the service not been able to sound out her lungs, she would have had to travel to the Ulster Hospital, which she ultimately had to do the following week, as her ear infection burst an ear drum. Unfortunately, she is one of many. My aide met doctors who were harassed—not because they were nasty people, but because of their workload—but doing the best they could. When she asked whether there is insufficient funding to pay for out-of-hours care she was told that there is insufficient desire. How do we inspire doctors to be part of the out-of-hours service, which can only function with GPs who want to be part of it?

The new remuneration system came into operation in Northern Ireland in 2003. Although the system was designed to give GP practices much more flexibility on how they deliver services, allowing them to choose how to organise patient care and rewarding them for the quality of that care, the introduction of the new general medical services contract also allowed GPs to opt out of providing out-of-hours services, leaving the system essentially on its knees.

The fact is that the A&E in the Ulster Hospital in Dundonald simply cannot cope without the service. The fact is that nursing homes that rely on GPs coming out to drivers into patients who are in agony and pain, or to call time of death, need the service, as do parents who need someone to sound out the chest of their asthmatic child without being subjected to a four-hour wait in a room with ill, injured and drunk people in the middle of a cold winter’s night.

The service is vital. I read a report in July this year that referred to Wales as having similar circumstances and similar difficulties with their GP service. I am interested to know whether the shadow Minister or the Minister are aware of similar circumstances across the UK mainland. I suspect any MP in touch with their constituents, as we all are, will be able to replicate the stories that I am telling.

I very much respect GPs and the hard work that they do and their right to a social life. No longer do we expect the village doctor to be on call every day and night, but we need them to be available. There are no longer enforceable contracts, and I believe that, in any new NHS reorganisation or strategy, we must find another way of operating the out-of-hours service that gives the care that our constituents want at the times that they need it, which is usually out-of-hours or whenever they are under pressure.

I spoke very recently to a recently retired GP. He had been doing the night shift four nights a week, but realised that that was too much and pulled out. Perhaps if he had been asked to do only one or two nights, he would have stayed. Too much has been asked of too few people. We need to ensure that funding and people are available.

I know he will be mortified, but I am going to name one local GP, because he is a very popular and well liked GP in my constituency. Dr Doyle has his own practice and can be found a lot more than is right, and than is probably his duty, in the out-of-hours surgery. He makes time to help his patients by writing support letters for personal independence payment and employment and support allowance applications and he genuinely cares. I am not saying that others do not care; I am picking out this man as a representative of what happens. I look at Dr Doyle and wonder how much longer he and others like him can possibly continue. We need to spread the burden through the area.

I would urge the Health and Social Care Committee here to look at what is happening with the out-of-hours service, see the good that it does and perhaps look at a different way in which the out-of-hours provision could work. The Select Committee on Northern Ireland Affairs, on which I serve as one of the members from my party, is doing inquiries into many things, and one of them is health. People from Northern Ireland with a knowledge of and interest in health are coming here to make presentations to the Committee. And one thing that crops up is the out-of-hours service.

The question is how we adjust to the demands on the health service for the future. I started my comments by saying how much I genuinely welcome the £20 billion that the Government have set aside. We will get some of that through the Barnett consequential, so we are very pleased, but I see the needs in my constituency among the elderly population. I am also very keen that there should be early diagnosis and that preventive steps should be taken in delivering a health service for the future. If we do that, we will be doing the right thing. We must not just react all the time. Let us have a strategy that looks forward and aims to prevent things happening.

I am a type 2 diabetic, and many in the House are, as it turns out. Our Prime Minister is a type 1 diabetic. We all live with our particular ailments. But how much better would it have been if I had known about my condition earlier. I suspect that I was a diabetic for perhaps a year before I was diagnosed as one. I did not know at the time what the issue was. It was only when I went for a check-up with a doctor that I suddenly realised when he told me what was wrong. That makes me wonder whether there are steps that we can take for education, awareness and prevention. That is what we should be doing.

The Northern Ireland Affairs Committee will come to a conclusion in our inquiry on the health service in Northern Ireland, but I will conclude my speech today with this point for the Minister. The problems that I have referred to are specific in some cases to Northern Ireland and to my constituency in particular, but I believe that problems exist UK-wide and therefore that the response must be UK-wide as well.

Order. I think that there will be a vote imminently. If so, we will break for 15 minutes and get back as quickly as possible.

Thank you, Mr Gapes. I am sure hon. Members will be keen to return for the remainder of my speech, however long that turns out to be. It is of course a pleasure to serve under your chairmanship.

