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Healthcare Optimisation Plan: Kirklees

Volume 633: debated on Tuesday 12 December 2017

I beg to move,

That this House has considered the healthcare optimisation plan, Kirklees.

It is a pleasure to serve under your chairmanship, as always, Mr Hollobone. As is now widely acknowledged, our NHS is under ever-increasing pressure, and budgets are stretched beyond capacity in almost every part of the country. In my area of Kirklees, we face unprecedented cuts and challenges. Both of the local hospitals that serve my constituency have been subjected to downgrades and the closure of vital services.

The financial challenge in health services across Kirklees is unprecedented. There are reports that deficits are forecast to reach record levels by the end of this financial year. Sadly, that is mirrored across the country as a result of the Government’s onslaught of cuts to our public services. To be frank, our NHS is being starved of money to the point at which lives are being put in danger, and financial decisions are being given priority over clinical judgments. Every day, we see the pressure that the NHS is under. Hospital waiting times are up, it is harder than ever to get a GP appointment, ambulance waits are increasing, and hospital wards are seriously understaffed. As the weather turns to freezing, we are all fearful of a repeat of last year’s winter pressures, when people were dying on hospital trolleys, waiting to be seen.

Only this week, the highly respected Lord Kerslake resigned his post as chair of King’s College Hospital board, claiming that NHS funding desperately needs a rethink and that the demands for savings are unrealistic. That came on the back of comments from NHS England’s chairman and its former national medical director, following their disappointment that sufficient money was not made available in last month’s Budget.

The chairman, Professor Sir Malcolm Grant, said:

“We can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available.”

Professor Sir Bruce Keogh added his personal view:

“Budget plugs some, but”


“not all, of NHS funding gap”,

which would

“force a debate about what the public can and can’t expect from the NHS”.

He added that it was:

“Worrying that longer waits seem likely/unavoidable.”

In the face of such financial pressures, the two clinical commissioning groups covering my constituency, North Kirklees and Greater Huddersfield, have recently released plans to introduce what they refer to as a health optimisation programme, which would restrict access to elective surgery for those who smoke or who are obese. Make no mistake, whatever title is given to the scheme, it is nothing more than a thinly hidden attempt at rationing healthcare for those in need. Smokers would be given six months to quit, and for those who are considered to be obese—measured by a body mass index of more than 30—the requirement would be to lose 10% of their body weight within 12 months.

Does my hon. Friend agree with me that the use of BMI to classify whether someone is obese is, frankly, laughable? Does she agree that Greater Huddersfield CCG needs to look at an alternative measure that would not put Huddersfield Giants prop forward Sebastine Ikahihifo, whose BMI is 32.3, in that category?

I thank my hon. Friend and neighbour for her very valid intervention. I was just about to say that BMI is very subjective. As we are all aware, some high-performance athletes or bodybuilders have a BMI higher than 30 but are at the peak of health.

Obviously I agree that any moves to aid weight loss and stop people smoking are a good thing, but not at the expense of excluding people from NHS treatment. If the CCGs were so determined to achieve better outcomes in those areas, they would invest in better smoking cessation services and weight-loss programmes, but the reality is that in recent years those services have been among the ones to suffer cuts.

Given the budget restrictions and taking into account the views of the professionals, who advise that there is little if any evidence in support of any improved outcomes as a consequence of such measures, I can only draw the conclusion that the proposals to ration surgery are nothing more than a cost-saving exercise. The CCGs argue vehemently against that view, but North Kirklees CCG admits that health optimisation is one of 21 cost-saving measures identified to meet the existing financial challenge that might see its deficit rise well beyond predicted levels by the end of the financial year. At best, it seems to be an ill-conceived plan that has not been thought through correctly.

As anyone involved in healthcare knows, the providers and commissioners in any area often form a hectic Venn diagram. That is no different in the borough of Kirklees where my constituency lies. The two hospital trusts that serve my constituency are overseen by four CCGs. Of those, only three are considering and proposing to implement a health optimisation programme. That means, in effect, not only a postcode lottery but a waiting list for elective surgery—a smoker from Wakefield might be allowed on to the list while his or her equivalent in Dewsbury, some nine miles away, would be forced to wait six months before even being considered for surgery. That would be completely unjust, unfair and morally wrong. The irony is that those same two patients would have their surgery in the same hospital.

When reading further into the small print of how health optimisation would work, I became even more alarmed. The decision on whether people can be referred for treatment would lie initially with their GP. He or she is able to make the decision on whether to refer or to put the patient on the health optimisation programme. Patients put on the programme would have six months to quit smoking or 12 months to lose weight. After that time they would be referred to a specialist who would decide if they qualified for treatment. My understanding is that that means, in effect, people could lose 10% of their body weight in the hope of receiving a knee or hip replacement, for example, only to be told that they do not qualify for the surgery. Not only that, but one month from the end of the programme, patients are asked if they still wish to be referred. That is where louder alarm bells started to ring for me. It is absolutely clear that the decision on whether to operate, or whether the patient needs surgery, must be made by the relevant surgeon and not by people who do not have all the facts in front of them.

