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NHS Efficiency

Volume 702: debated on Tuesday 2 November 2021

[Sir Gary Streeter in the Chair]

Before we begin, I encourage Members to wear masks when they are not speaking, in line with current Government and House of Commons Commission guidance.

I beg to move,

That this House has considered NHS efficiency.

It is a pleasure to serve under your chairmanship, Sir Gary. I draw Members’ attention to my entry in the Register of Members’ Financial Interests.

Our NHS is in my DNA. Both of my parents were nurses and worked in the NHS for most of their working lives. It was the NHS that brought my family to Peterborough when I was just five years old, and I have worked in NHS policy for 20 years. My commitment to our NHS and its principles is clear. Few things inspire as much national pride as our national health service, and I want to keep it that way.

The NHS has lost its ranking as the best healthcare system in a study of 11 rich countries by an influential US think tank. Most worryingly of all, it fell to ninth when it came to healthcare outcomes. We must do something about this. We must ensure that the record investment that we are putting into our NHS is spent well. I suggest that that money should come with some very specific key performance indicators that would ensure that it is not wasted.

I feel strongly that the money should be in the gift of Ministers in the Department of Health and Social Care, who are accountable to Parliament, rather than NHS England or NHS Improvement. Like the Department for Levelling Up, Housing and Communities would do with a local authority that does not run a balanced budget or provide statutory services, the Department of Health and Social Care should be able to intervene directly, or at least provide incentives. Recipients would not get their share of the extra cash unless they addressed the challenge of access to care and improved outcomes.

I am keen to help Ministers. I almost feel thwarted, because progress on many of the things that I spoke about at the party conference last month have started to be reflected in Government announcements. That is obviously a good thing, but extra money must come with strengthened incentives to do the right thing and, quite honestly, consequences for not doing the right thing.

The first area in which we need to make progress is local NHS management. Local government has had to make a series of savings in recent years. Armies of local government managers all doing the same jobs in neighbouring local authorities have been an easy target for those defending the interests of taxpayers. However, local authorities have done rather a good job of sharing senior officers. For instance, the chief executive of Peterborough City Council is also the chief executive of Cambridgeshire County Council. As a former Hammersmith and Fulham councillor, I also remember the 2011 tri-borough shared services agreement in west London, between Westminster, Kensington and Chelsea, and Hammersmith and Fulham, which saved over £33 million in just four years. Labour-controlled Hammersmith and Fulham petulantly took their toys home a couple of years later, but the bi-borough arrangement is still saving the taxpayer millions, and this practice is replicated across the country.

That practice is unheard of in our NHS, but why is that? There are no reasons why NHS trusts and new integrated care systems cannot share officers and back-office functions. Let us do away with every NHS trust having its own specific CEO, finance director, human resources director, estates director or diversity director. It is not controversial to ask our NHS to learn from local government. If certain localities cannot make those management savings, are unwilling to share back-office functions, cannot look to make savings, why would we give them the extra cash? I suggest a KPI on a reduction in management costs and back-office costs. I think it would be warmly welcomed by the taxpayer and those in our NHS who know that money is wasted.

I draw colleagues’ attention to my declaration of interest as a practising NHS doctor. Does my hon. Friend agree that one of the challenges is attracting good expertise, perhaps from the business world, into the NHS and that that sometimes costs money and resources? While he is wishing, correctly, to make savings in back-office costs, we should not be too prescriptive because we need to make sure the best people are coming into the NHS, both from within and without, to deliver the productivity gains he desires.

That is a characteristically well-made point by my hon. Friend. In the current system, NHS chief executives spend 18 months in one trust, then travel to another, spend 18 months there and then travel to another. That is no time at all to get to grips with the challenges that these organisations face. We absolutely need people from the private sector to come in and do these jobs. If they were doing these jobs on a larger scale, that would be welcome. I am specifically requesting that we look to local government, where people have come in and transformed services. I suggest we do the same in our NHS.

My second point is on innovation and new ways of working. Innovation is the way an organisation develops. It should be a constant process—trying to do things better, improving outcomes for patients and trying to be more productive. Across the NHS there are those that innovate with new technology, those that adopt new pathways and service delivery, and clinicians who want to train and learn new techniques. However, the NHS can be poor at spreading best practice at pace and scale. Like any bureaucracy, it can be slow at looking at new ways of working.

There have been attempts to address this. We spent millions funding organisations such as Getting It Right First Time—GIRFT—under Professor Tim Briggs, which is a national programme designed to improve the treatment and care of patients and collect best practice. We created the National Institute for Health and Care Excellence—NICE—which, when it was created, was considered to be a model for the world to emulate on determining the cost-effectiveness of technologies and drugs. NICE also produces quality standards that set out priority areas for quality improvement in health and social care. After all this work has been done and all this money has been spent, many parts of our NHS just ignore it. They say things such as, “This can’t possibly apply to us,” or, “This is merely guidance, and we don’t need to do this here.”

