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Primary Care: North Essex

Volume 623: debated on Tuesday 14 March 2017

[Mr Philip Hollobone in the Chair]

Order. Would those who are not staying for the debate please leave quickly and quietly? Television sets are being switched on all over Essex to hear the hon. Member for Clacton (Mr Carswell) move the motion and start his debate. I call Mr Douglas Carswell.

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.

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.

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.

I am most grateful to the hon. Gentleman for inviting us to take part in his debate, and I commend him for securing it. We are now in the throes of the so-called sustainability and transformation plans, which are being constructed on the acknowledgment, confirmed by the Boston Consulting Group, that there has been underinvestment in primary care in Essex for 20 or 30 years. If the STPs are to address the demand on the primary care units and deal with the shortage of GP facilities, there has got to be a programme, supported by Ministers, of investment in primary care in Essex so that the GPs can do far more for their patients without sending them off to hospital.

The hon. Gentleman is absolutely spot on. This is a cumulative problem that has been allowed to get worse over decades—perhaps a generation or more. I am often struck by how some of the GP surgeries in my constituency are located in what started out as residential houses built in the 1930s. There has simply not been the investment that was needed over a long period of time. That is also part of the problem. To be fair to GPs, if we do not provide attractive surroundings and surgeries, people are not going to want to work in those 1930s houses. If anyone in the district council is listening, I urge them to take that into account when talking about new planning for the area. Some top-quality, first-rate surgeries in which GPs are happy to work would go some way to addressing the problem.

I am incredibly grateful to the Minister for coming along to respond, and to the hon. Members for Harwich and North Essex (Mr Jenkin) and for Colchester (Will Quince), who are committed to this issue and have done a lot of work for their constituents. I hope to hear from the Minister not only about how we can get more GPs in our area but about the reforms we need to change the way people obtain primary care, so that they are no longer supplicants standing in a queue to receive care on the system’s terms but valued patients who get the care they need when they need it.

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.

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?

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.

A moment ago the Minister mentioned some extra money for primary care. Who is responsible for investing that money? Does it come from NHS England and not from the CCG? How do we influence how that money is spent, so that there is some accountability in the process?

All money goes into the health service through NHS England, which used to be called the NHS Commissioning Board. The money is then given to the CCGs around the country to spend. In terms of a funding formula and so on, there are some specific primary care initiatives, including infrastructure-based ones for new premises and things of that type, and specific ones, which I am about to talk about, such as recruiting more GPs. We absolutely need more GPs, not only in Essex but across the country, although we do need them in particular in parts of Essex. The responsibility for that lies with NHS England, through the CCG. It is the CCG that has the accountability—to answer the earlier question, “Who do we blame for this situation?”—and I want to make that quite clear.

As for what all that means, we have workforce issues in primary care, and the Government and NHS England are committed to having 5,000 more doctors working in primary care by 2020, which should mean more availability and vacant jobs in Clacton being filled. We are determined to meet that commitment with progress made this year, with more medical students going into GP training than has ever been the case before in the history of the NHS—just over 3,000 of them. The hon. Member for Clacton was right to talk about pharmacists, and we also need to make progress with them. We aim to have 2,000 pharmacists working in primary care by 2020, as well as 3,000 mental health therapists.

All of that matters, but in addition we have to allow people to work in a different way from how they have up to now, and some of that is happening across the CCG in Essex. Broadly speaking, however, we find that a GP hub of 30,000 to 40,000 patients enables more scale. That would let us employ physios, pharmacists, mental health therapists and, indeed, social workers—in terms of the relationship with hospitals and the transfer of patients—and to have longer opening hours. I therefore completely accept the hon. Gentleman’s points about working and being open on a Saturday. We are determined to achieve that by 2020, although we are starting from a difficult position in Essex, given the lack of GPs generally. Only by collaboration and working across practices will we make progress. The model of a single GP practice—and such practices still exist—is self-evidently not viable and does not allow us to do some of the things that we need to in primary care, such as employing pharmacists and other such disciplines.