I ask Members to picture this scenario: Mrs Smith has been told that she has to lose 3 stone before she can be referred to a specialist regarding the pain in her knee. She tries to lose weight but finds it incredibly difficult, not least because her knee pain prevents her from exercising. Mainly being housebound affects her mental health, causing depression, which in turn leads to comfort eating. She tries to attend the weight management group that she was referred to but becomes disheartened and embarrassed when each week her weight either stays the same or increases, so she stops going. After 11 months she receives a letter asking her if she still wants a referral to an orthopaedic specialist to look at her knee. She knows that her weight has actually increased so she ignores the letter, because the thought of having to face up to her weight gain is far too humiliating. The pain in her knee is now excruciating, but she dare not face the surgeon when she feels such a failure. That could be a very real outcome if the plans are implemented. The NHS might save money and waiting lists could look far better, but what about the human cost? I implore the Minister to think about just that—the human cost.

A list of exceptions in the rationing proposals include: conditions that are immediately life threatening; patients who require emergency surgery or have a clinically urgent need where undue delay would cause clinical risk of harm; and patients undergoing surgery for cancer. Nowhere do the proposals mention any measure of the patient’s quality of life. I have heard stories from constituents who have had to give up work because their mobility has become so restricted while waiting for knee or hip operations, or whose weight has increased to levels of obesity simply because they cannot walk or exercise like they used to. How does naming and shaming those people on a rationing list improve their quality of life?

I also ask the Minister where the rationing ends. Is there a plan to stop providing surgery and treatment for, perhaps, people who play rugby, or teenagers who break their leg horse riding? Would we say, “No, you can’t have surgery, because your own actions led to this”? What about people who drink alcohol moderately? Would we say, “You cannot have treatment for your liver sclerosis because this is a lifestyle choice”? Is this the start of the beginning of a much bigger rationing programme?

In preparation for the health optimisation programme, Greater Huddersfield and North Kirklees CCGs stated that they had carried out a public engagement exercise. On research, I found the questions that they had asked, which included: “Please tell us how we could encourage people in Kirklees to live a healthy lifestyle?”; “Please tell us what support you think should be available to help people lose weight and stop smoking before their surgery?”; “When and how do you think that support should be provided?”; and, “Please use this space to provide any additional comments you have about supporting people to lose weight or stop smoking?”. Nowhere did the questions ask for opinions on whether people should be excluded from surgery because they are overweight or smoke. The CCGs’ failure to be up front and honest about their proposals can only indicate their embarrassment at having to implement such a scheme simply as a result of budget restraints.

Statistics show that approximately 30% of the population of Kirklees either smoke or have a BMI of more than 30, so almost one in every three people in my constituency could be turned down for elective surgery. North Kirklees and Greater Huddersfield CCGs acknowledge that there is not enough existing provision to support people being put on to the health optimisation programme, whether in smoking cessation services or weight-loss programmes. In the health optimisation programme proposal, the CCGs state that they will undertake a tender exercise for a

“‘Zero Value - Activity based’ contract with additional providers”.

What that means is anyone’s guess, but I strongly suspect that no new money will be made available, given the financial position of our local NHS services.

The plans have so many pitfalls that they simply must not be implemented, and the Minister can be sure that I will fight them every step of the way. Clinical commissioning groups should not face such intolerable choices. I do not believe that anyone delivering healthcare entered the profession to make cuts or to restrict people from receiving treatment that they desperately need to improve their quality of life. I therefore call on the CCGs to halt their plans to introduce the health optimisation programme for all the reasons that I have listed and many more. I ask the Government to listen to the experts, including the Royal College of Surgeons, to put an end to the draconian cuts and to provide us with a fully funded healthcare system that is accessible to all.

I would like to finish with a quote that I have used many times before, both in this Chamber and away from it. Nye Bevan, the founder of our great national health service, said that the NHS will last as long as there are folk left with the faith to fight for it. I will never lose faith or stop fighting. I hope that the Minister will say the same.

The debate can last until 5.30 pm. There is one Member who wishes to speak, and before the debate ends, Paula Sherriff will have three minutes to make her concluding remarks. The guideline limits on speeches are ten minutes for Her Majesty’s Opposition and ten minutes for the Minister, but I expect that they will be able to speak a little longer. I call Rachael Maskell.

It is pleasure to serve under your chairmanship, Mr Hollobone. I want to start by thanking my hon. Friend the Member for Dewsbury (Paula Sherriff) for making such a powerful case about why the health optimisation programme is failing the public, failing patients and failing all of us. Her contribution to today’s debate reminded me of the Adjournment debate that I brought to the Chamber on 28 February, which the Minister attended. My speech was parallel. That reinforces how urgent it is that this issue is addressed.

