NHS Sustainability and Transformation Plans
(Limited Text - Ministerial Extracts only)
Read Full debate18:37 - The House divided: - Ayes: 195 / Noes: 280 - Question accordingly negatived.
The Minister of State, Department of Health (Mr Philip Dunne)
It is a pleasure to be here today, and I welcome the hon. Member for Hackney North and Stoke Newington (Ms Abbott) to her post. I think this is the first time she has opened a debate in her present position, and I am pleased to be doing so for the first time myself. I believe that she was appointed about three weeks before me, and I think it would be fair to say that we are both on a steep learning curve.
I am also pleased that the hon. Lady has chosen the sustainability and transformation plans as the subject of the debate, because that gives me an opportunity to correct some of the misconceptions that she has just revealed, and, more importantly, to inform the whole House of the status of the NHS’s plans. Let me begin by reminding the House of their origins. The NHS’s own plans for the future, set out in the “Five Year Forward View” and endorsed by the Government—but not, as it happens, by the Labour party— recognised three great challenges facing the NHS: health and wellbeing, care and quality, and finance and efficiency.
Bill Wiggin (North Herefordshire) (Con)
May I congratulate my hon. Friend, and say how delighted I am to see him at the Dispatch Box fulfilling such a crucial brief? While he is on his steep learning curve, will he visit Hereford County hospital, so that he can understand the difficulties faced by rural patients and see what he can do to help us?
Mr Dunne
I am delighted to accept that invitation from my neighbour and friend, not least because many of my constituents look to Hereford County hospital for their acute care, but also because it is one of the hospital trusts that are in special measures, which is my specific responsibility. I look forward to seeing my hon. Friend there, perhaps even during the coming recess.
Norman Lamb
I wish the Minister all the best in his new role. Does he share my concern about the evidence from around the country that in many areas mental health is peripheral to the STP process? Will he ensure that no STP plan will be accepted unless mental health is central to it?
Mr Dunne
I am grateful for that intervention from the right hon. Gentleman, who has taken such a personal interest in this subject. I can confirm that mental health is one of the issues that will be addressed in each of the plans that will be taken forward. I hope that reassurance helps.
Several hon. Members rose—
Mr Dunne
I am going to make a little progress, as I have only just started.
The “Five Year Forward View” also recognised that the challenges facing different areas of the country differ, so the issues facing Hackney are not the same as the issues facing Ludlow, and a single national plan would not be effective or appropriate. Indeed, the Labour party recognised that in its 2015 general election manifesto, which most Labour Members present stood on. It said:
“To reshape services over the next 10 years, the NHS will need the freedom to collaborate, integrate and merge across organisational divides.”
Catherine West
I thank the Minister for giving way and hope he does well in his first performance here in the House. What percentage of acute trusts are in deficit, and what proportion of clinical commissioning groups are in special measures?
Mr Dunne
Many trusts were in deficit in the last financial year, and those deficits were funded by the Department of Health. Looking forward, we are using the financial discipline of control totals not to instigate cuts, as the hon. Member for Hackney North and Stoke Newington suggested, but to hold the accountable managers to account for delivering within the financial envelope that those control totals represent. That is what a responsible Government do—we give money to public services and expect them to live within those means. This year the NHS has received one of the largest cash settlements it has ever had, three times more than the rate of inflation.
Dr Murrison
I am very grateful to my hon. Friend for giving way, a courtesy not extended by the Opposition Front Bencher.
May I ask my hon. Friend to look very closely at STP footprints? The experience of those of us who represent rural areas is that aligning our areas with more urban centres can often mean that our constituents get a raw deal, and since my footprint includes urban areas in Bath and Swindon I am slightly concerned that the same thing may happen again.
Mr Dunne
If I manage to get there, I am going to come on to the footprints and how it was that 44 areas were identified, but in rural areas in Wiltshire and Shropshire we do look to urban areas to provide the acute care for all our local residents, so it is appropriate that the footprint areas encompass both the acute and the full range of primary sectors.
Mr Jim Cunningham (Coventry South) (Lab)
I welcome the Minister to his new job. What is happening in relation to bed-blocking, and what are the Government and the national health service doing to deal with care in the community in particular?
Mr Dunne
The hon. Gentleman raises a critical point and one of the real challenges facing the NHS at present, which is how to make discharge out of the acute setting, and movement right the way through the patient flow, more effective. As I will come on to say—if I get there—that is precisely why we are looking at bringing local authorities into the footprints for these STPs, so that the entire patient pathway can be taken into account.