The use of insulin pumps and implantable cardiac defibrillators or vascular technologies should not depend on where someone lives, but it does. The solution is certainly not to reduce GIRFT’s budget from £22 million to £10.8 million, but that is what has happened. GIRFT should be empowered to develop best practices in primary and community care, and we should look at the GIRFT model of hot emergency and cold elective centres to help us power through the backlog.

What is the solution? How do we make outliers adopt best practice and do the right thing? A KPI, and perhaps even GIRFT or NICE, can help us with technology and pathway adoption, which could transform productivity, powering us through the backlog. Backed up with an incentive such as a generous and workable best practice tariff, a KPI could focus attention. If outliers persist in a practice that has been shown to be outdated and to follow pathways that do not lead to optimum outcomes, why would we give them the extra money?

On capacity, staffing is recognised to be a risk factor in delivery for our NHS. The money is there, but it takes a long time to train a doctor, GP or nurse. That is why every hour of a medical professional’s time is valuable. We have to make sure that they are doing what they are paid for and what they went into medicine to do.

My hon. Friend is making a fantastic speech. Does he agree that every hour of a clinician’s time is valuable? The average clinician loses about 10% of their workload simply chasing up letters, following up blood tests or trying to find scans, which is a complete nonsense in our current system. It could easily be ironed out by joining up simple IT between primary and secondary care. Is that a KPI my hon. Friend could support?

My hon. Friend is a champion of efficiency in the NHS and in his profession, and he makes such points regularly in the meetings of the Select Committee on Health and Social Care. Perhaps he has already read my speech, because I think that the winter access fund is an excellent start. It will address what many GPs have rightly complained about for some time, which is the amount of time they spend on fitness notes and chasing appointments, as well as something that I only realised when I met GPs in my constituency. I want to give a quick shout out to the super Dr Neil Modha and his team at the Thistlemoor surgery, who are doing a fantastic job in a very challenging catchment area. What I realised was how much time GPs spend providing medical records to insurance companies and other bodies, which just is not their job.

We need clinicians to practise at the top of their licence. We need GPs seeing ill patients, not prescribing things a nurse could easily do. Nurse-led prescribing has been around for a long time, but it has not been rolled out across as many areas as it should. We need a revolution in physician associate and nurse-led prescribing, which will free up the time for GPs and consultants to do what they need to do.

That same waste of clinician time happens in secondary care. We need surgeons using their skills in the cath lab or the operating theatre. They should not be in theatre only one day a week; they need to be there multiple days a week, every week. I hope surgical hubs and other initiatives will help, but I fear that without a strict KPI on clinician time on highest-skill, highest-value activity—and I am not opposed to backing that up with financial incentives—we will not make the savings in clinicians’ time that we need. Only with such a KPI, together with an effort to demonstrate how valued our clinicians are, will we ensure that their valuable time is not wasted. If an integrated care system or the management structure at an NHS trust cannot or will not do that, we should make it dependent on the extra cash.

Finally, much of this is dependent on greater transparency. I was very pleased to hear the Secretary of State for Health and Social Care say this morning to the Health and Social Care Committee that we are going to be able to see more data relating to the performance of GP practices, but that needs to happen with ICSs as well. In the past, clinical commissioning groups in this country could be guilty of hiding commissioning policies, rationing hip and knee surgeries to those with a body mass index of below 30—or even 25 in a handful of cases—on page 145 of a 278-page document on a website that no one ever reads.

NHS England is just as guilty of doing that with national service specifications and commissioning policies, and politicians have very few means of challenging that as politics has been taken out of the NHS. We need to open up the windows and let the light in. Accountability and transparency have always been the way to improve performance and efficiency, so let us have the Ofsted-style rating for ICSs and other NHS bodies. Let us know who does well and who does not. Together with clear KPIs, transparency and accountability, we can ensure that the record cash injection, which my constituents applauded, is spent well. The NHS is a source of national pride, but its performance post-pandemic can and should improve. I offer Ministers a few ideas—a few acorns—for how we might do that.

It is a pleasure to speak under your chairmanship, Sir Gary, and an absolute honour to follow the excellent contribution of my hon. Friend the Member for Peterborough (Paul Bristow). I refer to my registered interests and, in particular, I raise the fact that I am the chair of the all-party parliamentary group on digital health, which very much informs some of my points today.

I will be brief, as I am conscious that this is a big debate to have in a small period of time. One of my passions for looking at efficiencies in the NHS comes from my own experience. About 12 years ago, I was asked by the Department of Health to do a strategic review of every NHS website in England and Wales. I will cut to the punchline: there were more than 4,000 live sites. I did the financial calculation and worked out that between £87 million and £121 million a year was being spent on websites, many of which people did not even know existed. That highlighted that one of the challenges for the NHS is that, because of its immense scale, even though people want to do the right thing, duplication inherently causes extra costs on a scale that one cannot really comprehend in a normal business, or even in a global business.

