NHS in London

Heidi Alexander Excerpts

Thursday 24th March 2016 Westminster Hall

[Bob Blackman]

I will come on to a CQC report on the Royal National Orthopaedic hospital in my constituency in a minute. The reality is we can pick and choose from CQC reports, but I want to ensure that the brilliant doctors, nurses and support staff who work in Northwick Park hospital are recognised for the work they do and not the fear, uncertainty and doubt created by Opposition Members about the performance of an outstanding hospital.

I will move on to the Royal National Orthopaedic hospital in my constituency. The Minister knows about this subject extremely well. The reality is shown in the most recent CQC report, which I will quote directly. It said that the hospital has

“Outstanding clinical outcomes for patients”

in premises that were—and are—

“not fit for purpose—it does not provide an adequate environment to care and treat patients.”

I could not have put it better myself. The reality is that, over the past 30 years, under Governments of all persuasions, we have heard promises to rebuild the Royal National Orthopaedic hospital. The medical and support staff there do a brilliant job; if I took you to that hospital, Mr Turner, you would see for yourself. They are treating patients in Nissen huts created during the second world war. It is an absolute disgrace that staff have to operate in such dreadful facilities. They do brilliant work to rehabilitate patients who come in crippled and leave much better able to live a decent-quality life.

That is why I am concerned about national health service bureaucracy. Previous Governments have committed to funding. The Chancellor stood up at the Dispatch Box during the emergency Budget in June 2010 and agreed and confirmed funding to rebuild the hospital. None the less, we still drag on. It is nothing to do with the Government; it is NHS bureaucracy. I will not go through all the details of everything we and the board have had to do to get to the point where the hospital can be rebuilt.

We have a plan. The hospital will be completely rebuilt. We will have a private hospital alongside the NHS hospital, so that consultants and medical staff will not have to leave the site to do their excellent work. We will sell off part of the land for much-needed housing. Instead of selling it off as a job lot, we will sell it off in tranches to ensure that we get the best value for money, and then the money can be reinvested in the national health service, in the hospital itself.

One would think that, if someone came up with a plan like that, the NHS bureaucracy would be leaping to say, “Yes, let’s get on with it.” Instead, we have had report after report, and business case after business case. I will not, as I did once in the Chamber, describe the 11 stages of the business case that a hospital must go through to get approval for finance. More money is spent on management consultants producing reports than on hospital consultants delivering health services.

[Heidi Alexander (Lewisham East) (Lab)]

I think I agree with the hon. Gentleman on that last point. In last week’s Budget, the Government shifted more than £1 billion within the NHS from the capital budget to the revenue budget. How does he think that helps deliver the kinds of building that we need to provide health services in the 21st century?

[Bob Blackman]

Clearly, the Government must balance the capital and revenue budgets and ensure that they and the national health service are fit for purpose. I believe passionately that it is wrong to expect our medical professionals and brilliant staff across the health service to operate out of substandard buildings. The more that we do to improve them, the better.

As the Minister will know, I have been agitating on this issue for the past six years. I will not stop until we get what we deserve—a rebuilt hospital of which we can all be proud. The reality is that the NHS Trust Development Authority, which seems to dictate finances within the national health service, is holding up this prestigious project. The hospital now has planning permission, and we are ready to go. Immediately on approval by the TDA, demolition of the existing buildings will start, and work will begin on the new hospital in June or July this year. However, the TDA has yet to approve. We now have a further eight-week delay while the TDA looks again at the business case to see whether it is justified. The staff, patients and everyone connected with the hospital are growing frustrated as a result of what has happened over not just the past six years but the 30-odd years before it as well.

We seek assurances from the Minister that the prevaricating TDA will be leaned on to give a decision, which will be to the benefit of the hospital, the patients and the health service in London and nationally, so that we can ensure that this brilliant hospital continues with its great work. I apologise that I will not necessarily be here to hear the Minister confirm the good news that she will do all that she can to make that happen, but I will sit down—

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[Heidi Alexander]

The hon. Gentleman is referring to community pharmacies. One of the latest estimates of the Government’s proposals is that up to 3,000 community pharmacies could close. What impact does he believe that would have on his constituents?