Several hon. Members rose—
Sir Simon Burns
I am very grateful to my hon. Friend. So that there can be no misunderstanding, because the shadow Secretary of State does not seem to have fully grasped the brief, will my hon. Friend, with his superior knowledge, explain categorically to the House about transparency in the health service with regard to not only STPs but other reconfigurations? There automatically always has to be a public consultation with local communities before any decisions are made— something that the shadow Secretary of State seems to be totally oblivious of.
Mr Dunne
I am grateful to my right hon. Friend, who has a great deal of experience in this area, having served in the Department for many years. He has pre-empted what I am about to say, which is that all the STPs will be subject to full and appropriate public consultation once we are in a position to do that.
Several hon. Members rose—
Mr Dunne
I am going to continue my remarks, as I have already been quite generous in taking interventions.
As part of its annual planning round in 2015, NHS England published planning guidance last December—nine months ago—calling for clinical commissioning groups to come together with their providers across entire health economies to develop a collective strategy for addressing the challenges in their area. Those are the sustainability and transformation plans. There are 44 areas, which were agreed six months ago in March. They cover the whole of England, bringing together multiple commissioners and providers in a unique exercise in collaboration. Their geographies have been determined not by central diktat but by what commissioners and providers felt made the most sense locally.
Each area has also identified a strong senior leader who has agreed to chair and lead the STP process on behalf of their peers. They are well respected, credible figures in their local health economies, and we and NHS England are committed to supporting them to bring people together to agree a shared plan for how best to improve and sustain health services for their local populations. Local authorities, too, are fully engaged in the development of the plans. In some cases, local NHS organisations have agreed with local authorities that a senior council leader will lead the STP for their area. I think that is happening in Birmingham—I see a number of Birmingham Members present.
Maria Eagle
It is clear from the leaked document that Merseyside and Cheshire are looking to save £1 billion by 2021. In that context, does the Minister not agree that there will be an outcry when the secret proposals—which have now been leaked—to merge much-loved hospitals and cut services in Liverpool, for example, are finally consulted on? Does he acknowledge that they will have no chance of receiving any support?
Mr Dunne
The hon. Lady is leaping much too far ahead. There are no proposals at this point—[Interruption.] I will explain the exact state of the STPs shortly. There are a number of draft ideas to try to improve the services that are delivered to patients. Looking to the future and the efficiencies that need to be provided, as part of the five-year forward view the NHS leadership asked the Government to fund £8 billion of additional cash for the NHS. We provided £10 billion; the Labour party refused to provide anything like it. In return, the NHS agreed to look for £22 billion of efficiencies up to 2020. We have assisted it through the efforts of Lord Carter, whom we asked to undertake a review of efficiencies across the NHS. He has identified 10 work streams in which clear efficiencies can be found—many of which, incidentally, have been identified by Opposition Members. The hon. Member for Hackney North and Stoke Newington herself has referred in the past to areas of the NHS in which there is waste, and a newspaper article this week by the former Chair of the Public Accounts Committee, the right hon. Member for Barking (Dame Margaret Hodge), referred to “absurdities” in the spending practices in the NHS. We are trying to put right some of the practices that have been swept under the carpet for too long.
Mr Dunne
I am going to make some progress.
I turn now to the timetable and the progress that has been made so far. Each area was asked to work together over the first six months to draw up its initial thinking into a first draft plan by the end of June. Those plans were individually reviewed by senior leaders from NHS England and NHS Improvement during July and August. Each area is now in the process of developing its STP, with a view to submitting a worked-up plan to NHS England in October. The plans, as one would expect, will vary in their proposals, but all are expected to demonstrate a shared understanding of where an area is in relation to the three challenges set out in the five year forward view and where they need to be by 2020-21.
Mr Gareth Thomas (Harrow West) (Lab/Co-op)
I am grateful to the Minister for giving way. He was very generous the last time I had an opportunity to intervene on him.
Part of the concern in my constituency about the north-west London STP relates to the fact that Harrow receives less NHS funding per patient than any other part of London. For some months we have sought a meeting with a Health Minister to discuss that issue. Is the Minister prepared to receive a delegation from our clinical commissioning group?
Mr Dunne
I am grateful to the hon. Gentleman for his kind words about my willingness to take interventions from both sides of the House.
I am interested that the hon. Gentleman should mention funding allocations. Across the NHS, the allocations are a legacy of the formulas that were set in place by the Labour Government, of which he was a member. People across the country, not least in rural areas such as Shropshire, cannot understand why the funding per capita is much less generous in some parts of the country than in others. I am taking an interest in that and would be willing to sit down with him and other colleagues to understand the particular circumstances in north-west London, which we will have to do after the coming recess.