I congratulate my hon. Friend the Member for Warrington South (Faisal Rashid) on securing this extremely important debate. It is also very timely as we eagerly await the NHS long-term plan. He made a powerful case about the weaknesses in the Government’s approach and the disgraceful lack of parliamentary oversight of very significant changes to local and national services. I agree that the creation of the NHS was one of the great achievements of this House and this country.

My hon. Friend was right in his analysis of the Health and Social Care Act 2012. He highlighted his concern about accountability in CCGs and the potential for conflicts of interest in them. He also highlighted the lack of transparency that has characterised the STP process since its inception, and he summed up the benefits, from the patient’s perspective, of good integration —of course, no one wants to have to repeat their story on multiple occasions.

My hon. Friend talked about the challenges that the NHS faces with its infrastructure. He will know that those challenges have been exacerbated by the continual capital raids on budgets. His analogy about a football team was amusing—sadly, my own team appears to be taking things rather too seriously at the moment—but it did sum up a lot of the confusion and the illogical approach that we have to healthcare in this country. He was of course right to say that the hard-working staff of the NHS bear the brunt of these many pressures. He also made the point that many of the changes that we have been talking about have not been made in the most open way.

We also heard from my hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh). She followed up her question to the Prime Minister with a much more detailed, and devastating, critique of the proposals that affect her constituency. I was staggered to hear that £50 million has been spent on consultation so far. It was also disturbing to hear how bad things are at her accident and emergency department now, before we enter the real depths of winter. I was staggered to hear about the approach to consultation there. I am sure the Minister will want to address that. [Interruption.]

Sitting suspended for Divisions in the House.

On resuming

Before we were interrupted by important business in the Chamber, I was referring to contributions from other hon. Members. The hon. Member for Strangford (Jim Shannon) gave his perspective from Northern Ireland, and set out clearly what a proper consultation should look like—a standard that, as we have heard, is not really being reached by the NHS at the moment. He also raised issues with the GP out-of-hours service. That is slightly beyond the scope of the debate, but he is right to say that the issue covers the whole United Kingdom. Indeed, recently there have been numerous newspaper reports about people having to wait for many weeks to get a GP appointment.

Looking at current NHS performance, it is clear that, on all key performance measures, as my hon. Friend the Member for Warrington South said, the NHS is struggling to keep up with demand. A&E performance is at a record low this year. More than 4 million people are stuck on waiting lists, and cancer targets are being repeatedly missed. This has led to the Government effectively giving up on trying to meet the NHS’s constitutional targets. As my hon. Friend said earlier, waiting lists for operations are likely to hit 5 million people within the next three years. While the eight years of a financial plan that has failed to keep up with demand have clearly been a driver of that failure, it is also clear that the 2012 top-down reorganisation has exacerbated the issues that the NHS faces.

We have been left with a fragmented, marketised system, which prevents the kind of transformation and integration of services that we would all like to see. At a time when everyone is calling for various parts of the health and social care sector to work together, we remain bound by legislation. As my hon. Friend said, it is this legislation that enforces a siloed, market-based approach, which imposes statutory barriers to integration.

Against this backdrop we have seen a whole series of acronyms encapsulating a range of reorganisations to health services, including STPs, ACOs, ACSs, ICPs, ICSs and so on—all part of what the Health and Social Care Committee has described as a culture of

“changing titles and terminology, poorly understood even by those working within the system.”

It is all clearly an attempt by NHS leadership to reverse the impact of the Health and Social Care Act 2012 by any means that do not require primary legislation or parliamentary oversight. These reforms could have wide-ranging impacts, from causing walk-in centres, cottage hospitals, maternity centres and A&Es to relocate or close altogether, to introducing a new form of 10-year contract, which raises the spectre of private companies once again running our local health services.

I know the Government are not particularly fond at the moment of testing the will of the House, but something as fundamental as transforming our most treasured asset clearly should not be taking place without parliamentary consent. Ministers and NHS leaders are tiptoeing around the 2012 Act, but if we are to have meaningful proposals and an effective integration process, we need an admission that that legislation has had its day. To all intents and purposes, the 2012 Act is no more; it has expired and gone to meet its maker. Yet the Government refuse to acknowledge that central fact.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others a vast and unwieldy network of commissioners and providers with completely different approaches was put together at very short notice. The only beneficiaries of that process seem to be the private consultants who were drafted in to complete these hastily arranged plans. Professor Chris Ham has pointed out that

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Despite the fact that plans were designed to cover the period from October 2016 to March 2021, NHS England and NHS Improvement said in a letter to local leaders last month that sustainability and transformation partnerships and integrated care systems will be expected to develop and agree their plans during the first half of 2019-20. Will the Minister update us as to how many of the 44 STPs developed as part of this process have, as NHS Providers puts it, had no further work done? What was the cost of developing those plans? Can the Minister justify forcing the entire health and social care sector to stop what it was doing and embark again on a hasty and expensive process to come up with new five-year plans, only to be asked to do the same again a few years later? In the few local areas that have proceeded to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean.