I am proud of so many things about York, but one thing I am really ashamed about is the way that it has gone about rationing healthcare. It was one of the first places to ration healthcare. When the Health and Social Care Act 2012 came in, it had to back-pedal, and then it stepped forward in 2016 in rationing healthcare, particularly surgery for patients who urgently needed it to be provided. There seem to be some key issues that we need to address that are not being addressed in the debate. I had a very helpful meeting with the Minister the other day, but there was little progress on the back of it. We need the Minister to make an intervention and not to say that it is a matter for CCGs to change their practices.

What is evolving is a massive postcode lottery across the country. My hon. Friend referred to a BMI of 30, which her CCG uses as an indicator to draw the line to provide access for surgery. I know that other CCGs use a BMI of 35. That absolutely demonstrates that this is not based on clinical evidence, but is about the financial expediency of CCGs. Therefore, it is absolutely crucial that we go back to clinical evidence when making decisions about patients. That is why we invest so heavily in our medical profession: to go through that training, to have the skills and the ability to do that. They are being completely undermined by these arbitrary figures that are being put into use for the basis of saving money. That is what this is all about, but they are not saving money, because people come back more poorly in future and require even greater resources. It may be save today, but it is spend more tomorrow. Surely that should not be the policy of any Government, let alone the one we have at a time when they keep claiming that there is not enough money.

It is absolutely crucial that the Minister intervenes because we are talking about a population with health inequality. All the demographics and the research show—I am particularly grateful for the University of York’s work on epidemiology—that there is a correlation between health inequality and social and economic inequality. The very people who are being denied surgery are the people who are most disadvantaged in society. There is a whole predication against those individuals. We know that there is a correlation with shorter life expectancy.

It is absolutely crucial that the Minister makes an intervention to improve the quality of life for these individuals. Therefore, although it seems that my hon. Friend’s CCG is attempting to do more than mine in the health optimisation programme, the problem is deeply concerning. This is not about health optimisation at all. I want to see the Minister step forward on a case of health optimisation. I absolutely agree that we have to address the obesity crisis in our country. Twenty five per cent of people are obese—that has an impact on the draw around diabetes and on other needs. I would welcome a health optimisation programme being in place in my CCG, but that is not what is happening. As I demonstrated to the Minister last week, patients in my constituency are being handed a letter that refers them to a website about some health programmes that may be far away—they are certainly not in our city because the local authority has cut them, such as the health walks. Therefore, individuals themselves have no choice about how to lose weight.

Looking at the issue of losing weight or smoking, I know as a clinician—as a former physiotherapist—those individuals need to be taken by the hand and walked through that journey, looking at all the markers around either their weight or their relationship with smoking. In the case of smoking, people need help to deal with an addiction. In the case of obesity or a high BMI, those issues need to be addressed.

I would welcome a health optimisation programme because that means that people will have a better life and they will probably not have the wear and tear on their joints. I welcome early intervention. We need to see that right through our school system, which is why I am worried about the massive fall in the number of health visitors, who could make those interventions at any early stage—as could school nurses, who have virtually disappeared—to enable people to have better, healthier lifestyles. I am particularly disappointed that the local authority withdrew the money from the NHS Health Checks, which enabled people to get their lives back on course from the age of 40 and have a healthier existence.

We fail people right through the system. At the point of crisis when they are in pain and needing surgical intervention, the system says to them, “No, you can’t access healthcare because of your behaviour over the years.” We have let people drift into that position. It is a completely failed system, which is causing individuals to be denied the surgery that they need. There is the complete nonsense of the amount of weight that people have to lose. People are told they have to lose 10%, but for somebody who is morbidly obese, 10% may take them down to the weight of somebody who is obese and who has to lose 10%. It is not a measure of a weight or a BMI figure at all. That is complete nonsense. Any clinician will absolutely recognise that this is a completely failed system. Therefore, I urge the Minister to make an intervention with the CCGs and to set the standards and the bar to enable clinicians to make the right decisions.

We had a discussion with our CCG in York and with the Minister about the programme. Obviously, we addressed the inadequacy of the healthcare optimisation programme, but we also talked about particular groups of patients who are denied treatment. Some people are on drug therapy that causes them to gain weight and are being denied the surgery they need. I gave examples of people with polycystitis, which has a particular impact on women, who are denied fertility treatment and the free surgery that would enable them to receive that treatment, because their condition is causing them to put on weight. That shows that the programme is discriminatory not only on grounds of economic status, but against women.

We have to look at the issue in the round. What we are trying to achieve? If we are trying to improve people’s health, let us put in the measures to achieve that, but let us ultimately move to a place where the right people in the system are making the decisions. Surgeons will not proceed with or recommend surgery if it puts someone’s life at risk. They know those parameters. That is what they are trained for, and they need to assess each patient in turn. I have had patients who have needed only an arthroscopy—an operation given under local, not general, anaesthetic—who have been denied surgery. We need to ensure that the surgeon makes the decision. No disrespect to GPs, but they are not specialists, and that should be a specialist’s call. I therefore urge the Minister to move clinical decision making to the right place in the health service and to ensure that surgeons, who have a responsibility to their patients, are able to put things in place.

