Westminster Hall
Thursday 14 May 2009
[Janet Anderson in the Chair]
NHS Next Stage Review
[Relevant documents:First Report from the Health Committee, Session 2008-09, HC 53—I, NHS Next Stage Review, and the Government’s response, Cm 7558.]
Motion made, and Question proposed, That the sitting be now adjourned.—(Claire Ward .)
2.30 pm
Mr. Kevin Barron (Rother Valley) (Lab): May I say how pleased I am to be in Westminster Hall to debate a report from the Select Committee on Health? The last time that we attempted to have such a debate on the Floor of the House, it was knocked down the pecking order by two statements, and we barely had an hour left for it. At least, we have ample time to debate the report and the Government’s response today.
Hon. Members might be aware that “High Quality Care For All: NHS Next Stage Review Final Report” was published by the Department of Health on 30 June 2008. That was the latest of many reviews of the national health service. The Department stated that the review was different from others because it was led by an eminent surgeon—Lord Darzi—and was the subject of a wide-ranging consultation. For probably the first time, that consultation was not just with NHS managers or senior civil servants, but with clinicians themselves.
I was contacted about the shape of the consultation that took place in my region of Yorkshire and Humber, because people felt that the representatives from the acute sector were too prominent on the original board. That alleged imbalance was put right. Indeed, the Government responded to some people’s concerns that the primary sector of health care was not represented and, for the first time, many clinicians were consulted. Will my hon. Friend the Minister say how many were consulted? I am not sure how many clinicians throughout the country were consulted, but doing so was probably a first for the national health service, and is a good thing.
The report’s main focus is on improving the quality of care provided by the NHS. Variations in quality have been known about for a long time. As Lord Darzi acknowledged, those variations continue despite the doubling of NHS expenditure in real terms since 1997. Lord Darzi also believes that, during the past decade, health policy has rightly focused on access and argues that it is now time to improve quality. I will come to our comment about that, but the focus has been on access. Even five years ago, in my constituency, the wait for things such as orthopaedic surgery on knees and hips was years—not months or weeks, as it is currently. There has been a big move in relation to access, and that is to the credit of the NHS.
The Committee published its report on the review on 13 January this year. We took oral evidence from a wide range of witnesses, including the Royal College of General Practitioners, the Academy of Medical Royal Colleges,
the British Medical Association, the chief executives of three strategic health authorities, academics and national health service manager representatives. We also held an evidence session with Professor Lord Darzi himself and David Nicholson, who is the chief executive of the NHS. Many of the review’s key recommendations have been made in previous reports and White Papers, but, nevertheless, we still welcome the extensive consultation undertaken as part of the review and the emphasis that it places on improving quality throughout the system.
The Committee’s main finding was that there are doubts about the capability of primary care trusts to implement Lord Darzi’s recommendations successfully. Despite the Department’s world-class commissioning programme, which aims to improve PCT commissioning, the NHS does not afford PCT commissioning sufficient status. As we said in the report, we found that to be “striking” and “depressing”.
Like most things in the NHS, some aspects of it are good and some are not so good. We cannot sign off any report by saying that commissioning must be present in all aspects of the quality improvements that we would like to see in the NHS. It would have been wrong to come to that conclusion. Some parts of the NHS are quite sensitive about the comments made about the lack of comprehensive commissioning. Indeed, that issue will cost me a couple of hours next Friday morning, when I will meet someone from a national organisation and the chief executive of my local PCT to discuss what they think are some of the report’s implications. That is not part of this inquiry; it is just something I am happy to do.
If the people who I meet in any way think that the evidence that we took was inadequate or we were wrong in our conclusions, I will be more than happy to go along with that. I think that our conclusions on commissioning were well thought through. Perhaps it was a bit emotive to use the words “striking” and “depressing”, but at least we brought the issues forward, so we can further discuss the ability of the NHS overall—or, indeed, of individual PCTs—to commission for quality. I will come on to that in a moment, because it is a different issue.
We are also concerned that the review provides little detail about costs and that it provides many priorities without ranking them. In the NHS, everything is a priority—if someone is ill, what is wrong with them is a priority. We thought that there should have been some prioritisation in the review. However, it was not surprising that that was not the case, because it has happened in many past reviews.
