The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, with the leave of the House, I will now repeat a Statement made in the other place by my right honourable friend the Secretary of State for Health on seven-day health services and junior doctors’ industrial actions. The Statement is as follows:
“Mr Speaker, we have many choices in life but one thing over which we have no control is the day of the week when we get ill. That is why the first line on the first page of this Government’s manifesto said that if elected, we would deliver a seven-day NHS so that we can promise NHS patients the same quality care every day of the week. We know from countless studies that there is a weekend effect showing higher mortality rates for people admitted to hospital at weekends. The British public know it too and today we reaffirm that no trade union has a right to veto a manifesto promise voted for by the British people. We are proud of our NHS as one of our greatest institutions but we must turn that pride into actions. A seven-day service will help us turn the NHS into one of the safest, highest-quality healthcare systems in the world.
This week, the BMA has called on junior doctors to withdraw emergency care for the first time ever. I will update the House on the extensive measures being taken up and down the country to try to keep patients safe but, before I do that, I wish to appeal directly to all junior doctors not to withdraw emergency cover, which will create particular risks for A&Es, maternity units and intensive care units. I understand the frustration which many junior doctors feel: that because of pressures on the NHS front line, they are not always able to give patients the highest quality of care they would like to. I understand that some doctors may disagree with the Government over our seven-day NHS plans, and particularly on the introduction of a new contract. I also understand that doctors work incredibly hard, including at weekends, and that strong feelings exist on the single remaining disagreement of substance—Saturday premium pay. But the new contract offers junior doctors who work frequently at weekends more Saturday premium pay than nurses, paramedics, the assistants who work in their own operating theatres, police officers, firefighters and nearly every other worker in the public and private sectors.
Regrettably, over the course of this pay dispute 150,000 sick and vulnerable people have seen their care disrupted. The public will rightly question whether this is appropriate or proportionate action by professionals whose patients depend upon them. Taking strike action is a choice. If they will not listen to the Health Secretary, I urge them to listen to some of the country’s most experienced doctors. Professor Sir Bruce Keogh, Professor Dame Sally Davies and the former Labour Health Minister Lord Darzi have all urged doctors to consider the damage both to patients and the reputation of the medical profession that this will cause.
Let me also address today some of the other concerns that have been raised by junior doctors. First, there is concern that a seven-day NHS might spread resources too thinly. This Government’s financial commitment to the NHS has already seen a like-for-like increase of 10,700 more hospital nurses and 10,100 more doctors. This is following last year’s spending review which, despite the pressure on national finances, committed the Government to a £10 billion real-terms increase in the annual NHS budget by 2020. So while it is true that pressures on the NHS will continue to increase on the back of an ageing population, we are not saying that the current workforce will have to bear all the strain of delivering a seven-day service, even though they must of course play their part.
Secondly, there is concern that the Government may want to see all NHS services operating seven days. Let me be clear: our plans are not about elective care but about improving the consistency of urgent and emergency care at weekends and evenings. To do this, the Academy of Medical Royal Colleges has prioritised four key clinical standards that need to be met. These include: making sure that patients are seen by a senior decision-maker no more than 14 hours after arrival at hospital; the seven-day availability of diagnostic tests with a one-hour turnaround for the most critically ill patients; 24-hour access to consultant-directed interventions, such as interventional radiology or endoscopy; and twice-daily reviews of patients in high-dependency areas such as intensive care units. Around one-quarter of the country will be covered by trusts meeting these standards from next April, rising to the whole country by 2020.
Thirdly, there is concern that proper seven-day services need support services for doctors at the weekends and evenings, as much as doctors themselves. Less than half of hospitals are currently meeting the standard on weekend diagnostic services, meaning that patients needing urgent or emergency tests on a Saturday or Sunday, such as urgent ultrasounds for gallstones or diagnostics for acute heart failure, face extra hours in hospital at weekends or even days of anxiety waiting for weekday tests. Our new standards will change this, with senior clinician-directed diagnostic tests available seven days a week for all hospitals by 2020.