[Paul Scully]

The pharmacists raised that with me last week, and I am meeting a delegation of them next week as well. Rather than an estimate, I want to see more detail on that to work out how we can give pharmacies more information, data and space to use their consulting rooms, to make them the true first port of call. It occurs to me that people tend to look to their GP when they are ill, whereas pharmacists—especially the ones that deliver and go into people’s homes—can see people in their homes and get indicators that may predict other illnesses. Any preventive measures that can be taken through community pharmacists would be very useful.

In conclusion, I come back to the fact that I really do not want to see hospitals and healthcare used as a political football in Sutton or across London. I want to ensure that we have excellent healthcare in St Helier, but this is not about saving St Helier per se. It is about saving and protecting local healthcare, so that every one of the 190,000-odd residents in the London Borough of Sutton can get easy access to a GP, a community pharmacy, A&E, maternity services, children’s services, daycare and the whole range of services in their local area. I want to ensure that they can do that not in a building that is making them feel worse by its very nature, design and crumbling fabric, but in a building that is designed to help them get better.

Sutton has made one innovation particularly well. It is one of two trusts in London that is running a vanguard scheme in nursing homes. That kind of innovation is really interesting: a group of nursing homes have got together in Sutton with the hospital trust; there are ward rounds in the nursing homes, so that the patients do not have to go into hospital. Although hospital is the best place to get treatment, it is not usually the best place to recuperate. The more we can work effectively out in the field—in people’s homes and in care homes— the better. I want that collection of innovations to develop over the next few years for excellent healthcare in Sutton.

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[Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Ms Buck. I congratulate my hon. Friend the Member for Ealing Central and Acton (Dr Huq) on securing the debate, and I thank the Backbench Business Committee for granting it.

I represent the Homerton hospital, which is a foundation trust, and a clinical commissioning group in Hackney that has good, clear clinical outcomes in a very deprived population. The level of deprivation is such that we have underlying population health outcomes that are not good despite the good healthcare available locally.

There is huge pressure on GP surgeries across east London in particular and London in general. Funding for the minimum practice income guarantee is under threat, and recruitment of GPs is very difficult now. Too often, committed but demoralised GPs, many of whom are older, are—in line with national trends—retiring early. We also have a devolution model that is being piloted in Hackney.

Given the time and to give the Minister the chance to respond, I will jump to some of the questions that I want to put to her. I will refer to the McKinsey report that has just seen the light of day today, although it was published in July 2015. It is very worrying. I do not have time to go into the report in detail, but it raises issues about my area that are similar to those raised by my hon. Friend the Member for Ilford North (Wes Streeting). It gives an indication of the gap in the health economy and the funding. We have looked at this type of gap in the Public Accounts Committee, holding three hearings on these issues in recent months. Those hearings have underlined the crisis in recruitment, poor retention of experienced staff and particularly the financial crisis in the NHS.

The PAC, which of course is a cross-party Committee, is not alone in looking into this situation; the National Audit Office has, too. The NAO tells us that in 2014 NHS commissioners and providers overspent for the first time, with a deficit of £471 million. It must have been around that time or before then that McKinsey was commissioned to do its work. We know that the position is deteriorating, despite the efforts of consultancies to come in and save the day—let me make it clear for the Official Report that I am being slightly ironic. The position is deteriorating so much that the total deficit in NHS trusts and foundation trusts is projected to be £2.2 billion.

As I highlighted in my intervention, in a PAC hearing on the subject, Jim Mackey, the head of NHS Improvement —we have also heard from Simon Stevens, the head of NHS England—acknowledged that the 4% efficiency savings target that was established by the Department of Health in 2010-11 was unrealistic. In fact, that target was set by the Chancellor, so I should perhaps absolve the Department of Health a little, as it was clearly set by the Treasury. Both Jim Mackey and Simon Stevens acknowledged that. Simon Stevens has said on the record that he would call delivery of 2% efficiency savings “more reasonable” for trusts. As I have highlighted, we have said in our report that there is not really a convincing plan for closing the £22 billion gap in NHS finances now looming.