This highlights various points. First, if we want to improve efficiencies, we need to make sure that patient experience and patient care is at its heart. There were 4,000 websites at the time, of which several hundred were about how to stop smoking. It would probably have been more efficient to have one really good stop smoking website, rather than 200 average ones.

Patient experience is not just about the outcome but about how patients find the right information, how they get to the source and how we make sure they are not having to repeat the same thing every time they go for an appointment, which is where technology is so important. We often think of technology in the NHS as big, expensive, lumbering IT systems that are hard to comprehend, but the world has changed. We now have a consumerised approach to healthcare. People have watches that can track their heartbeat. They can go online and book appointments by email. They can use apps to do so much more, even track their covid status.

We need to look to the future, not just on efficiencies for cost savings but on patient experience. Thinking about the sort of experience we want patients to have over the next 10 or 20 years, it has to be seamless and efficient. Seamless in the sense that if a person breaks their arm, they do not have to say that they have broken their arm every time they see a new clinician, go on to a new website or use a new app. Their broken arm might mean they need additional wraparound care or it might affect their ability to work, so what will be the impact on social care? If we start to put patients at the heart of what we do, we can create efficiencies around them, rather than requiring them and the NHS to duplicate their efforts.

There is a great opportunity to look again at patient experience, given the technology that is available not just in the NHS or in social care but generally. We are now used to using social media, apps and phones for so many different things. If we can start to bring that into how we look at the future world of health, we would have a powerful opportunity to say to patients, “What would you like your health system to look like?” Rather than imposing variations of the health system of the past 40 or 50 years, we could ask, “What is it that you, as an individual, would like to see in how we look after you, your children and your parents, not just now but for decades to come?” We could then create an efficient and effective system that has patient outcomes at its heart and that ultimately creates a superior patient experience that helps everyone and, as I always say, is free at the point of use so we can make sure that the NHS continues to live up to its values as it always has.

Let us look to the future and let us see what is available, rather than just relying on what we had in the past.

It is a pleasure to serve under your chairmanship, Sir Gary.

I welcome the idea and the timeliness of this debate. My hon. Friend the Member for Peterborough (Paul Bristow) has raised an important issue, and I know many hon. Members present have great experience of various parts of the NHS, including my hon. Friends the Members for Watford (Dean Russell), for Bosworth (Dr Evans) and for Central Suffolk and North Ipswich (Dr Poulter). I thank them for their contributions to the debate.

We all have a responsibility to taxpayers to make sure that the NHS uses its resources as effectively as possible. To do that, we need to ensure that productivity grows every year, which is why the NHS long-term plan includes financial test 2:

“The NHS will achieve cash-releasing productivity growth of at least 1.1% per year.”

I make it clear that increasing productivity does not mean making staff work harder or making cuts. It means getting the most out of every £1 the NHS spends, and making sure that as much as possible is spent on frontline care. It means doctors and nurses doing the tasks they are trained to do and that nobody else can do. It means buying the right drugs at the right price. It means more patients getting the right treatment in the right place at the right time. That is good for patients, good for clinicians and good for the taxpayer.

Thanks to the hard work and innovative mindset of many NHS staff, the NHS is regularly recognised as one of the world’s most efficient health systems, although I take the point made by my hon. Friend the Member for Watford that there are different ways of measuring efficiency globally. In fact, in the decade before the pandemic, productivity growth in the NHS was faster than in the wider economy, as was independently verified by the Office for National Statistics.

Furthermore, the UK spends only around 2% of healthcare expenditure on administration—we spend a lot on the NHS, but only 2% of it on administration—and managers make up only 2.6% of the NHS workforce of 1.35 million. They might be an easy target for criticism, but good managers are of course essential to making services work, and many of us will have had experience of that throughout our various careers. If there were no managers, clinicians would have to manage their own workforce, logistics, finances and websites, and spend less time with patients. None the less, we want to improve the quality of management further, which is why we have asked General Sir Gordon Messenger to lead a review of leadership in health and social care.

I refer to my earlier declaration about my entry in the Register of Members’ Financial Interests, as a practising NHS doctor. On the point that the Minister just made, of course we want to promote clinical leadership in the NHS in senior management positions, because we know that that benefits patients and leads to efficiencies, but we also need to consider the fact that although there are many good NHS managers, a lot of them have never had experience of life outside the NHS. I wonder whether my hon. Friend the Minister could briefly say how we can draw in better business experience and other experience, so that NHS managers have broader experience, and can bring that benefit to the NHS and drive efficiencies.