Finally, I call on the Minister to look at NHS finances, which we know really drive the equation. We have had a bit of an exchange about that previously, too. We cannot ignore the driving factor. The Vale of York CCG in my area has done everything—it has put in the most draconian rationing system there is—but its finances do not add up. We have to be cognisant of what has happened at King’s College Hospital and the real concerns there, but CCGs up and down the country are wrestling with their finances. Public health is being cut massively by local authorities as they become risk averse, trusts themselves are in a desperate state as they gear up for a winter crisis, and the social care system is not working. We have real financial pressure.

In York, we have a capped expenditure process that limits CCGs’ choices. We need to be able to release the money to address the need. The NHS is not being fed the money it needs, and it is therefore in crisis. We cannot keep saying that it has to do more and there has been personal failure. This is becoming a national crisis, which is deeply concerning because, as my hon. Friend the Member for Dewsbury said, lives are at risk as a result. We cannot go to that place.

This is about funding. It was always going to be about funding. I remember having an exchange with Andrew Lansley about the funding formula back in 2011, when he was introducing the Health and Social Care Bill and I was head of health at Unite, to highlight this risk. I therefore feel it on my conscience. I raised these very concerns about the failed funding formula and the way that finances in the NHS work against each other rather than together. That is what creates these issues, so we can avoid them not only by ensuring that there is enough money in the system, but by ensuring that the relationship is right and the funding formula works in the right way.

In my exchange last week with the Minister, we talked about individuals in the system being able to put their hand up, in the light of the massive inequality they face and the big no on money, and say, “By the way, can I have an individual funding request? I don’t like the decision that’s been made, so I’m going to challenge what my doctor”—let us face it, doctors have stature in society—“has said and say, ‘Actually, I want to have an individual funding request.’” Making that point to a GP is a massive step, and it shifts the risk in a system that is there to care for people on to the individual patient—the smallest person in the whole health system. Patients have to say, against the weight of the system, “You got it wrong over my healthcare, and I want you to review that and put the money in,” when there is no money in the pot. That is a complete nonsense of the process. We therefore need to shift the debate back to putting the right funding into the NHS so that patients are not discriminated against and clinicians can make the choices they are trained to make.

It is a pleasure to serve under your chairmanship, Mr Hollobone. I pay tribute to my hon. Friend the Member for Dewsbury (Paula Sherriff), who has been an assiduous campaigner on health issues since her election to this place. She has fought NHS downgrades in her area and, as a former member of the Select Committee on Health, forensically scrutinised the Government’s health policies. She has rightly gained a colossal reputation across the House for her committed campaigning. Today, she has turned her attention to another extremely important issue, which, as we heard, affects not only her constituents but millions of people up and down the country, and made a typically strong case.

My hon. Friend is right to categorise this as a dangerous time. Financial priorities are taking precedence over clinical judgments. Her CCG has been candid about the health optimisation programme being one of 21 cost-cutting measures that it is required to introduce. She highlighted the absurdity of that policy with the example of two patients who would be treated at the same hospital but live 9 miles apart: apparently, one would be entitled to surgery and the other would not. She is absolutely right that the decision about whether to operate should always be made by the consulting surgeon. I know that some people in the Government do not have a great deal of time for expert opinion, but that is a clear example of something on which there ought to be unanimity about the way ahead.

My hon. Friend gave examples of the questions that the CCG asked during the consultation on the health optimisation programme. As she said, nowhere was there a question about that very policy. As my hon. Friend the Member for York Central (Rachael Maskell) said, denying surgery is a draconian measure and an important matter. It was a real abdication of responsibility by the CCG not to ask that specific question but to couch it in general terms. What can the Minister do to ensure that the standard of consultation by CCGs is such that we can be assured that the resulting decisions are robust and supported by the public? What is the Government’s view on the consultation standard that is currently used throughout the country?

My hon. Friend the Member for York Central also said that the public and patients are being failed, and highlighted the fact that other CCGs use a different BMI level. Indeed, my CCG uses a different one again, which highlights the totally arbitrary nature of these policies. She was absolutely right to say that people need help to stop smoking and lose weight. Those are not easy things to do. Sadly, public health cuts have made assistance much more limited. She highlighted well how losing 10% of body weight can mean entirely different things to different people, depending on what their weight is to start with; how the system fails people by not supporting them to make healthy choices; and how people are failed again when it comes to referral. She also illustrated well how the capped expenditure process in her area undermines the very basis of the NHS. I totally agree that it is time for the Minister to step up to the plate and challenge the many inconsistencies that we have heard about.

The proponents of this scheme can dress it up however they like, but we should be very clear about what it is: rationing of treatment for financial reasons—no more, no less. As we know, we have a growing population with longer life expectancy, and medical advances continue. Those are of course welcome developments, but they increase demand across the board and in this area led to a 27.5% increase in finished admissions between 2006-07 and 2016-17. The NHS has made enormous efficiency improvements to cope with that demand at a time of financial restraint. I am sure that the Minister agrees and will join me in paying tribute to the hard work of NHS staff, who made those efficiency improvements possible. However, it is clear that we have reached the limit of what can be achieved through efficiency alone—in fact, we are now moving well beyond that point.