I will come back to the McKinsey report as it relates to my own area, referring again to huge financial gaps in the NHS budget locally. However, it also refers to how to deal with those gaps, and that is what really concerns me and it is what I am seeking an answer from the Minister about. The report refers to the engagement that McKinsey had:

“an intensive series of meetings and engagement…with material senior time and…complemented this with numerous sessions with Chairs, CEOs, Clinical Leaders and Finance Directors.”

So McKinsey has been getting people round the table, which is all well and good. However, the report continues:

“This engagement has been focused on building alignment around the case for change”—

so change is looming—

“on forcing the pace of this work and also in scoping future governance changes to sustain more rapid future delivery.”

Will the Minister be clear about what the plans are for “future governance” of health services in my part of London? I am sure that other Members will be interested to hear about their parts of London, as well. I ask her directly: is there a plan to amalgamate CCGs or to establish sub-regional health commissioners in London? We need to know what is happening and what the timescale is for any proposed changes.

Also, while we are considering the budget and the gaps in the budget, what commitment can the Minister make about NHS land? That has been a constituency concern of mine for some time. The PAC has heard fairly recently that the capital released to balance the budget deficit that we are seeing among trusts factors in some land for homes for health workers. So the full dividend of sale will not be taken and some land will be used to build homes for health workers, but figures were very light on the ground. If the Minister is able to respond today on this issue, I would be very grateful; if not, I would welcome a detailed letter from her on it.

In particular, I would be grateful if the Minister provided more information about the list of NHS sites released under the Government’s land disposals programme. The programme was overseen by the Department for Communities and Local Government and required every Department to come up with a list of sites that could be provided to build new homes. So far, it has been difficult to identify the sale of land and how many homes have actually been built. Again, that may not be something that the Minister has answers on today, given that another Department is the lead, but I think her Department should have some figures. Once again, if she cannot tell me about that today, I ask her to write to me about it, because housing for health workers is a key concern.

[Heidi Alexander]

My hon. Friend is making a very important point. I intervene to put on the record my desire to be copied in to the response that she receives from the Minister.

[Meg Hillier]

I am sure the Minister will do that, but I am happy to share anything I receive from her. I am sure she will not be writing me secret letters, and even if she told me that she was I would ignore her, so I hope she provides information that is fully public.

There is a real concern about health workers being unable to afford to buy homes. When a group of local MPs met officials from the Barts trust after one of the trust’s more recent crises—it was around the time of, or just before, the general election—we asked them about the release of land for health workers. We got the distinct impression that those running the trust at the time—we have had new management in since—did not think that it was their responsibility to provide housing; the process was just about disposing of the land to fill the black hole in the trust’s budget. However, we know that health workers cannot afford to live in London and work locally; that is often true of doctors on good salaries, let alone anyone on a lower salary. There will be a real crisis if we cannot recruit health workers, and I will touch on that issue in a moment.

NHS England is keen to lay the blame for the financial crisis in acute trusts at the door of agency staff costs. The Secretary of State announced a cap on the pay rate in October, but the National Audit Office found that that is not the underlying problem. We also touched on the matter in a Public Accounts Committee hearing. It is the volume of agency working, rather than the rate paid, that is the bigger problem—the vacancy rate, requiring backfilling with agency workers, rather than the amount that they are paid. No doubt there is an problem there and the NHS should begin—I hope that it is beginning—to use its purchasing power to tackle that, but the foundation staffing model for hospitals, which is designed to fit the budget allocated by the Department, often has too few staff to deliver the required health outcomes. The NAO has uncovered the fact that 61% of temporary staffing requests in 2014-15 were to cover vacancies, not emergency cover.