I have heard exactly the same point being applied to many different industries, even politics—how many people come from business into politics, or go from politics to business? That crossover between the public sector and the private sector, including bringing particular skills and learning from one to the other, is not done nearly enough, which is why I spend a lot of my time trying to get more business people involved in politics. However, I am sure that it is a challenge for people to do that, because I guess that people tend to get stuck in the way that they know and go up the career ladder in the world that they know, so there is too little crossover. I guess that the recruitment companies have something to answer for here. They look for square pegs for square holes—namely, people to do what they have already done, so that there is a natural progression.

Nevertheless, we need to encourage that crossover. If we put out a call to say, “Actually, we really do want businesspeople to join us and help us,” I am sure that many businesspeople would be interested in having a second career in public service, as we ourselves are all doing here in Parliament.

As I was saying, General Sir Gordon Messenger will review leadership; the terms of reference for that review are being developed right now.

There is no doubt that covid has had a severe impact on NHS productivity. Covid significantly increased costs for the NHS, while we also had to stop some regular activity, so productivity was obviously much lower than it would have been otherwise; indeed, many patients did not even wish to attend in-hospital services. Of course, covid made more stringent infection prevention and control measures necessary. Those measures, such has having to put on and take off personal protective equipment, slow staff down and limit the number of patients they can see, and will probably continue to hold down productivity in the immediate future. We know that that has happened, with the existence of green zones and red zones, and other new processes to try and control infection during this period.

We do not yet know what impact covid has had on NHS productivity, but we expect that it will turn out to be large and negative. The ONS estimated that public service productivity as a whole fell by 22.4% between July 2020 and September 2020, compared with the same quarter a year earlier. Even as productivity recovered, it was still 9.8% lower in the first quarter of 2021 compared with Q1 in 2019. Covid has definitely had a massive impact on productivity, and it is reasonable to expect that the impact on NHS productivity will be similar.

At the same time, however, the pandemic has been a spur for innovation. Across the NHS, clinicians said that the pandemic offered an opportunity to cut through bureaucracy and try new ways of working and new ways of partnering with local services. In London, the hospitals worked together and, as my hon. Friend the Member for Peterborough mentioned, their Getting It Right First Time programme will pilot a new approach to high-volume, low-complexity surgery. That is now being rolled out across the NHS. My hon. Friend also mentioned budget numbers, but it is not easy to compare like with like, because that programme has been integrated into the NHS Improvement budget and is now embedded within the plan for elective recovery, so that is where the finances are coming from.

Trusts will be benchmarked against the programme standards for surgical productivity through the model hospital system, and NHS England and NHS Improvement have set up a beneficial changes network to collect evidence of innovation during the pandemic. The network has distilled 3,000 submissions and 700 examples of recognised beneficial changes into 12 high-impact change areas, which will now be rolled out to the NHS. That is something good that has come out of the pandemic through the need to work together to face challenges.

As the NHS begins to recover, increasing productivity is more important than ever. Many patients could not receive the care they needed during the pandemic, and the NHS faces unprecedented waiting lists. We owe an immense debt of gratitude to NHS staff, who have worked so hard to care for patients throughout the pandemic, but the NHS now needs to use the investment that we have provided to deliver more care more effectively and to remove the burden from staff. This year, we are providing £2 billion through the elective recovery fund to increase activity levels, and £700 million through the targeted investment fund to fund improvements in surgical productivity and digital productivity tools. Digital will be a big feature—we have all learned a lot during the pandemic.

We have announced a further £1.5 billion to build surgical hubs across the country in order to develop new models of care and increase productivity, which is being piloted by GIRFT and the London region. Some £2.3 billion has been allocated to transform diagnostics by rolling out at least 100 community diagnostic hubs and investing in digital diagnostics that will deliver 10% higher productivity. Another £2.1 billion has been allocated to digitise frontline services and free staff from admin tasks, so that they can spend more time with patients—something that was mentioned by my hon. Friend the Member for Bosworth.

Our aim is to return productivity to an ambitious trajectory, so that we can deliver on our ambitious plan to build back better and to clear the waiting list, but also to build an NHS that is fit and able to cope with the demands of the future. Of course, we have more work to do on integrating social care and developing best practice so that the systems work well together. It is not over and we have a lot of work to do, but I am sure that with all the measures that we have put in place, my hon. Friend the Member for Peterborough will feel satisfied that the NHS is continuously looking at continuous improvement.

I am impressed by the Minister’s response. She talked a lot about how the NHS will improve efficiency and productivity post pandemic. I remind her of the plea that I made at the very end of my speech: the key to this issue is transparency and accountability. If we do not open the windows and let the light in, the Government’s ambitions will not be realised, and money will be wasted through other means. Let us try to create an NHS that is as transparent as possible and accountable to Ministers, then we might be able to see some of the changes that the Minister talked about in her speech.

Question put and agreed to.