Those are my general comments, but I completely agree that unless all that lands in Essex, it is just words. Judge and jury on it will be the extent to which we are successful in landing some of that stuff in Essex. To address the specific issues, I will now talk about a number of things that have gone on in the hon. Gentleman’s local CCG. Of the nine practices in Clacton, a number have been closed to new patients, as he said. I am informed that the East Lynne practice, the Ranworth practice and the St James practice all closed to new patients in 2015, but two of those are now completely opened. The other has temporarily closed again but is expected to reopen soon. On the statistic he cited at the start, my understanding is that only one practice in Clacton now has no immediate opening in its list. The CCG has worked hard on that.

There are clearly specific issues with getting people with a GP background to move into the area. The CCG has put in place a workforce plan to address matters of recruitment and retention of GPs principally, but also of pharmacists, nurses and allied health professionals. Again, the judging of that will be in something actually happening and the vacancies in Clacton being filled. The plan exists and is being managed, and I understand that the CCG expects to make progress with it.

The practices in the CCG have come together in three collaborative groups, covering about 80% of the total number of patients seen, although the patient who sees the same GPs from the same practice and goes to the same clinic might not realise that. GPs are working collaboratively in a way that should enable better leverage of their time—I return to that point made in connection with pharmacists. We have to get away from every patient’s principal contact in the primary care system having to be a GP, rather than other professionals who could help a great deal. For example, I was recently in a practice where a pharmacist was conducting a diabetes clinic. Diabetes clinics are routine, happening perhaps every month or so, with a set of standard questions to be asked, and there is absolutely no reason why they need to be conducted by a GP, as opposed to a pharmacist. That applies in Essex, too.

I draw the attention of hon. Members from Essex to a couple of grants lately given to practices in their area. A £46,000 resilience funding grant has gone to the Clacton GP Alliance and, in a specific effort, almost £400,000 of capital funding to three GP practices that are coming together I think in Clacton hospital. The CCG understands that the standard of premises and infrastructure in Clacton is generally weaker than in other parts of the country—certainly weaker than is needed to attract the sort of talent necessary.

I have a “jam tomorrow” point to make, but it is worth putting it on the record. There is a plan to have a medical school in Essex, in Chelmsford, I think in 2018. That will obviously help, because people who train as doctors in that part of Essex will be more likely to live there, enjoy living there and, in time, make their careers and lives there. We have found that to be so in other parts of the country; I hope it works for Essex.

In connection with the minor injuries and walk-in centres, I want to speak briefly about the consultation. Members have pointed out that it would be absolutely ridiculous if, by closing those centres or doing anything to affect patient flows, more patients were to go to Colchester hospital. That is self-evidently true, and the CCG believes so too. Interested Members will know that the consultation, which set out four options, has received more than 3,500 replies. In all fairness, I do not believe that the CCG was consulting in order to close; it was consulting because contracts were up, and it wanted to look at the options and how to do better. One view given to me was it was more confusing than it ought to be for patients to know where they ought to be.

I cannot say anything today about the outcome of the consultation, other than that the CCG board will consider the recommendations received in the 3,500 responses and the various other pressures that have been discussed today. Frankly, people in the CCG will also be listening to our debate today. I would be surprised if closure of the centres was top of the list, given the other pressures on GP practices, the hospital and so on. The decision will be made by the CCG at the board meeting on 30 May.

I will finish as I started, by saying that there is a problem with the number of GPs in Clacton and North Essex. The problem is understood and action is being taken that I hope does not all amount to “jam tomorrow”, to use the phrase of the hon. Member for Clacton. Although progress has been made in getting lists open and so on, clearly a lot more needs to be done. I am happy to continue to meet the hon. Gentleman in the months ahead if we are not making progress and getting things better.

Question put and agreed to.