Returning to the progress that is being made, all the plans are expected to present an overall strategy for their area and to identify the top three to five priorities required. In the most advanced plans, we are also expecting areas to set out how they will deliver a number of national priorities, including on mental health and diabetes. Some will build on the early work of vanguard or Success Regime joint working, which has been developing better co-ordinated care models over the past year or so.
Mr Dunne
Shortly. I must make some progress.
The plans offer the NHS a unique opportunity to think strategically. For the first time, the NHS is planning across multiple organisations—both commissioners and providers—with local authorities to address the whole health needs of an area and the people it serves. Also for the first time, the NHS is producing multi-year plans showing clearly how local services will develop over the next five years to deliver real improvements in patient care and better efficiency to ensure that the NHS continues to be able to cope with rising demand from our ageing population. That is leading some STPs to face up to tough choices about the future of some services. Such choices have often been postponed again and again because they were too hard or relied on individual organisations operating on their own to shoulder the responsibility rather than it being shared across the geography or the whole healthcare economy.
Antoinette Sandbach (Eddisbury) (Con)
Does the Minister recognise the concerns in constituencies such as mine that have a border with Wales? The numerous closures of hospitals in Wales by the Labour Welsh Government are placing pressure on NHS trusts in Cheshire and Merseyside.
Mr Dunne
My constituency also shares a border with Wales, so I am acutely aware that Welsh patients regrettably have to wait longer and have worse access to treatment than those in England. Many of them look to English hospitals for services that are unfortunately not available in Wales, in part due to a conscious political decision of the Welsh Government to allocate less funding to the health service in Wales.
Alex Cunningham
I met a young surgeon at my north-east hospital in a personal capacity last week. She was excellent and caring and was clear in what she had to explain to me. She was so dedicated that it made me proud that she worked for the NHS. I was not proud, however, to hear about the facilities with which she has to work following the cancellation of our new hospital project in 2010 by the Tory-Lib Dem Government. Does the Minister agree that we can have as many plans as we like, but if we do not have the infrastructure, we cannot deliver the care required by some of our neediest communities?
Mr Dunne
There is undoubted pressure on infrastructure, as there is on technology. As technology improves and becomes available to the NHS, it provides opportunity—for example, for much more care to be undertaken closer to the patient. In many cases, this can be done increasingly in or near their home. That will have consequences for our existing infrastructure estate, and some of that will lead to a reconfiguration of existing hospital services. There is a programme of renovation across our hospitals, but of course that cannot get to everywhere at the same time. I apologise to the hon. Gentleman that he does not have the shiny new hospital that he would like, but there is a building programme, which will continue in the future.
Sue Hayman
I appreciate that. As the Minister is aware, we face particular issues in Cumbria, which has led to our having the Success regime. We are about to go into consultation on that, in key areas such as maternity, accident and emergency and the community hospital’s future. My constituents are concerned about how the STPs are going to fit in with the Success regime, what the fit will be and whether all that will be challenging and confusing.
Mr Dunne
As I have said, and as the hon. Lady knows, the Success regime in her area will become subsumed within the STP, but the advantages for areas in the Success regime is that it means the organisations have been working together for much longer than in the pure STP areas, and that will bring benefit in terms of the maturity of their plan and their willingness and ability to implement it.
Several hon. Members rose—
Mr Dunne
I am not going to take any more interventions, as I am going to have to wind up shortly.
The hon. Member for Hackney North and Stoke Newington has raised concerns in her remarks today and outside this place, and I would like to address a few of them before I finish. She has said that the STPs will result in significant cuts and changes to front-line services. I wish to make it absolutely clear to the House that, for all her protestations, these plans are not about cuts; they are about local areas, including commissioners, providers and local authorities, coming together and deciding how to improve services in the medium and long term. Some areas are taking difficult decisions, often looking to tackle long-standing problems, but this will be subject to rigorous local and national scrutiny. I can categorically assure her and this House that no changes will occur without local consultation and the normal process in the event of any proposed reconfiguration.
The hon. Lady has also accused the STP process of lacking transparency, being undertaken in secret and lacking time. Planning within the NHS is not new; an annual planning round culminates in December each year. As I have said, NHS England announced STPs publicly in its planning guidance published in December last year, and since then local STPs’ leads have been engaging locally, as they deem appropriate—there has been no secret. What is new is that for the first time in years different NHS bodies, with local authorities, have been working collaboratively together to develop these plans. The 44 local areas are submitting their worked-up plans to NHS England for consideration in October. The NHS will scrutinise these plans and make recommendations over which to take forward and prioritise for discussions with Ministers and for formal public consultation, which will follow. Implementation will take place once the feedback from consultation has been assessed, so that this implementation will begin from early next year, with timings dependent on each individual area’s specific proposals.