As my hon. Friend the Member for Dewsbury said, just this week Lord Kerslake resigned as chair of King’s College Hospital NHS Foundation Trust because, he said, the NHS is under-resourced and we “desperately need…a rethink” amid unrealistic demands for savings—the kind of unrealistic demands that lead to the nonsensical and counterproductive policies we have heard about. In the aftermath of the Budget, the national medical director, Sir Bruce Keogh, said that the failure to close the funding gap would

“force a debate about what the public can and can’t expect from the NHS.”

While that was an extraordinary comment for a public servant to make, it is also something of an understatement, as it is clear to everyone—we have heard it today—that CCGs are already debating those issues and deciding what treatments should be available. So far, however, the Government have refused to acknowledge the debate or even engage with it.

I will give some further examples of where rationing is already happening. In February this year, the CCG in West Kent implemented a policy to suspend all elective surgery until the end of the financial year in an attempt to save £3.2 million. More recently, Cambridgeshire and Peterborough CCG proposed a new policy requiring patients to wait a minimum of 12 weeks for surgery. While that decision was later reversed, it is a worrying example of the kind of policy we may see spreading across the country as the financial situation of the NHS continues to deteriorate. It is not just in surgery where such rationing applies: earlier this year, I responded to a debate in Westminster Hall on infertility treatment, and it was revealed that of 209 CCGs in England, just four follow in full the National Institute for Health and Care Excellence’s guidelines on IVF treatment.

The individual funding request process, once reserved for rare conditions, is routinely applied by CCGs for a range of treatments. In some areas, including east Berkshire, routine hip and knee replacements are now being considered only if an individual funding request is made. Analysis by The BMJ found that the number of individual funding requests has increased by 47% in the past four years. As my hon. Friend the Member for York Central said, that shifts the burden on to the patient to prove that they need treatment, which is not what the NHS is there for. The Minister may well say that these are matters for individual CCGs, but there has to come a point where the Government must take responsibility and accept that the rationing of treatments taking place on their watch can be traced back to central Government funding decisions.

To turn to the matter at hand in Kirklees, when responding to these debates on behalf of the Opposition I have never failed to be impressed by the euphemistic names for schemes that no doubt are dreamed up by handsomely paid consultants but actually limit patient access. I have to say that the use of the term “health optimisation programme” to describe a system that could delay treatments for a year, leaving patients in chronic pain, is well placed to win my 2017 award for worst use of NHS management-speak. In Kirklees, as we have heard, about one in four people will be affected by the new restrictions based on weight, while 14% of the population are smokers. As the Royal College of Surgeons has pointed out, while obesity leads to poorer health outcomes, its relationship with post-operative success is less clear, and there is a lack of evidence that rapid weight loss before surgery makes much difference. It goes on to point out that there is evidence of a lower risk of post-operative cardiac and respiratory complications among obese patients.

It is clear that this policy, which will leave patients in unnecessary pain and discomfort for a prolonged period, is not motivated by medical considerations or necessity. Indeed, in many cases, patients are actually prevented from losing weight effectively as a result of the debilitating condition that they are seeking treatment to correct in the first place. Given that that goes against NICE guidance, will the Minister explain why CCGs are being permitted to pursue a course of action that causes so much discomfort and has no clear clinical benefit? As my hon. Friend said, we all want levels of smoking and obesity to be reduced, but leaving people in excruciating pain for months on end is simply not the right way to do it. If the Minister disagrees, I ask him to point out even one piece of evidence that suggests that denying access to surgery helps patients to improve their behaviour.

We all know that the best way to see sustained improvements in smoking cessation and obesity reduction is though well funded, consistent public health policies, which is why it is very disappointing that the Government chose to cut significant funds from public health budgets, a move that the King’s Fund described as

“the falsest of false economies.”

In 2015, Kirklees lost £1.6 million of public health funding, which could have been used to tackle the issues we have been discussing in a much more positive way.

Concern has also been expressed about the use of BMI as a measure. As we have heard, it is a particularly crude and unsophisticated way of estimating excess body fat by simply comparing weight and height. We gave the example of a professional rugby league player, I believe, who has a BMI of over 30. It is clear to anyone that if my BMI were to be in any way elevated, that would be as a result of body-building rather than any consumption of alcohol. As the Minister will know—I say this with the greatest of respect to him—there are people far healthier than either of us who happen to have a higher BMI. Will he therefore advise whether the Government support the use of such a crude measure to determine whether someone is allowed to undergo surgery?

Of all the inequities of this scheme I have referred to, the greatest is the fact that it applies to children aged just 5 and over. Is the Minister really prepared to stand by while children in primary school, who have no say over their own diet, are being left in pain while they wait for operations, or does he agree that they would be infinitely more likely to improve their fitness if they were not suffering from a medical condition in the first place?