The accountable care organisation—now rebranded as integrated care provider—process has the potential to radically alter the entire health and social care landscape, but, again, it is continuing without any parliamentary legislation. One of the primary concerns about that new model is that it would be compulsory to advertise the contracts to the market, and commissioners are forbidden from discriminating between NHS and non-NHS bidders. Bids can be made by a group of organisations, so an NHS trust or a group of GPs could partner with a private company. Previous high-profile attempts to do this kind of thing in Staffordshire and Cambridge collapsed spectacularly with millions of pounds wasted. As my hon. Friend said, it is also deeply worrying that one of the criteria used to assess bids will be whether they are able to deliver value for money. That marks a significant change to the status quo, and one that I do not believe should be countenanced without new legislation.

I have heard Ministers speak on several occasions to assure those of us who have concerns that this will not see mass privatisation. However, during the debate on integration in September, the previous Health Minister, now the latest Brexit Secretary, was asked four times by Conservative, Scottish National party and Labour Members to expressly rule out new organisations being run by the private sector. He failed to do so on every occasion he was asked. Is the Minister now prepared to give that kind of assurance, and if not, why not?

It is also less clear what will happen in the event that an ICP ends up in deficit, particularly if a private sector organisation or a charity has won the contract. While the consultation document sets out that efforts will be made to ensure that ICPs are financially viable, the same assurances have been offered about the existing configurations, and almost half of all NHS providers were in deficit last year. That has led us to the disastrous situation where, according to the 2017-18 accounts published by NHS Improvement, NHS providers owed the Department of Health and Social Care more than £11 billion, up from £8.1 billion in the previous year. That sharp increase was a result of bail-outs given to trusts that ran into deficit as a result of underfunding. Borrowing from the Secretary of State now exceeds private finance initiative liabilities. In 2016-17, £1.3 billion was repaid from trusts to the Department, of which £161 million was interest. Can the Minister set out what will happen if an ICP reaches financial deficit or collapses?

One thing that is clear from the draft ICP contract is that if the annual budgets provided are not sufficient to deliver the current levels of service, the ICP will be responsible for “managing changes in demand.” While there are merits in a system that incentivises keeping people well, there is a clear danger that demand will be managed by rationing access to treatment. Will the Minister rule out unilateral rationing of services by ICPs if they cannot keep to their budgets? What safeguards are in place to prevent further rationing of services, and who will be accountable in the event that patients want to challenge such a situation? It is far from clear who will ultimately make these decisions and who will be accountable for them. Where the split between the legal commissioner and provider is technically maintained, it is impossible to see in practice how an ICP would not be taking on core commissioning functions.

All this raises the spectre of a new postcode lottery, where patient experiences are uneven depending on who was contracted by an unaccountable panel of commissioners. The whole approach is farcical, and none of this has come before the House for what could be described as a meaningful vote. Experts from across the health and social care sector, and even the chief executive of NHS England, have all acknowledged not only the desirability, but the inevitability of new legislation. Will the Minister commit as part of the NHS long-term plan to set out in full the direction of travel for NHS reorganisation, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for the necessary primary legislation?

It is a pleasure to serve under your chairmanship, Mr Gapes. It is a pleasure to respond to the hon. Member for Warrington South (Faisal Rashid). I am pleased that he secured this debate, and I agree with him that the NHS is a great credit to our country. I know that the Opposition spokesman will have heard me say yesterday—I will repeat it—that the Government and I, as Minister for Health, greatly value the staff who work in the NHS. It is our absolute intention to ensure that they recognise that and that we continue to show that.

I want to start with a few facts, because having listened to what the hon. Member for Warrington South described, I think there are other things that are worth pointing out. There are 11,000 more nurses in the NHS than there were in 2010. There are 18,200 more doctors than in 2010. Almost nine out of 10 patients are seen within four hours in an emergency department. We are committed to 5,000 training places for doctors in general practice—this year saw 10% more than we aimed to achieve. Of course, this is the highest level of funding that the NHS has had in its 70 years. The hon. Gentleman raised a number of other issues, as did the Opposition spokesman, and I will try to respond to those in my speech.