The hon. Lady has claimed that the process does not allow for adequate public or parliamentary engagement. These proposals remain at a draft stage, but we have made it clear to local leaders that they are responsible for ensuring that plans engage with all local stakeholders when they are ready, and proposed changes will be subject to local consultation. Many have already engaged with groups of clinicians and other stakeholders in their area in preparing draft plans. I have also indicated that local areas will be launching public consultations shortly, once their updated plans have been scrutinised by NHS England, and we welcome involvement from the public and from MPs. I have no doubt that there will be opportunities in the coming months for us to continue these discussions in this House and in the Department, and I will be willing to talk to MPs who are concerned about activities in their area.
The hon. Lady has called on the Government to publish the plans. As I have said, these plans are being prepared by local areas within the NHS, and they will be published and subject to further consultation in due course. She has also raised concerns about the use of private sector advisers in developing the STPs. I just point out gently to her the irony that 38 Degrees, which she prayed in aid for much of her advice in preparing for this debate, relied itself on a private sector advisory group, whose report I happen to have here—Incisive Health, a recognised private sector adviser within the NHS and elsewhere. It is a bit rich of her to come to this House arguing against the use of the private sector when she does so herself.
Norman Lamb (North Norfolk) (LD)
I want to start by saying that I very much agree with the point made by the hon. Member for Central Ayrshire (Dr Whitford) that this ought to present a real opportunity. It has brought people together, and discussions have started across organisations that in the past have not talked to each other nearly enough—both across the health and social care divide, and also bringing in people from outside the health service and social care system—but I fear that the opportunity will be fatally undermined for three central reasons.
First, there is the point that I made in my challenge to the Minister, on mental health: unless every STP addresses the burden of mental ill health in every community centrally as part of its plan, it will fail. There is no doubt about that. I noted the Minister’s attempt to reassure me, but the parliamentary answer I received recently did not reassure me, because it appears that it is not going to be a requirement that every plan must centrally address this problem. I understand that the more developed plans will do so, but if this is not done, it will absolutely fail. We are dealing often with some of the people who are failed most by the system, and who use A&E departments more than any other people, yet my fear is this will be a massive missed opportunity in that regard.
The Parliamentary Under-Secretary of State for Health (David Mowat)
I thank the right hon. Gentleman for giving way, because I want to make the point again—I will say it very clearly—that if an STP does not come forward with very clear plans as to how the mental health and dementia programmes are going to move forward quickly, it will not go ahead. That cannot be clearer.
Norman Lamb
I am grateful to the Minister for that, and I hope that that message goes out across the country, because Andy Bell from the Centre for Mental Health today has again raised concern about the process in many parts of the country.
The second issue that causes me very real concern is the financial backdrop and the ability to deliver on the plans given the finances that are available. We have already heard that the bulk of the money that is available is going into clearing the deficits of providers, rather than into the transformation that is so necessary in order, as the hon. Member for Spelthorne (Kwasi Kwarteng) made clear, to spend money more efficiently and effectively in delivering care for our communities.
Chris Ham, chief executive of the King’s Fund and a well-respected commentator, says that its assessment of the draft plans
“shows that, in the absence of eye-watering efficiency improvements, there will be a financial gap running into hundreds of millions of pounds by 2020/21 in most of the footprints”—
not across the country, but in most footprints. This is completely unachievable, and he questions the deliverability of plans which include the closure of cottage hospitals in many areas—the very things that can keep people out of acute hospitals, yet we are planning in many areas to close them down. This seems to me to make no sense at all.
There is a related concern about governance. Currently in the NHS we regulate organisations, not systems, so within an STP footprint every organisation still has to focus on its own financial survival, rather than looking at the best approach for the entire health and care system in that locality. I fear that that in itself will be a central flaw.
Finally, there is the question of openness and transparency. I note the point that there will be a consultation process, but let me just tell the Government that if they really think that a formal consultation process after full draft plans have been produced in a secret process will in any way convince the public that they are being properly involved, it will fail. It is inevitable that it will fail. People are so suspicious of consultation processes that they simply do not believe that they are being properly engaged in them.