Just as public health cuts are a false economy, as my hon. Friend the Member for Dewsbury said, delaying treatment will cost far more than it saves in the long term. There is a clear risk of patients developing complications if their treatment is delayed. A National Audit Office report on the costs of clinical negligence highlighted that 39% of claims are related to failures or delays in diagnosis or treatment of a condition, and it stated that that is likely to

“increase if waiting times are longer”

and treatment is arbitrarily rationed. I know the Government are committed to reducing the cost of clinical negligence in the NHS, but this policy seems to run counter to such intentions.

These episodes of localised rationing are becoming far too commonplace and creating a postcode lottery for patients. It is a lottery that patients did not ask to enter and one that leaves them suffering in pain. If we are truly to have a national health service, I hope that the Minister will reflect on what has been said today and take meaningful steps to end this unnecessary, unfair and counterproductive rationing of treatments.

It is a pleasure, as always, to serve under your chairmanship, Mr Hollobone. I am conscious that there is the possibility of a vote coming rather earlier than we had anticipated; in which case, I will try to ensure I do not use up all the available time. I congratulate the hon. Member for Dewsbury (Paula Sherriff)—Dewsbury, Mirfield, Denby Dale and Kirkburton, but I will use Dewsbury for shorthand—on securing the debate and securing the support of the hon. Member for York Central (Rachael Maskell), who made a compelling case today. She referred to our recent meetings on this subject and previous debates on it in the Chamber, demonstrating her clear commitment to the cause.

It is no secret that the NHS faces significant challenges. All the Opposition Members who spoke referred to some of the financial pressures currently acknowledged as affecting the NHS. However, I do not think they quite recognised that the NHS’s own five year forward view identified some significant challenges that need to be addressed in relation to the way in which the nation supports the healthcare of the population as a whole. Throwing money at it inexorably is not always the right solution. Some difficult choices have to be made about the way in which the public lead their lives. What we can do, through a combination of public health support, advice and education, to encourage the public to lead healthier lives is an important responsibility of Government. It is important for individuals to help to ensure that they lead long, independent lives in as healthy a condition as possible.

The five year forward view was put in place long after people established lifestyles either of being overweight or of smoking. To penalise them after the event was not the intention of the five year forward view. That strategy is about improving people’s health, whereas this programme is about causing health to deteriorate.

I do not accept that. It is important that we use all the tools at our disposal to encourage the public to lead healthy lives where possible. These measures form part of the suite of measures that are necessary to bring that about.

The Government have backed the five year forward view. Opposition Members raised the issue of finances. We have committed to a real-terms increase in funding through the spending review period. Most recently, in the Budget only last month, we committed an additional £2.8 billion on top of the £8 billion real-terms increase by 2020. We are providing significant extra resource, but we recognise that different areas of the country will face different challenges and so will develop different approaches to how they use their resources most effectively in patients’ interests. That will inevitably involve making difficult decisions. It is right that we trust local NHS organisations, clinically led, to make those decisions, rather than second-guessing them centrally.

Having said that, we have set certain expectations of the system, one of which is that blanket bans on treatments are completely unacceptable and incompatible with the NHS constitution. That is why I refute the challenge from Opposition Members to say whether or not we are imposing rationing on the NHS. The local management responsible for the NHS in their areas have to respect the constitution and should not introduce blanket bans, but they do have to look at ways to provide care for their populations in a manner that lives within the budgets they have been provided with.

I have listened to the Minister carefully. Can he explain why he feels it is acceptable that someone in Wakefield could have surgery, while someone nine miles away in Dewsbury could not? They might both be smokers, and the surgery would be carried out by the same surgeon, probably in the same hospital. Are we not in danger of going into a very big postcode lottery once again?

The hon. Lady made that point in her remarks, and I will try to address it. She can pick me up on that again.

To put this into the context of how it is working in reality, patients who do not meet the thresholds are automatically put through a system, and therefore it is completely in breach of the NHS constitution. There is no individual input about the clinical needs of a patient.

I will come on to that. We are talking primarily about what is happening in North Kirklees and Greater Huddersfield CCG areas, which have not yet implemented this policy. I will explain why I do not think that that should be the case.

On the healthcare optimisation plan, I take the gentle chiding from the hon. Member for Ellesmere Port and Neston (Justin Madders) about the way in which the NHS describes proposals. I have some sympathy with what he says about the way in which language is used, but this is a plan to encourage greater public health among the population of North Kirklees and Greater Huddersfield CCG areas, for which they are responsible. I talked to the CCGs in preparation for the debate and was advised that they do not see this as a blanket ban on treatment. I have emphasised to them that they should not do so and that there should not be a blanket ban on treatment.

I will describe the proposals, as I understand them. They have been developed by the CCGs since autumn 2016, and the objective is that patients who are overweight with a body mass index of 30 or above will have 12 months to lose at least 10% of their overall weight or to reduce their BMI to less than 30, while patients who smoke will be encouraged to take up to six months to quit smoking before undergoing routine surgery. Those who quit smoking for four weeks or achieve their target weight loss will be able to be referred for surgery under the policy.