Finally, there is a legitimate concern that a seven-day NHS needs to apply to services offered outside hospitals if we are properly to reduce pressure on struggling A&E departments. So, as announced last week, this Government’s seven-day NHS will also see transformed services through our GPs.
We are committing an extra £2.4 billion a year for GP services by 2020-21, meaning that spending will rise from £9.6 billion last year to over £12 billion by 2021—a 14% percent real-terms increase. Thanks to this significant investment, patients will see a genuine transformation in how general practice services operate in England. By 2020 everyone should have easier and more convenient access to GP services, including at evenings and weekends. We will not be asking all GP practices to open at weekends to deliver this commitment, but instead using networks of practices to make sure people can get an evening or weekend appointment nearby, even if not at their regular practice. We have committed to recruiting an additional 5,000 doctors to work in general practice to help meet this commitment and we will support GPs in this transformation by harnessing technology to reduce bureaucratic burdens.
Returning to the strikes, the impact of the next two days will be unprecedented, with over 110,000 outpatient appointments and over 12,500 operations cancelled. However, the NHS has made exhaustive preparations to try to make sure patients remain safe, and I want to thank those people in NHS England, NHS Improvement and every trust in the country, who have been working incredibly hard over this weekend to that effect.
I have chaired a number of contingency planning meetings, bringing together the operational response across the entirety of the NHS and social care. From this, NHS England has worked with every trust to ensure that it has plans in place to provide safe care, with particular focus on its emergency departments, maternity units, cardiac arrest teams and mental health crisis teams. As part of their duties for civil contingency preparedness, trusts also have major incident plans in place which are ready to be enacted if required. NHS England has also asked GP practices and other primary care providers in some areas to extend their opening hours so patients can continue to get the important but non-emergency care, such as follow-ups and assessments, they need.
Finally, we have set up a dedicated strike page on the NHS website to provide as much information as possible to the public during this strike action on local alternatives to hospital care, where these alternatives are and when they are open. This website is now live and can be reached at www.nhs.uk/strike. The NHS 111 system will also work as normal during the strike and has been provided with additional staff to cope with the expected increased demand. We would encourage people who are concerned that they may need urgent care to visit this website and call 111 in advance of showing up at their local A&E.
The NHS is busting a gut to keep the public safe. However, we should not lose sight of the underlying reason for this dispute: namely, this Government’s determination to be the first country in the world to offer a proper patient-focused, seven-day health service. To help deliver this, the NHS will this year receive the sixth biggest funding increase in its history. However, it is not just about money, as we know from the mistakes of previous Governments of all colours. It is also about taking the tough and difficult decisions necessary to make sure that we really do turn our NHS into the safest, highest-quality healthcare system in the world. This Government will not duck that challenge, and I commend this Statement to the House.
Baroness Walmsley (LD)
My Lords, instead of reeling off the litany of justifications and figures that we have just heard, is it not really time for the Secretary of State to put aside his pride, stop being pig-headed and listen to people in the national interest? He is clearly not listening to the junior doctors but will he not now listen to the sensible compromise proposal from other parties, including my own, which, I point out, does not undermine the Government’s objectives in the long term?
There are two big differences between the euphemistic “gradual introduction” that he is proposing and the pilot projects proposed by other parties. The first is that of course a pilot scheme can be independently evaluated. If the Secretary of State is so confident that this scheme will not damage patients or doctors, why is he afraid of proper evaluation? The proper and safe implementation of the new contract is surely worth a very small delay. Secondly, a pilot would mean that all junior doctors evaluated in a hospital would be on the same contract, whereas piecemeal introduction, which he is proposing, could mean that two doctors working side by side in the same department were on totally different contracts. Does the Minister not agree that this would be deeply divisive, as well as very difficult practically?