The hon. Member for Spelthorne made a good point: people are often prepared to go on a journey. They are prepared to listen to potentially radical changes and potentially to use money more effectively, but the only way they will do that is if they are involved from the start—involved in shaping the proposals, rather than responding to something that has been fixed behind closed doors. The hon. Member for Bedford (Richard Fuller) knows full well how the public react when they are presented with what looks like a fait accompli. If the public are not involved in the development of plans to close cottage hospitals, to slim down acute hospitals and to merge hospitals around the country, we should be in no doubt that those plans will be rejected. The Government will be facing a political disaster if they plough on in this way. They must, for example, open up and involve the non-executive directors, who have been told that they cannot even be part of the discussions. That is ridiculous. For goodness’ sake, if we are to take people with us, we have to take them on a journey, engage with them and involve them in the plans.
The Parliamentary Under-Secretary of State for Health (David Mowat)
In the six minutes available to me, it will not be possible to respond to the 40 or so speeches that we have heard today. I shall just pick out two contributions for special mention. First, so far as I can see, the shadow Secretary of State genuinely believes that an organisation that provides care to 45 million people on a budget of £100 billion should not do planning. That really appears to be the view of the hon. Member for Hackney North and Stoke Newington (Ms Abbott). Secondly, the hon. Member for Central Ayrshire (Dr Whitford) made an excellent speech, in which she used the word “opportunity” in connection with STPs, which is what they provide. She also said usefully that healthcare systems were about “more than buildings.” As we go forward with this process, it is important that we all think about what that means.
The health service is not static. Technology is changing; drugs are changing; expectations are changing; and, as we have heard, demography is changing. It is right to try to make it evolve and help it to change. The STP process is the planning mechanism to do so. It is a planning mechanism to put in place a five-year view—this was in the manifesto—that NHS England has developed. If it is to work, it must have three things: it has to be care driven; it has to be properly funded; and it has to be locally driven. It is all those things.
David Mowat
I shall not take interventions; I now have only five minutes left.
When it comes to funding, we have put in an extra £10 billion, and it is real money. If that money had been available in Wales, some of the points raised in the debate about the interface between us and Wales would have been quite different. This year, the increase in health funding is 4% in real terms—three times the rate of inflation. The real point, however, is not to do with money—however much the Conservatives put in and however much Labour says it might put in, although we have not heard that yet. But however much is put in, it does not detract from the need for the health service to be managed effectively and properly so that it can improve and innovate.
There is a prize from these STPs. At the end of the process, we will have a health service that is more oriented towards primary and community care where people live. The health service will provide better access to GPs, emphasise prevention more than ad hoc responses, properly address long-term conditions such as diabetes and begin to address more quickly our mental health and dementia commitments. I say again that if STPs do not address those things, they will not go forward. Perhaps the most important of all the advantages is that the unacceptable gap that currently exists between healthcare and social care will be breached. That is at the centre of the whole process.
David Mowat
No, I will not. I have only four minutes left, but the hon. Lady, who worked with me on the Public Accounts Committee, can come and see me.
It is also true to say that if we achieve all those things, there will be lower hospital admissions and more humane and timely discharges. That might save money, but it is not being driven by the need to save money. It is driven by care needs because that is the right thing to do.
Let me deal quickly with the STP process. We have been told that it is a secret process and a Trojan horse for privatisation, and we have heard that we are not going to consult. Well, let us talk about consultation first. The right hon. Member for North Norfolk (Norman Lamb) made some good points about the difficulties involved in change programmes on which proper consultation does not take place. However, we must have something on which to consult that is reasonably agreed and reasonably stable, because if we do not, we shall give rise to expectations that cannot necessarily be fulfilled—in both directions, positive and negative.
When the STPs come back in October after being signed off, they will be consulted on. A document that will be in the House of Commons Library by the end of the week will describe in detail how all the stakeholders will be consulted and what we will do, but in any event—this point was made by my right hon. Friend the Member for Chelmsford (Sir Simon Burns)—no consultation and no engagement will take away the statutory commitments, the need for configurations to be looked at properly, and the requirement for nothing to proceed that has not been locally agreed.
We were told that the plans were secret. In fact, they were so secret that they were announced in December 2015, in the NHS planning guidelines. They were so secret that 38 Degrees, which was responsible for the principal leak, obtained its information from the websites of the organisations that were keeping it all secret. If we ever do something in secret in future, it really will be done better than this.
The STP process is complex. It will not work equally well in all the locations, and there will be issues to resolve. Some plans, if they are not adequate, will not be proceeded with in the same way as others. I say this to Members, however: we need you to engage with the process—
Dame Rosie Winterton (Doncaster Central) (Lab)
claimed to move the closure (Standing Order No. 36).
Question put forthwith, That the Question be now put.
Question agreed to.
Main Question accordingly put.