The hon. Member for Mitcham and Morden (Siobhain McDonagh) made a contribution. I have immense respect for her. Anyone who knows her knows that she always argues her case passionately and stands up for her constituents, and she did that again today. She and I have occasionally shared joint endeavours on St Helier Hospital. I think we both agree that there is a substantial case for keeping the acute services there. I think we would both agree—I say this in a constituency capacity—that the infrastructure needs upgrading, and I think we have had that discussion. She rightly points that we have had another consultation this year. As a Minister, I say that we expect any significant service changes to be subject to exactly the full public consultation she has described, if it is going to happen, and that the proposals must meet the Government’s four reconfiguration tests, which are support from GP commissioners; strengthened engagement with the public; clarity on the clinical evidence; and clarity and consistency with patients’ choice. She says that there have been rounds of consultations, as I certainly saw when I was on the council—I think she was already a Member of Parliament then—under Governments of all colours over the past 20 years.

It is the same with the hon. Member for Strangford (Jim Shannon). I have had the pleasure of taking interventions from him in several debates. He is always a powerful advocate for his constituents. I listened carefully to his point about out-of-hours care, which may have been slightly out of the scope of the debate. Yesterday, I had the chance to visit the North Middlesex University Hospital. Some of its work on the integration of out-of-hours care and triaging in A&E moves along the lines that he discussed. I have seen that several times.

To address the crux of the debate, between 2016 and 2036, the UK population is expected to increase from 65.6 million to 71.8 million, which is a growth rate of about 10% in 20 years. In the same period, the number of people aged 75 and over is expected to grow by 64% from 5.3 million to 9 million. Those figures are clearly something to celebrate, showing that the NHS is doing exactly what we want it to, but they mean that more will need to be done to make sure that those years are quality years.

For the NHS to continue to deliver high-quality care in the next 20 years, as it has done for the last 70 years, we need to look at new models of care that promote more joined-up care across the NHS and social care. In the past few years, the Government have supported a number of pilots at local and national levels to test new models of care that bring together the NHS, local authorities and wider public services to develop new ways of ensuring that services are delivered in a more joined-up way. Those areas have seen some improvements in access to services, patient experience and moderating demand for acute services.

It is time for the NHS to move beyond those pilots and embrace wholesale transformational changes across the whole system in every part of the country. It is therefore developing a 10-year plan for its future, which is underpinned by a five-year funding offer. To support the NHS in delivering for patients across the country, the Government announced a new five-year budget settlement for the NHS, in which funding will grow on average by 3.4% each year to 2023-24. The hon. Member for Strangford, who has just left the Chamber, welcomed the fact that that means the NHS budget will increase by more than £20 billion compared with today, underpinning the 10-year plan to guarantee the future of the NHS.

The hon. Member for Warrington South remarked on sustainability and transformation partnerships, and commented on his own local STP. The Government are fully committed to NHS England’s vision of STPs transforming how care is delivered and putting the system on a sustainable footing for the future. We will back STPs where they are clinically led and locally supported.

The hon. Gentleman questioned some aspects of local democracy. Each partnership has to set out agreed priorities and say how they are going to be delivered, and have a strategic priority to work with partners in local authorities. The Cheshire and Merseyside STP is making some progress in building those relationships, but he is right to acknowledge—I acknowledge it as well—that it is an extremely large and diverse area.

Clearly, the hon. Gentleman and the hon. Member for Ellesmere Port and Neston (Justin Madders) will recognise that there are now nine local footprints, including Warrington Together. The idea is that they will develop some of the integration suggestions and plans, and the consultation with local authorities to which the hon. Member for Warrington South referred. The STP brings local areas together to tackle the challenges, and I think he would acknowledge that it makes sense to do that across a bigger area, so the smaller areas build into the larger area.

Last week, the Government announced that they were supporting the Cheshire and Merseyside STP with £11 million in capital spending for improving emergency department capacity at the St Helens and Knowsley Teaching Hospitals and for a 12-bed, tier-4 child and adolescent mental health services unit at Alder Hey Children’s Hospital. The hon. Member for Ellesmere Port and Neston challenged me on STPs, so I will say that, in their more mature form, they are integrated care systems that promote collaboration between NHS bodies, local government and local communities. The 10-year plan will set out how they will spread the integrated care models that have been developed and tested through the whole vanguard programme.

There was also a challenge about what were formerly known as accountable care organisations and are now called integrated care providers, with several questions about that. At a small number of sites, commissioners are looking at how contractual models can support more integrated care. To support that, NHS England has developed the draft integrated care provider contract which, if introduced, will give the NHS the option of having a single lead provider that is responsible for primary, community and hospital services, with the aim of integrating services across traditional silos.