I am also very concerned about the idea of consultants manning A&E departments this week. While I am grateful to them for being willing to step forward in the interests of patient safety, I am concerned that it might work in the opposite direction in their own departments. Who will take the difficult decisions in, for example, cardiology or vascular medicine when urgent cases come up and the consultant is setting somebody’s broken finger in A&E? Has the Minister thought about that?
Should not the Secretary of State consider his position? Is he really the right person to solve this dispute? Patient safety, not the future of his own job, should be his prime consideration. This week, that will be at risk—website or no website.
Lord Prior of Brampton
My Lords, I am personally massively sympathetic to the concerns expressed to me by many junior doctors over the last three or four months, and in fact over the last 12 or 13 years. For family and personal reasons, too, I feel hugely in sympathy with the situation in which they find themselves. There is no doubt that the training of junior doctors is wholly inadequate. Their placements are short term and they move from one rota to another, with many rotas unfilled. There is a lack of teamwork now that the old firm has gone and nothing has replaced it. There is also a lack of leadership and mentorship for juniors.
When I compare the training and TLC that junior doctors get with that received by those going into accounting, law, big corporates, investment banking or other areas like that, I think that the lot of the junior doctor is not a good one. I remember reading a paper, probably 10 years ago, by Dame Carol Black when she was president of the Royal College of Physicians. She talked about the deprofessionalisation of the profession, and that really will come to pass if we are not careful. So I am hugely in sympathy with many of these issues and I have particular sympathy for women—especially young women with families and so on.
But let us be honest about this. That is not what this contractual dispute is about. Those are the big issues but this dispute is about pay on Saturdays. That is the issue that the contract fell down on. The noble Lord and the noble Baroness opposite talked about a pilot—but are we really talking about piloting a different Saturday pay structure? Everything else was agreed between the BMA and Sir David Dalton. To be honest, it is disingenuous to say that we could pilot something like that. Fundamentally, this is about pay, and I think that the junior doctors have got it wrong when they go on strike and withdraw emergency cover over an issue related to premium pay on Saturdays. It is simply not a big enough issue to cross the threshold of withdrawing emergency cover. They must recognise that. There will be a time to address the more fundamental issues affecting the training of junior doctors, and they must be addressed for the sake of the profession, of patients and of hospitals—but, sadly, that is not the issue that we are confronting today.
Two other important issues were raised. In answer to the noble Baroness, not all cardiologists and cardiac surgeons are rushing off to an A&E department. They will cover urgent and emergency cases in their own specialties as well.
Although in a way it is not for debate today, the noble Lord, Lord Hunt, raised the very fundamental, long-term problem of whether there are the resources within the system to deliver the ambitions that we all have for a world-class health service. Maybe today is not the time to answer that: we should probably focus on the matter in hand.
Lord Campbell-Savours (Lab)
My Lords, perhaps I might ask two very brief questions. First, I recognise the undertaking that the Conservative Party gave in its manifesto, but were the BMA—or the junior doctors, more widely—consulted prior to the general election on their views on seven-day working? That is quite a simple question. If they were, what was their response in that consultation? Secondly, following the Written Questions that I tabled recently on information that the Government might hold on the position of junior doctors, why do the Government not keep statistics on doctors’ resignations from the National Health Service and on the emigration of doctors who cede their posts in the United Kingdom to take up posts overseas? Why are those vital statistics not available, particularly when we are going into this very difficult period?
Lord Prior of Brampton
My Lords, first, the need for a seven-day service has been recognised by the medical profession for a number of years. I remember reading the Future Hospital report four or five years ago in which the Royal College of Physicians talked about a seven-day service. Of course, it was the academy of the royal colleges that produced the 10 clinical standards that underpin a seven-day service. The issue is not whether or not there should be a seven-day service; the more serious issue that has been raised is whether we have the resources to deliver a seven-day service. We argue that we are putting enough resources into the NHS to do that. So I think that the principle of a seven-day service, certainly for urgent and emergency care, if not for elective care, is well accepted by the medical profession.