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[Heidi Alexander (Lewisham East) (Lab)]

It is a pleasure to serve under your chairmanship, Ms Buck. I know that, on another day, you would be participating in this debate yourself. I congratulate my hon. Friend the Member for Ealing Central and Acton (Dr Huq) on securing the debate and for introducing it in an engaging and wide-ranging way. I commend the excellent contributions of my hon. Friends the Members for Hammersmith (Andy Slaughter), for Edmonton (Kate Osamor), for Ilford North (Wes Streeting), for Hackney South and Shoreditch (Meg Hillier), for Ilford South (Mike Gapes), for Brent North (Barry Gardiner) and for Eltham (Clive Efford). They all expressed their concerns about the quality of care that their constituents receive. It is really good to see my hon. Friend the Member for Ilford South back and to hear his reflections on his experience of the seven-day service. I am not medically qualified, but I want to offer him a bit of advice to help his continued recovery: he should limit his time on Twitter.

Many of us in this Chamber have discussed the NHS in London previously. I cannot but reflect on the fact that, back in 2010, when I was first elected to this place, the NHS was hardly ever raised with me on the doorstep, but at the previous election it came up on every road that I canvassed. It is clear from the many contributions today that the NHS in London is under real pressure. We heard about the huge financial pressure, crumbling buildings and difficulty accessing GP services—and that was just from the Conservative Members.

As a London MP, I know that some of the health challenges that our city faces are specific to the capital. Others, such as the rising hospital deficits and declining staff morale, are symptomatic of problems that affect the whole country and can be traced back to decisions made by this Government and their coalition predecessor.

Let me start with the issues that are specific to London. London is a fast-growing city. More than 1 million more people are living here in 2016 than in 2006. The birth rate is higher in London than in almost every other major European city. London is a city of huge economic contrasts. Some of the wealthiest parts of the country are here, and also some of the poorest.

The vicious cycle that links poverty and poor health is all too evident in the advice surgeries that London MPs hold weekly or fortnightly. Overcrowded, damp housing and low incomes cause depression and anxiety, which place significant strain on the mental health system and the NHS more broadly. London contains diverse communities with different needs, from City workers dealing with stress to recent migrants from war-torn countries, so the NHS in London faces multiple and complicated challenges.

The huge contrast that characterises our city also creates problems in the delivery of health services. The lack of affordable housing, which my hon. Friend the Member for Hackney South and Shoreditch mentioned, and the instability of the rental market makes staff recruitment and retention a particular challenge. The London Health Commission found that NHS staff cited the high cost of living and the lack of affordable housing as two of the biggest barriers to living and working in London.

The sister of a very good friend of mine used to work as a cancer nurse at the Royal Marsden. She lived outside London and commuted into Clapham Junction by train. She then cycled from Clapham Junction because she could not afford the fare to a zone 1 station. Her daily round trip took four hours. It is probably no surprise that she has now moved to a new job in Huddersfield.

Nurses in my constituency rent single rooms in flats, so they can live close to the hospitals where they work. Nurses with families are desperate for social housing because private rents are unaffordable and owning a property is a pipe dream for them. We should use the NHS’s large footprint to solve that problem.

[Meg Hillier]

My hon. Friend underlines my concerns. Is she also concerned about the advent of PropCo? It took land away from Hackney, and we now have no control of it locally. It would do more for health outcomes to turn that hospital land into good-quality housing, rather than luxury flats, which are unfortunately becoming the norm in Hackney.

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[Heidi Alexander]

I entirely agree. We need to look at how we can use the NHS estate to provide more affordable housing for key workers and NHS staff, in particular.

A related issue is the quality of the buildings in which healthcare is delivered. London has some state-of-the-art hospitals but, because of the property prices, some of the poorest-quality GP premises. Some of our facilities look like the first-class lounges at international airports, while others look like unloved community centres. According to figures I obtained recently in answer to a parliamentary question, that difference in quality could get worse. Hospitals in London face a £1.2 billion backlog for key maintenance and repairs, including a £150 million bill for high-risk repairs, which the NHS should address as an urgent priority to prevent catastrophic failure. It might sound like that problem should concern only NHS property managers, but that backlog will have a negative impact on the NHS’s ability to provide high-quality, safe and effective care for patients.