If NHS England chooses to introduce a contract for the ICPs, Parliament will have a chance to debate the regulations. I recognise that the regulations are subject to the negative procedure, so there is not an automatic debate, but as the hon. Member for Warrington South will have spotted, in those circumstances, if Parliament decides, there will be an opportunity to have that debate. NHS England has recently concluded the public consultation on the draft ICP contract and we expect a response in due course.

I want to touch on the premise that the ICP contract is privatisation. It is completely misleading to suggest that an integrated provider model is a step towards privatising the health service. The NHS will always offer free healthcare at the point of use—that is not just the Government’s view. I am sure that the Library briefing that the hon. Member for Strangford challenged me to read notes the evidence from the Health and Social Care Committee, whose Chair, my hon. Friend the Member for Totnes (Dr Wollaston), said that the evidence received by the inquiry into integrated care—the report was published in July 2018—was that ICPs

“and other efforts to integrate health…and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”

That is quite powerful and I hope that the hon. Members for Ellesmere Port and Neston and for Warrington South take note.

I know what the Select Committee said; I am interested in what the Government are saying. Is the Minister ruling out any private provision from ICPs?

I am not ruling out private providers from bidding, but it has been made clear, and I say again, that we expect any ICP contract to be won by NHS bodies. As I said, the evidence to the Select Committee inquiry tends to support that that is our view and that is what is likely to happen.

The Government have made it clear that the change is not about reorganising the NHS from the centre or adding more layers to an already complex system. As the Prime Minister reiterated in her speech in June, the Government should learn the lessons of the past and not try to impose change on the NHS. To achieve that, we firmly believe that any changes to the model of care for patients need to be locally led, informed by knowledge of the population and the population need, and supported by clinicians on ground.

That is why we have asked local leaders in STPs and integrated care systems to create five-year plans detailing how they will improve local services for patients and achieve financial sustainability. Of course, this is something that we may want, but it cannot just be wished into being, which is why the Government are supporting the NHS with £20 billion of additional funding.

Local plans will build on the work of the last three years to develop new ways of delivering services and enhance collective efforts to use that additional funding to improve people’s health and wellbeing. It is essential that that process proceeds in a spirit of genuine partnership and that all local partners, including local government, are fully involved from the outset.

For any significant system reconfiguration, we expect all parts of the system to be talking to the public regularly; it is vital that the public shape the future of their local services. That relates directly to the point that the hon. Member for Mitcham and Morden made earlier. To make it absolutely clear, no changes will take place without public consultation and engagement.

After all, the aim of integrating services is not an end in itself; it is to improve the patient experience and quality of care, so it is essential that the views of the public should be at the heart of local plans. Integrated care means a health and care system built around people’s needs, whereby physical, mental and social care needs can be addressed together, and patients should feel as if their care is being provided by one organisation.

Integration also gives us the means to avert ill health, preventing unnecessary hospital visits and supporting patients to have happier, healthier lives into old age, and taking the pressure off NHS staff. For example, in Thanet, the Margate Task Force is an integrated service that brings staff from 16 different agencies together in a single “street-level” team.

In conclusion, integrated care provides the best opportunity to ensure that the NHS continues to deliver the highest level of quality services to people and to meet the demands of the 21st century. The Government have supported the NHS to implement the five-year forward view and to develop new integrated ways of working to meet those demands. It is now time to drive those initiatives and spread them across the whole country. That is why we are committed to those plans and it is why we have committed to increase the NHS budget, to support the national move towards integrating care.

First, I thank all the Members who took part in this very important debate: my hon. Friends the Members for Coventry South (Mr Cunningham), for Mitcham and Morden (Siobhain McDonagh), and for Ellesmere Port and Neston (Justin Madders); and the hon. Member for Strangford (Jim Shannon). I also thank the Minister for giving some reassurances and the answers to some of my questions.

I will make a couple of points. I have heard time after time that there are more doctors and 11,000 more nurses than there were in 2010. Clearly, the demand has been even greater, which is why there are still shortages. We really need to invest in more doctors and more nurses, to cope with the demand for them, which is quite significantly higher than the numbers from 2010 to 2018 that the Minister cited. The numbers do not really make sense. The Minister also mentioned value for money. He said that there was no privatisation as such, but he is not ruling it out. At the same time, if value for money is the criterion, one will definitely think that privatisation will happen.

In conclusion, the NHS is a very precious institution for all of us; the Minister agreed with me about that. I urge him to look very carefully at reorganisation and to get everybody involved. Let us work together to make it happen for the people of this country in the long term.

Question put and agreed to.


That this House has considered NHS reorganisation.