Interestingly, on the point about the number of people leaving—the resignations that the noble Lord referred to—I was pretty horrified to hear about the son of someone on the noble Lord’s Benches who had left the NHS to go to work in America two years ago, I think. He described a pretty torrid time working in the NHS as a junior doctor. To cap it all, when he went, there was no exit interview. No one was really concerned or knew that he had gone. That is just another illustration of the fact that we have not sufficiently respected or valued junior doctors in the NHS.
Lord Birt (CB)
My Lords, I wholly support the Government’s objective of seven-day working in every part, eventually, of the health service. However, I observe that the Government are trying to achieve these objectives, as the noble Lord, Lord Hunt, has just said, in a very economically adverse climate where health spend per head is in decline, in a country where the population is expanding very rapidly, and where we see significant bottlenecks right across the system. All of us can see how important junior doctors are to the system. I do not know how many of your Lordships saw the excellent BBC series on junior doctors a year or so ago set at the Royal Liverpool Hospital, in which their importance to the system and dedication was simply remarkable. We would all, I am sure, stand behind that. They should not be threatening to withdraw their labour, but it is amazing that a group of such dedicated workers can even consider doing such an inappropriate thing—they are not natural strikers. The question I put to the Minister is this: as I said, the Government’s objective is correct, but should they not move towards it with greater stealth in the context of moving towards a health service that is again appropriately funded?
Lord Prior of Brampton
My Lords, I echo the sentiments of the noble Lord. I recognise the vocational commitment of junior doctors and that they are not natural strikers. It is a tragedy that we have got into this situation. There are no winners in this dispute and only one absolutely clear loser: the thousands of patients who are now suffering. The noble Lord asked whether we could have got here with greater stealth. These discussions have been going on for three years. We have had one independent review done by the DDRB and a number of independent assessments of the impact on mortality of not working at weekends. The Government are putting £10 billion of new money into the health service over the next five years, which was asked for by the NHS. In the NHS there will always be a lack of resources: demand will always exceed supply in a system where there is no price mechanism. That is an issue that all Ministers have lived with in the NHS since 1948. However, I echo his views: it is tragic that we find ourselves in this position with junior doctors. They are not natural strikers.
Baroness Bottomley of Nettlestone (Con)
My Lords, is it not unworthy to describe the Secretary of State for Health as being anything other than unequivocally committed to improving patient safety in the NHS? Consistently and throughout his time as Secretary of State, this has been a priority of his with total dedication, and I much regret that anybody should question that. However, is it not equally deplorable that junior doctors, who are respected and loved by the public and are on a step on their career towards consultant posts, should take an action that will undermine the respect and confidence in which doctors have long been held? My noble friend rightly pointed out the many issues concerned with junior doctor training, but extra money for working on a Saturday, which junior doctors have always had to do, as have those in many other professions, is not the reason now to jeopardise their reputation among the public.
Lord Prior of Brampton
I can confirm both those points. If the Secretary of State for Health was to fall under a bus tomorrow and somebody was writing his obituary, it is “patient safety” that would be written on his tombstone. That is the one big issue that he has consistently fought for ever since the problems at Mid Staffordshire were uncovered three years ago. Patient safety is his guiding star as Secretary of State for Health. I agree with my noble friend that it is tragic to see thousands of highly committed, highly intelligent and otherwise sensible young people going out on strike.
Lord Beecham (Lab)
My Lords, I am sure that there are many in your Lordships’ House, and perhaps people outside it, who rather regret that the noble Lord himself is not Secretary of State for Health as opposed to the present incumbent of the office. He has shown great sensitivity about this issue and, indeed, all others, and is widely respected here. However, is it not unfortunate that the Statement made this afternoon is somewhat disingenuous? It refers, for example, to the high mortality rates for people admitted to hospital at weekends—something which has been disputed in the sense that, to the extent that it exists, it is not necessarily connected to the issue of a seven-day service but rather a function of the emergency situation that many people face which is why they are admitted to hospital at that time.
