NHS Reorganisation

Faisal Rashid Excerpts

Wednesday 12th December 2018 Westminster Hall

[Faisal Rashid (Warrington South) (Lab)]

I beg to move,

That this House has considered NHS reorganisation.

It is an honour to serve under your chairmanship, Mr Gapes. It is my pleasure to open this debate on our NHS as we near the end of the year marking its 70th birthday. In debating its reorganisation, we should not lose sight of what a great credit the NHS and its staff are to our country. Its foundation represents arguably the greatest achievement of this House. It is for precisely that reason that its reorganisation matters so greatly.

Let me set the context. Eight years of cuts and the biggest financial squeeze in its history have pushed the NHS to the brink. On all key performance measures, it is struggling to keep up with demand—A&E performance hit a record low this year, more than 4 million people are stuck on a waiting list, and cancer targets are repeatedly missed. In a speech last year, the chief executive of NHS England warned:

“On the current funding outlook, the NHS waiting list will rise to 5 million people by 2021. That is an extra 1 million people on the waiting list. One in 10 of us waiting for an operation. The highest number ever.”

As the NHS is pressurised to do more with less, it is imperative that Parliament properly scrutinises the ongoing process of its reorganisation. We should not allow the Government’s shambolic handling of the Brexit negotiations to distract us from reforms that are critical to the livelihoods of millions in this country.

I acknowledge that this subject is wide-ranging and complex, so I intend to focus on a few key issues: clinical commissioning groups; sustainability and transformation plans and partnerships; integrated care partnerships; health and social care integration; and healthcare infrastructure.

Let me start with the Health and Social Care Act 2012 and CCGs. Six years on from the coalition Government’s top-down reorganisation of the NHS, it is clear that that initiative has been as much of a disaster as Labour warned it would be. My hon. Friend the Member for Ellesmere Port and Neston (Justin Madders) rightly described those reforms as having put in place

“a siloed, market-based approach that created statutory barriers to integration.”—[Official Report, 6 September 2018; Vol. 646, c. 176WH.]

The 2012 Act removed regional health planning by abolishing strategic health authorities and creating a complex and fragmented system of clinical commissioning groups. Strategic health authorities helped co-ordinate the provision of healthcare across an area. Subsequent NHS reorganisations have often felt like partial attempts to reverse the damage done by the 2012 Act. It is therefore unsurprising that little effort has been made to keep the public informed of those changes.

[Mr Jim Cunningham (Coventry South) (Lab)]

I congratulate my hon. Friend on securing the debate. He touches on the reorganisation way back in 2012. Clinical commissioning groups were created, but they are not accountable to the public—we have problems trying to find out what their budgets are and so forth. We have the same problem with NHS England, which is another very difficult organisation to deal with. As a result of all this reorganisation, we have organisations that are not really accountable to the public, and the public do not get their voices heard.

My hon. Friend touched on staff salaries. If we worked it out, we would probably find that they have had an 8% real-terms cut in wages over the past seven or eight years, on top of which they have to pay car parking charges for the privilege of serving the public. Does he agree that that cannot be right?

[Mike Gapes (in the Chair)]

Order. Can I just request that interventions are not long speeches?

[Faisal Rashid]

I thank my hon. Friend for his intervention. I totally agree with him, and I will come to that point later.

The Health Secretary has not even put out a press release about his most recent set of NHS reforms. I wonder when that will happen. Despite not being locally accountable, CCGs hold more public money than local authorities. That lack of accountability is particularly concerning given the large sums CCGs handle and the potential for vested interests to benefit in ways that do not best serve local populations. For example, although GPs acting as both commissioners and providers of care are allowed to sit on local NHS boards, elected and accountable local officials are not. It is alarming that current arrangements allow for such potentially significant conflicts of interest while resisting local democratic oversight.

I turn to sustainability and transformation partnerships. Since the 2012 Act, we have seen the launch of 44 STPs, covering all aspects of NHS spending in England. That process has been characterised by Government secrecy, with little or no engagement with staff, patients, unions or the public before the publication of plans. Despite being asked by the Government to deliver changes to local health services, STPs were given no statutory status, and their meetings are held in private. In the majority of cases, councils have not been included at all, and a number have passed motions or issued statements condemning the process. Under this Government, changes have been initiated with no proper consultation or engagement locally with the public, patients or staff. Without accountability to local democracy, we cannot ensure that health and care systems are relevant to the people and places they are intended to serve.