The development of the plan coincided with the UK’s childhood obesity strategy and the proposed introduction of the soft drinks industry levy, reflecting the Government’s commitment to tackling the major public health problems affecting large sections of society. The hon. Member for Dewsbury and the hon. Member for York Central recognised the need to address the obesity crisis in this country. I am grateful for their support and that of the Opposition spokesman, the hon. Member for Ellesmere Port and Neston. I think we are united in recognising that something has to be done about this. I hope they support the proposals that the Government have made for the obesity strategy and the considerable progress we have made in reducing smoking since 2010. Hon. Members have made the point that the policy should not be at the expense of treatment if treatment is urgent or, if there is no treatment, it might lead to degradation of the health condition of the patient subject to the policy.

I thank the Minister for his generosity in giving way. Does he agree that the decision must be made by a surgeon? That is so important, because they are highly trained and are surely the ones who can come to a decision on whether the patient can wait.

I will come on to that. The short answer is that I agree that the relevant clinicians should make those decisions.

Going back to where the CCGs are in this process, as I said earlier, they have not yet introduced the proposal. They have been working with the local population and with Healthwatch Kirklees, and have held a number of engagement events with local authorities and interested stakeholders to try to understand the reaction of those parties to the proposal. An engagement event was conducted in March and April of this year, and one with Kirklees Council in August and September of this year.

The CCGs have listened and responded to some of the points made. They have made several changes to their original proposals, including exempting children from the programme. They also recognise the limitations—amusingly identified by hon. Members in their contributions—of using BMI as a measure of body weight. Therefore, for example, people with high muscle mass should be excluded from the BMI calculation for the reasons that were well explained earlier in the debate.

The CCGs are including safeguards in the proposals, and they intend that, in exceptional circumstances, normal individual funding request processes will continue to apply. Hon. Members have criticised that as imposing an undue obligation on the individual to seek that route to secure treatment. That is effectively an appeal mechanism that applies across the NHS and is a well-worn and well-understood path for clinicians to support individual funding requests for patients where needed, which we should continue.

Both the hon. Member for Dewsbury and the hon. Member for York Central used the expression “lives at risk”. I would gently say that there is absolutely no intention that policies such as this should lead to lives being at risk. They are about trying to put individuals in a position where their own circumstances would lead to better outcomes from the proposed surgery. The hon. Ladies have called for evidence supporting the proposition —it was raised by the hon. Member for York Central when we met at the end of last month. I have asked for that evidence. A number of research papers support the propositions made by the CCG, in particular on the question whether obesity at the time of surgery is associated with a wide range of problems. Sustaining weight loss is the key. Rapid weight loss followed by rapid weight gain clearly do not help the patient, but the evidence from the research papers provided to me is that maintained weight loss or cessation of smoking undoubtedly and clearly have clinical benefits for the patient. There is evidence to support that.

I will come back to the point raised earlier on by the hon. Member for Dewsbury and the hon. Member for York Central, but I absolutely recognise that the clinician primarily responsible for the care, whether that is the GP or the secondary clinician, should have discretion to ensure that a referral is made, should a non-referral of a patient or a delayed procedure outweigh any benefits from a period of improving health and reducing risk factors prior to a routine operation. We will encourage the CCGs to ensure that that is in their final proposals, once those are made.

The Minister says he will encourage CCGs to listen to clinical advice when making referrals. Is there any mechanism by which he will actually ensure that that happens?

As the hon. Gentleman knows, CCGs are subject to appraisal and are accountable to NHS England, which is accountable to Ministers. It is not for Ministers to direct individual CCGs as to how they should enact their policies, but there is a route through which we can provide some encouragement to NHS England to ensure that these policies reflect its national position. That is what we will do.

On where the process is, in October the two CCGs presented details of the proposed plans to Kirklees Council’s health and social care scrutiny committee. The committee requested that the CCGs undertake a further six weeks of engagements, especially with hard-to-reach communities in the area of the hon. Member for Dewsbury. The CCGs have assured me that they are committed to that further engagement with the local community to ensure that the plan is fit for purpose, so there is a continuing opportunity to reflect on the revised iteration of the proposals. I am also advised that the CCGs have not yet made firm decisions on the plans. Instead, as a result of the engagement with local stakeholders, they are considering four options, and variations on the four options, for implementing the proposed plan, including not proceeding with the programme, which remains on the table.

Those options include: first, a phased approach, beginning with applying the programme initially only to patients who smoke and subsequently rolling it out further to obese patients if appropriate; secondly, only implementing the plan for smokers; thirdly, introducing health optimisation periods across clinical thresholds and pathways, in line with NICE guidance; or fourthly, moving away from implementation of the plan as previously defined and focusing on a strengthened education campaign to reinforce the benefits to patients of stopping smoking and losing weight. Those options remain on the table and there will be a further period of engagement. A decision on which option will be taken forward is due to be made by the CCGs in January, and further engagement on the implementation of the recommended approach will then take place later in the new year.