Is it not equally somewhat disingenuous to refer to the recently announced further investment in the NHS as something that is directed at the issue which is the cause of the dispute? As has already been pointed out, the service has been denied comparable funding to that in previous years and is in a very serious condition up and down the country. I hope that the Minister can persuade the Secretary of State that it would not be a futile exercise, as he has perhaps suggested today, to accept the suggestion made by the group of four people from different backgrounds, including a former Conservative Health Minister who was also a doctor, to have a discussion about trialling the new scheme? As is so often the case in this House in other contexts, decisions appear to have been made without any proper assessment of the potential outcome. In this case, there is a very serious potential outcome both for the service and for patients. Will the Minister speak again to the Secretary of State to reflect the view, which I suspect is fairly widely shared, that the Secretary of State is making a mistake in not acting on the suggestion that has been made?
Lord Prior of Brampton
On mortality rates at weekends, the noble Lord is absolutely right that there has been confusion about the difference between the terms “excess mortality” and “avoidable mortality”—the two are clearly very different. However, having said that, I think it is widely recognised that the lack of senior cover and diagnostic support, particularly at weekends, is not at all satisfactory. Certainly Bruce Keogh and others have looked at this—I think that there have been six very detailed studies looking at mortality at weekends. The fact that there is a higher level of mortality than you would expect is ground for providing greater support at weekends. As for the suggestion that there should be a pilot scheme to study the contract, I tried to answer that in my response to his noble friend and I have nothing else to add to that.
Lord Patel (CB)
My Lords, what will happen tomorrow and the day after is unprecedented in the history of the NHS: junior doctors will withdraw their services from emergency care. Despite some of my own family disagreeing with me, I, as a doctor, could never have contemplated taking that action. But the junior doctors today do feel hard done by for many reasons, which the Minister has stated, about how they and their training are valued—and that is an issue that we need to address. I am not allowed to make a speech today, and I will not, so let me come to the crucial point. The Minister said that the crucial issue is that of Saturday pay. It cannot be impossible for both sides to agree to sit down to break this deadlock and discuss these pay issues. Otherwise, where are we going to go? We have to find a solution. On the one hand, the junior doctors are saying, “Do not impose the contract on us”, and on the other hand, the Secretary of State is saying, “I have to impose the contract because you won’t agree with my pay conditions”. There has to be a solution. What solution does the Minister think we might have?
Lord Prior of Brampton
My Lords, we have discussed this issue outside the Chamber. Although one must never give up hope, I find it hard at the moment to see how a negotiated, agreed solution might be found. We have had three years of negotiations; we have had 75 meetings. We came within a hair’s breadth of a solution, with the Government making concessions around how much of Saturday should attract premium pay, but we were unable to do the deal. Sir David Dalton, a very distinguished, well-respected chief executive of Salford Royal, led those negotiations and his advice to us afterwards was that he could not find a way through it. His advice then was that we had no choice but to impose the contract. None of us wanted to impose the contract; we all wanted to find a solution. But with the current BMA executive we found that impossible. Much as I regret it, as things stand this evening, I do not see a solution.
Lord Ribeiro (Con)
My Lords, as a junior doctor in 1975, I went on strike, so I can understand why junior doctors might feel the way they do. The difference between 1975 and now is that we did not withdraw emergency cover. That is the point we should concentrate on, because I fear that, on Tuesday and Wednesday, people will be denied care irrespective of the cover provided by consultants and we will see some deaths occurring. When they do, the blame will fall squarely on both parties, which is most unfortunate. Something needs to be done. It is late and, as the noble Lord, Lord Patel, said, we are talking about a sticking point over Saturday. Surely we could agree that emergency care starts at 1 pm with premium pay. Perhaps that would be both sides meeting in the middle.
When this is all over—I regret that I think that tomorrow’s strike will go ahead—may I please ask that we have an independent inquiry and review? This is about the sustainability of a workforce that does not use junior doctors at the front door to deal with all the work. We need a workforce that will put senior decision-making at the front door of a hospital so that the juniors can have more time to be supervised and trained.