On quality costs, although Lord Darzi argues that improving quality saves money in the long term, that is not always easy to demonstrate. Of course, if we do not know the costs of these things, it is difficult to demonstrate that. An assumption is being made by Lord Darzi that, if quality is improved in the NHS, costs will be saved. That is a difficult assumption to accept without good and reasonable evidence. Certainly, during the years that I have been on the Health Committee, many of our reports have occasionally commented on the woeful omission of good, cost-effective evidence before decision making takes place. There has also sometimes been a lack of effective clinical evidence, which is something that we clearly need to consider.
The review proposes to seek improvements in quality through better measurement and the provision of financial incentives for providing a high quality of care. We strongly support the principle of using financial incentives, but we recommend that the Department should proceed with caution. Schemes such as advancing quality and PROMs—patient-recorded outcome measures—that link the measurement of clinical process and patient outcomes, must be piloted and evaluated rigorously before they are adopted by the wider NHS.
My reading of the NHS, which I truly support as an institution and an organisation that looks after the health of this nation, is that it is equitable in most respects—although not all. Such a situation has been going on for many years, but not much evaluation is done before things are rolled out, which is one of the reasons why many people who work in the NHS—as people have done for 60 years—get somewhat demoralised on occasions, particularly when a missive comes down from Richmond house without much justification other than, “We think that this is a good idea.” It seems that evaluation, knowing what works and piloting good schemes is the way forward in that respect. The evidence should be taken to those parts of the NHS that could do better and we should say, “We’d like you to improve what you’re doing on the basis of this evidence, which we have proven works in similar circumstances.”
The review also reiterated the Department’s plans to create 150 general practitioner-led health centres—one for each PCT in England. We welcome the provision of additional primary care services and acknowledge that there are strong arguments for increasing provision in under-doctored areas. However, the expansion of supply needs careful management and evaluation to determine whether it leads to better evidence-based medical interventions for patients and whether it reduces the disparities in health care access and utilisation between different classes. I do not want to drift off into our report on health inequalities. It has presumably been sitting on a Minister’s desk, but we are expecting the Government’s response to it soon. We believe that there should be better evidence-based medical interventions.
It should also be recognised that investment in primary care might increase demand for hospital care, as deprived people get better access to care and as referrals increase with more diagnostic tests. That is an interesting concept. If one considers the number of people that the NHS has served over the years at GP or another level, notwithstanding that other health professionals such as pharmacists speak to people about their health needs, even in times of plenty, when unemployment was low—before the current recession—there was no lack of attendance at GP surgeries. Just because people are better off financially and perhaps in many other ways, or just feel much better about life, it does not mean that they do not go to the doctor. That is an interesting point. More contact may mean that there will be more referrals to the secondary or hospital sectors.
Jim Dowd (Lewisham, West) (Lab):
While my right hon. Friend is on the subject of GP-led health centres, or polyclinics, as they are known—I do not know whether he will refer to this later in his speech—the Committee welcomed in some measure the establishment of what he has just described. However, it also expressed concern at the uniform—some would say doctrinaire—
attitude of the Department of Health that every PCT should have such a centre. We felt that that was far too prescriptive and that it would not necessarily be advantageous for every area, even though it would be for some areas.
Mr. Barron: I shall move on to that. My hon. Friend is absolutely right. This is probably one of the areas about which the Government feel a bit sensitive. Although some PCTs would undoubtedly benefit from more primary care services, particularly those in areas that are under-doctored or that have a high burden of disease, it is less clear how others would benefit. We are not convinced by the Department’s argument that all PCTs should have a GP-led health centre.
Whether a PCT has a centre should be decided locally on a case-by-case basis, as a witness stated, using the best clinical evidence available and a full assessment of the costs and the impact on patient access. PCTs should not make their decisions on a whim. National criteria should be set out to ensure that the benefits and costs of their decisions are known. I and the Committee were disappointed that neither the Government nor the witnesses who appeared before us as representatives of doctors could tell us what criteria should be used to decide whether a PCT needed a GP-led health centre.
I have no doubt that other Members in this Chamber, like me, might have had in their constituency a campaign run by the medical profession when the proposal was introduced. Before the local government elections last year, I had one doctor from a practice of five—not all five doctors—putting out letters saying that people should demonstrate in the ballot box against the proposed changes in primary health care. The letter was about a new primary care health centre in Rotherham that would be open seven days a week for 12 hours a day.