A review of Care Quality Commission inspection reports found hospitals in London with A&E equipment that is a year out of date, and heating that had been left broken for 10 months before being repaired. I do not blame hospital bosses for that situation; I blame Ministers for underfunding them. Rather than an investment in the NHS’s infrastructure, last week’s Budget included a £1.1 billion cut to its capital funding to pay for those repairs. The money is being switched to revenue budgets instead. That might plug a short-term gap on the NHS spreadsheets, but it does nothing to improve the quality of care that Londoners experience. As a number of hon. Members said, capital investment is essential when services are being reconfigured.

London’s NHS faces specific problems. At the same time, it also faces the enormous challenges that affect the whole country. How do we improve morale among a workforce who feel stretched to breaking point? How do we provide high-quality care when, despite what Ministers claim, the NHS faces its toughest funding settlement in a generation? How do we ensure that vulnerable older people are treated with dignity and respect when the budgets that pay for their care are being slashed?

A&E performance is often said to be a barometer for how the health service in general is performing. That is because a well-functioning A&E depends on accessible GP services, the availability of social care and adequate numbers of clinical staff. If we look at the latest A&E performance figures for London, however, they show a bleak picture. The number of people attending A&E has barely changed in recent years—perhaps surprisingly—but the number of people waiting longer than four hours in emergency departments has increased fivefold.

To quote the figures, in the third quarter of 2009-10, under the previous Labour Government, 20,000 patients waited longer than four hours to be seen in A&E; fast-forward six years and in the third quarter of 2015-16, the figure was almost 100,000. When we talk about national performance in A&Es, Ministers try to explain that away by claiming that more people go to A&E, but their claim is simply not borne out by the facts in London. The reality is that focusing solely on the number of people going to A&E is missing the point. We must also focus on the type of person going to A&E.

It is fair to say that in the past six months I have visited more hospitals in London than in the previous 40 years. From all those visits, one image sticks in my mind: hospital wards full of disorientated, frail, older people, many of whom should not be in hospital, and would not be had appropriate care been available for them in their home or community. I am clear—we cannot solve the crisis in our NHS until we solve the crisis in our social care system. That is as true of London as it is of anywhere. Furthermore, A&E is not alone in being under pressure; we can see the same problems affecting the ambulance service, primary care and mental health services.

In the 19th century, London led the way in how we responded to some of the major health challenges facing the world. In this century, London has fallen behind, and other cities are taking some of the bold and radical action necessary to improve health services and to help people live healthier lives. With the right leadership and the political will, London has an opportunity to be that world-leading city once more. I look forward to hearing what the Minister, who is also a London MP, has to say.

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[Dr Huq]

Will the Minister give way?

[Heidi Alexander]

Will the Minister give way?

[Jane Ellison]

No, I will press on, particularly as the hon. Member for Ealing Central and Acton, who introduced the debate, took half an hour for her opening speech. I will give way if I have time towards the end. It is a matter of record that we committed—[Interruption.] All right, I give way to the shadow Secretary of State, if she would like to remind us of what the Labour party pledged at the election.

[Heidi Alexander]

I am grateful that, when making a political point, the Minister is happy to give way to the shadow Front Bencher.

We have been clear that we would always have given the NHS every penny that it needs. However, the calculations for the five-year forward view were predicated on social care being properly funded and there being no further cuts to the public health budget. I think Simon Stevens would say that those two things are essential if we are to deliver a sustainable NHS. Will the Minister therefore tell me how much money her Government took out of adult social care in the previous Parliament?

[Jane Ellison]

We have been clear that we have given a large amount: £3.5 billion has been made available to local authorities for social care. Ditto on public health—we will spend £16 billion over the next five years. If I have time, I will come to the good point that was made earlier about the move to business rates retention. It is matter of record that the Government committed at the election to what the NHS had asked for in the five-year forward view, and we will continue to make that commitment.

The London health system—CCGs and provider trusts—has planned for a deficit in 2015-16 of about £350 million, and overall the system is expected to be in that position. Some recovery is expected during 2016-17, and I am sure we will debate that again. In addition, a £1.8 billion sustainability and transformation fund is available, designed to address provider deficits in 2016-17. However, I think all Members would accept that additional Government spending is not the only answer to the challenges faced by the NHS. We have taken action with our arm’s length bodies to support local organisations to make efficiency savings and reduce their deficits, but much of the change Members have talked about is driven by desire to get better healthcare rather than to make savings. If we can make savings as well, that is all to the good, because we can reinvest them in great healthcare.