Lord Prior of Brampton
My Lords, I completely agree with that. When the dust has settled, we have to take a wholly new and independent look at how junior doctors are trained. As the noble Lord will know, Sue Bailey, chair of the Academy of Medical Royal Colleges, has been asked to look at this, but I do not think it is possible to do that sensibly while the dispute is ongoing. We need the full co-operation of junior doctors in that review. I would personally welcome an independent assessment of the way we train junior doctors once this dispute has been settled. I share my noble friend’s views entirely: it would be wonderful if the junior doctors would agree to provide emergency cover on Tuesday and Wednesday this week. But it is now 8.15 pm on Monday and time is rapidly running out.
Lord Elystan-Morgan (CB)
My Lords, the High Court will adjudicate in the first week of June on whether the Secretary of State ever had the authority to dictate to the junior doctors. There are different views on that question, but it does not really matter if the judgment goes against the junior doctors; the question is whether it is politic, sensible and proper in all the circumstances for the Minister to proceed by way of diktat. I urgently ask the House to consider these words; they are not mine but those of Sir David Nicholson, who up to two years ago, as your Lordships will remember, was the head of the NHS in England. They are addressed directly to the Secretary of State:
“Our future consultants, leaders and chief executives will forever remember you win by the exercise of power and imposition a catastrophe for the NHS”.
Lord Prior of Brampton
My Lords, as I have said, this is not a place where we ever wanted to be. Imposition was absolutely a last resort and I again try to assure the House that it was arrived at only after three years of negotiation, an independent review by the DDRB and countless meetings. It was felt that, after all that time had elapsed, we had no choice but to impose the contract.
The Earl of Caithness (Con)
My Lords, I declare an interest as one of those who have suffered as a result of the doctors’ strike. My appointment on 9 March was postponed until tomorrow—that was a seven-week delay; I do not know when the next appointment will be—but many people are in a much more serious condition than me. Can my noble friend tell the House what the knock-on effect will be? The Statement referred to 110,000 patients who were due to be seen at the time of the last doctors’ strike, who were scheduled to come in for this doctors’ strike and who will now be delayed yet again and clog up the system.
Lord Prior of Brampton
My Lords, there is an important distinction to be made around withdrawal of emergency cover. I can of course sympathise with the tens of thousands of patients who have been badly inconvenienced—that is bad enough—but when you withdraw emergency cover, people can die. It will be surprising if there are not some severe outcomes from what is happening tomorrow. Tens of thousands of people have been severely inconvenienced; tens of thousands of people have had their treatment disrupted, but the real tragedy will be when people lose their lives.
Baroness Cumberlege (Con)
My Lords, I thank the Minister for setting out some of the difficulties that junior doctors face. I declare an interest: I run a company which trains a lot of junior doctors. Ten years ago I did the work on professionalism for Dame Carol Black and we produced our report, Doctors in Society. We said that professionalism is signified by the values, behaviours and relationships that underpin the trust the public have in doctors.
On Wednesday of last week I made a statement—I was asked to give a lecture—and I threw down a gauntlet to the Royal College of Physicians and said that it was 10 years since we did that work; would it not now consider redoing it? I am delighted to say that it has accepted that and I hope my noble friend will support it.
Medicine is a much-respected profession and withdrawing care from those in extremis is an erosion of professionalism. It is also an erosion of trust that the public have in doctors. I hope this strike will be resolved as soon as possible and that, at least, we can get on to see the issues that the Minister has mentioned and address them through the royal college and the academy.
Lord Prior of Brampton (Con)
My Lords, time is up so I shall be very brief. I am delighted that the Royal College of Physicians is going to redo its work on professionalism. My noble friend is right that the real damage could be a long-lasting damage to the public’s trust in the profession. However, I am sure it will be rebuilt in time.