STPs’ lack of accountability is even more significant given their role in administering spending reductions. Analysis by the Nuffield Trust found that some STPs are targeting up to 30% reductions in areas of hospital activity, including out-patient care, A&E attendances and emergency in-patient care, over the next four years. Those reductions are being planned in the face of steady growth in all areas of hospital activity. Too often, such initiatives encourage short-term savings, to the long-term detriment and overall cost of the NHS.

We should not forget that hard-working frontline staff bear the brunt of these pressures. It is sadly unsurprising that hospitals report growing shortages of doctors, nurses, midwives and therapists, while these bureaucratic bodies flourish.

--- Later in debate ---

[Mike Gapes (in the Chair)]

Order. I remind hon. Members that they should not make lengthy speeches in interventions. I would be grateful if all Members bear that in mind in future. I will not be very kind if I get the sense that we are getting three or four speeches from one Member.

[Faisal Rashid]

Thank you, Mr Gapes. I thank my hon. Friend for his intervention. I agree with him to some extent, but I think his microphone was not working, and it was very difficult to hear what he was saying. That needs to be looked at.

The Warrington and Cheshire STP is completely unworkable. It has the second largest footprint of the 44 STPs, covering 2.5 million people, 12 CCGs and 20 NHS provider organisations. There are so many bodies involved that the STP has been almost impossible to co-ordinate. It required £755 million in capital funding to be deliverable. Against a backdrop of cuts to NHS capital budgets it is unsurprising that the STP has made little progress.

Integrated care providers represent the latest iteration of the changes. Although ICPs could drastically change health and social care provision if adopted, their implementation is taking place without a vote or a debate. The details setting out what an ICP will do were published during the summer recess, with very little publicity. An ICP can be awarded a contract to deliver a general practice for up to 10 years. Significantly, these contracts can also be awarded to private companies. One of the criteria used to assess bids will be

“whether they are able to deliver value for money,”

moving away from an emphasis on quality and choice. Does the Minister believe that these changes should be made without parliamentary consent?

Mr Gapes, forgive me for using these confusing and seemingly never-ending abbreviations. The communication of the changes has been another major flaw in the process. Indeed, I echo the criticisms in the seventh report of the Health and Social Care Committee, published earlier this year, which noted:

“Understanding of these changes has been hampered by poor communication and a confusing acronym spaghetti of changing titles and terminology, poorly understood even by those working within the system. This has fuelled a climate of suspicion about the underlying purpose of the proposals and missed opportunities to build goodwill for the co-design of local systems that work more effectively in the best interests of those who depend on services.”

This unnecessary use of abbreviations and complex terminology has shut out the public and excluded them from the debate over the future of the NHS. The Government have a clear a responsibility to make the debate around NHS reorganisation far more accountable and accessible to the public.

Moving on to health and social care integration, there is broad consensus that if the NHS is to maintain levels of service provision while making the efficiency gains demanded of it, the integration of services across health and social care is vital. Demands on the NHS are becoming increasingly complex, and long-term integrated care has the potential to transform the lives of millions of patients, as well as improving the patient experience. It has huge potential to save money by cutting down on costly emergency hospital admissions and delayed discharges. However, a recent report on health and social care funding by the Institute of Fiscal Studies revealed:

“Social care is facing high growth in demand pressures, which are projected to rise by around £18 billion by 2033-34, at an annual rate of 3.9%.”

This is not something that can be done on the cheap.

For patients, the lack of integration of health and social care can be a maddening experience. I am sure many Members have heard complaints from constituents about having to constantly repeat their story to any number of different health and social care professionals. In my constituency, a community-led healthcare non-governmental organisation passed on the following patient comment, which sums up the problem well:

“When I get on a plane, there is a lounge, passport control, security, air traffic controllers—lots of separate organisations. But what I experience is a trip from A to B. In health and social care what most people experience is A to Z, B to Z etc. having to repeat their stories each time.”