In London, from early April, the new NHS Improvement body will be providing additional expert support and capacity to trusts experiencing particular financial challenges. That support will include identifying and implementing financial improvement and helping them to identify savings to put them in a stronger position to maintain those savings.

Let me talk about the pressures on urgent and emergency care. It is acknowledged that the urgent and emergency care system faces increasing pressure. More and more people are visiting A&E departments and minor injury units, which is stretching their ability to cope. Members listed some reasons for that in their speeches. A lot of visits are unavoidable, but some people are visiting because of inconsistent management of long-term health conditions, difficulty in getting a GP appointment or insufficient information on where to go.

Winter sees an even bigger rise in visitor numbers and pressure on staff. Although the debate inevitably dwelled on Members’ concerns about their local healthcare systems and problems in them, I am sure we all want to place on record our huge thanks and praise, as many have, to the staff of London’s NHS, who work extremely hard under a lot of pressure and delivering some really good results against that backdrop. I will come on to that.

London’s A&E units have been significantly challenged this winter, and that has been reflected in performance. However, despite those pressures, the capital’s urgent and emergency care system has proved its resilience, with fewer serious incidents declared than in previous years. This winter, London accounted for just three out of 625 serious incidents declared across England. It is important to praise the staff in saying that.

In January, London’s performance was significantly higher than all other regions, with 90% of patients seen within the four-hour A&E standard. London is also the highest-performing region in England this year to date, with 93.1% of patients seen within the four-hour standard. My thanks and congratulations on that improved performance go to the hard-working staff of London’s services.

Reconfiguration schemes have loomed large in the debate. The health needs of people in London are changing and demands on health services are increasing. The hon. Member for Ilford South in his excellent speech illustrated through his personal stories some of the reasons for the changes in the shape of our health service in terms of how we are investing in specialist services and centres of excellence. The work done to centralise stroke expertise was brought up earlier in the debate. I remind Members, although many will remember, that those changes were bitterly opposed by many people. I am not sure whether that includes anyone in the Chamber, but it certainly includes campaign groups. However, all our London clinicians now say with certainty that those changes, with centralised expertise and specialist care, have saved many lives. That is always worth reflecting on.

People are living longer, the population as a whole is getting older and there are more patients with chronic conditions. We often say that people are living longer, but we forget to say that they are living with chronic conditions for longer, and that presents a longer-term challenge than might be seen at first sight. Heart disease, diabetes and dementia will all increase as they are conditions associated with an ageing population.

We did not dwell on the prevention agenda, but I was delighted that the hon. Member for Edmonton (Kate Osamor) spoke about it. The shadow Secretary of State also touched on it when she mentioned dementia and the problems we all know of older people in hospitals. I urge her to look at the dementia implementation plan we published on 6 March, which is a detailed response to the Prime Minister’s 2020 challenge. Dementia has sat in my portfolio since the election, and that plan is a detailed look at how we deliver against that challenge and in particular at the joined-up care that is key to ensuring that people with dementia have safer and better care in our system and are kept out of the acute sector whenever that is possible.

In a number of areas across the capital, the local NHS has concluded that the way it has organised its hospitals and primary care in the past will not best meet the needs of the future. We are clear that the reconfiguration of front-line health services is a matter for the local NHS, tailored to meet the local population’s needs.

I was glad to hear that Members recently met with Anne Rainsberry. The Members who came to the cross-party “Shaping a Healthier Future” meeting last summer will know it is vital that officials at all levels and NHS managers engage with elected Members. I was therefore disappointed to hear what the hon. Member for Eltham (Clive Efford) said. I will ask my officials to look into that. A number of Members asked reasonable questions about why they could not have certain bits of information. I have some specific answers and it may be that we can take a moment after the debate and I will point them in the right direction.