I said earlier that the plan is not a blanket ban on treatment. Instead, the intention is to encourage patients who are obese or who smoke to lose weight and/or quit smoking. There is evidence that that will have benefits, in terms of both surgical outcomes, as I have said, as well as reduced risk for general medical conditions, and there are clearly also benefits to patients’ general health in the long term. Hon. Members can be assured that the CCGs are providing support to the patients on weight loss and smoking cessation, and have agreed to invest £133,000 a year in such services to account for any health optimisation-related increase in uptake.

The hon. Member for Dewsbury asked how we will assure that the plan is in accordance with national guidelines. As she would expect, NHS England has been closely reviewing this and similar proposals where they have been made to ensure that there is robust supporting clinical evidence and appropriate safeguards. The Government expect NHS England to ensure that the responsible CCG is not breaching its statutory responsibility to provide services that meet the needs of the local population. I can confirm to hon. Members that NHS England has had ongoing discussions with both CCGs about the health optimisation plan and will continue to do so to ensure that it works in the best interest of patients. That is the right approach, in terms of both protecting patients and both encouraging the population to put themselves in a condition to maximise the benefits from surgical procedures, without allowing CCGs to introduce an inappropriate blanket ban.

NHS England carries out regular assurance of CCGs and holds them to account through the CCG improvement and assessment framework to ensure that they are fulfilling their statutory requirements, and NHS England can and will intervene if a CCG is failing to discharge its key responsibilities. NHS England’s regional teams also have regular discussions with CCGs about their commissioning activities and plans.

It is important in a debate like this, in which there are allegations of there being a postcode lottery, that we recognise that it is down to clinicians at a local level, through their CCG bodies, to make decisions that affect their local population, rather than, as has happened in the past, central diktat from Whitehall. Those may lead to perverse consequences and a less relevant healthcare capacity and treatments for patients on the ground.

The Minister is being very generous with his time. Is it not important in a national health service that we use the very best clinical evidence on how to produce the best outcomes for all patients? Falsely drawn boundaries should not have any relevance to the kind of treatment people receive.

The hon. Lady will recognise that there are different health challenges in different areas, reflecting patients’ differing needs. Encouraging the public to stop smoking and to reduce their weight is, as she acknowledged, an ambition that is shared by Members across the House and across clinical leads.

I will not let the hon. Lady intervene again because, amazingly, I am about to run out of time, despite what I said at the beginning. I have taken a lot of interventions.

I conclude by assuring hon. Members that we are paying close attention to what is happening in Kirklees and Greater Huddersfield, and York Central. Other areas of the country may be considering similar proposals, and we need to ensure that it is done in a responsible manner, whereby clinicians stay at the heart of making referrals where appropriate and retain that discretion. We will not get to the situation that the hon. Member for Dewsbury described in her opening remarks, in which she said that people’s lives will be put at risk by policies such as this. That is not the case.

I thank the Minister for his considered response. Like the vast majority of MPs in the House from all parties, I care deeply about the NHS. However, I am getting slightly fed up with the platitudes that we hear day in, day out from the Government regarding their putting extra funding in. The NHS is in crisis, and I say that as someone who worked in the health service for nearly 13 years immediately before becoming an MP. I hear it from ex-colleagues of different political persuasions nearly every single day.

I maintain that the concept of the health optimisation plan in Kirklees, and undoubtedly those elsewhere, is deeply flawed. I plead with the Minister to use his influence to engage with the CCGs and to encourage them to go with option 4. I think we all agree that stopping smoking and losing weight is a good thing—my goodness, I could follow some of that advice—but not at the expense of people being in pain and potentially affecting their mental health, or of having a postcode lottery. I discussed the Wakefield-Dewsbury case with the Minister. That is happening, and it will happen because of the false borders to which my hon. Friend the Member for York Central (Rachael Maskell) rightly alluded.

My mum suffers from severe rheumatoid arthritis and has had it since childhood. She is 73 on Friday. A few years ago she started taking a drug that gives her a quality of life that she never had—she started using it as a guinea pig and has continued to use it. It used to take her hours every day to open her hand. She was in so much pain. I once found her at the top of the stairs and she could not go down them. She was crying.

She said to me on the phone one day that she is terrified that the Government will stop her receiving those drugs, because they are not cheap. I told her not to be silly. She knows that her quality of life would severely deteriorate once again if they did, and that she would probably be in a wheelchair. I am not sure I could say that to her now, because this plan is rationing, plain and simple. I cannot have that conversation and tell her that the Government will not stop her receiving the drugs because they are expensive.

I want the Minister think about that in the wider context. She is a 73-year-old woman. Is her life, and those of all the people affected, worth less than ours? We would not stand for our healthcare being rationed. I certainly would not.

Motion lapsed, and sitting adjourned without Question put (Standing Order No. 10(14)).