This confusion is the outcome to be expected from the unnecessary complexity and fragmentation that has characterised NHS reorganisation for several years. The fear is that the next NHS reorganisation will not take into account or optimise the 80% of individuals’ wellbeing impacted by the wider determinants of health—housing, employment and connectedness to the local community.

In my constituency, Warrington Together offers a potential way forward as a locally appropriate, collaborative model of care. Its rationale is a return to the principles of the NHS when it was established in 1948: a single taxpayer-funded organisation working to a single integrated plan; promoting healthy lifestyles; utilising doctors and hospitals, as well as community care, social care and mental healthcare; and striving to keep an entire population well in the most efficient way possible, with enhanced stewardship by those who are locally democratically elected.

Warrington Together offers the opportunity to stimulate a social movement to ensure that changes to healthcare are more accountable to the local population. It has established a third sector health and social care alliance, which is an umbrella group made up of 12 local voluntary health and care providers, who can act with one voice and be contracted as a single entity. That will enable a broad range of providers to come together, offering such diverse care as housing and home repairs, mental health support, and links to local leisure and cultural opportunities. While that is not without its challenges, it represents something we should try to achieve on a national scale: involving local stakeholders to provide integrated health and social care services.

My last topic is healthcare infrastructure. NHS reorganisations need to be informed by infrastructure needs. Buildings need to be more efficient and cost-effective. It is estimated that one third of GP surgeries are conversions of former Victorian terraces, 1960s bungalows or former offices. They are often unfit for purpose and cause significant waste. Innovative and modern infrastructure helps to reduce energy and utilities costs to our NHS, while also protecting our environment. The less money we spend on the maintenance of outdated NHS infrastructure, the more money we can spend on long-term care.

I have a number of questions for the Minister to answer. How can he justify the creation of ICPs without a parliamentary vote or debate? Does he acknowledge that ICPs are moving away from an emphasis on quality and choice by allowing bids to be assessed based on whether they are able to deliver value for money? How can he explain the Government’s decision to keep accountable, elected local officials out of the NHS’s decision-making process? Without accountability to local democracy, how can he ensure that health and social care systems are relevant to the people and places they are intended to serve? Will he now acknowledge that the Health and Social Care Act 2012 has been a disaster for the NHS, creating a fragmented and overcomplicated system that fails to meet patients’ needs?

The 2012 reforms have been likened by one commentator to

“a football team reorganised in such a way that the defenders, midfielders and forwards have to contract formally with one another for a certain number of tackles, saves, passes and goals, according to a general plan laid out by the manager, even though all the money comes from the same source: the club, and ultimately the fans. To make things more complicated, on match days, fans are encouraged to swap their tickets for another game, at another stadium, with other teams.”

Is that not an effective summary of these reforms? Finally, does the Minister agree that the unnecessary use of abbreviations and complex terminology has functioned to shut out the public and exclude them from the debate over the future of the NHS?

--- Later in debate ---

[Faisal Rashid]

First, I thank all the Members who took part in this very important debate: my hon. Friends the Members for Coventry South (Mr Cunningham), for Mitcham and Morden (Siobhain McDonagh), and for Ellesmere Port and Neston (Justin Madders); and the hon. Member for Strangford (Jim Shannon). I also thank the Minister for giving some reassurances and the answers to some of my questions.

I will make a couple of points. I have heard time after time that there are more doctors and 11,000 more nurses than there were in 2010. Clearly, the demand has been even greater, which is why there are still shortages. We really need to invest in more doctors and more nurses, to cope with the demand for them, which is quite significantly higher than the numbers from 2010 to 2018 that the Minister cited. The numbers do not really make sense. The Minister also mentioned value for money. He said that there was no privatisation as such, but he is not ruling it out. At the same time, if value for money is the criterion, one will definitely think that privatisation will happen.

In conclusion, the NHS is a very precious institution for all of us; the Minister agreed with me about that. I urge him to look very carefully at reorganisation and to get everybody involved. Let us work together to make it happen for the people of this country in the long term.

Question put and agreed to.

Resolved,

That this House has considered NHS reorganisation.