If we look at the disease burden of the three constituencies that cover Rotherham, there is a good case for a centre, in my view—this is anecdotal, to some extent—or we can look at the health profiles of the communities, which are not very good in most circumstances. The only things that make the Rotherham and Sheffield health profiles look good for the region are profiles of places such as Hull and Bradford, but they do not look good when the detail of the problems that we have are studied.
I had a public meeting with that doctor and some members of his association locally. I believe that we agreed that it would probably be a good idea to have the new primary care health centre in Rotherham and that there is a need for it. One of the witnesses who was a representative of one of the professions told us that he worked in a part of East Yorkshire that is, by and large, well off. That does not really mean that everyone is in good health. He said that one centre was going into his PCT, but that there was probably an argument that they ought to have two or three in Hull. Given the profile of the city of Hull and the surrounding area, I think that he was probably right.
It was greatly disappointing that the discussions that we had last year, which have ended now—I am pleased about that—were based on assumptions and not on any agreed criteria about where centres should go. Decisions should be based, by and large, on the health needs of the population, not on the structures of the NHS. All the members of the Committee felt strongly about that.
Another area that we looked at—at this stage, it is a train coming down the track—is the Department’s decision to conduct trials of personal budgets for health care. We welcome those trials if they are done rigorously, and if policy makers wait for the results before beginning any large-scale roll-out of the programme. We would be happy with that.
One or two members of the Committee received briefings prior to the debate. I want to quote from one that I received from Diabetes UK:
“Diabetes UK believes it should be clearly enshrined in legislation that Personal Health Budgets of any kind (notional, third party or direct payments) remain voluntary for pilot schemes and in the event they are rolled out further.”
I do not know whether my hon. Friend the Minister has seen the briefing. Diabetes UK goes on to state:
“Having a personal budget for the entire care package for a complex, changing and progressive condition such as diabetes, could potentially result in individuals receiving suboptimal clinical care if their budgets run out, or a process of self rationing in order to achieve all desired goals within budget.”
I thought I ought to mention that.
I know that my hon. Friend will tell us that the proposals are part of the Health Bill that is in the other place at present—it has not yet reached us. First, I would like to congratulate the Government on piloting the scheme. I hope that the results will be measured and evaluated properly before the scheme is rolled out.
I thought that I ought to mention what some of the major charities that work with people with long-term conditions feel about that prospect. They are not saying no, but it is clear that we must be careful to ensure that it does not disrupt the needs of people with long-term conditions.
The review also makes several proposals for improving work force planning and the quality of leadership in the NHS. The Committee welcomes the Department’s focus on those areas following the severe criticisms in our report, “Workforce Planning”. However, we note concerns that planning will be concentrated in the Department. Strategic health authorities have a key role in work force planning, and we believe that the Department should take steps to ensure that regional NHS employers are given a role in identifying future work force requirements.
When we were doing the work force planning inquiry, we looked at the projections made for the increases in the work force that were very much needed when the Government came to office in 1997. I recall that one of the figures—this was announced in 2000—was that we wanted another 20,000 nurses within five years. Within four years, we had 64,000 more nurses in the system—a 340 per cent. overshoot on what the politicians at the centre predicted.
The Committee tried to investigate why that happened—this is in a different report. By and large, it happened because there was little or no strategic planning for the work force inside the NHS. We think that the Department should use the reconfigured SHAs as one way to improve work force planning, and we hope that that will be taken on board.
We argued that it is unfortunate that the review does not place more emphasis on the importance of recruiting and developing better managers. In many inquiries, the Committee has heard concerns about the quality of management in the NHS, and witnesses to this inquiry
echoed those concerns. I am not having a go at management, or saying that managers are not needed. They certainly are needed in our NHS. I know that managers, and the number of them, have often been easy targets for politicians of all parties, but we should be looking at the quality of managers and what they are doing to ensure that patients get better-quality treatment than they have had in the past.
“Some managers lack the analytical skills or motivation to handle and interpret the wide range of performance and routine administrative data, such as Hospital Episode Statistics, that they have to deal with. With the introduction of PROMs and other quality related measures this issue is becoming ever more important. The Department must address the issue of weak management skills in this area with urgency.”
If we are going to measure the outcome of a patient episode from a quality point of view, as opposed to a quantitative point of view, we need to know how to measure and what we are measuring, and we need to ensure that quality is high on the agenda.
The Government response was published in March 2009. They argued that PCT commissioning would be improved through the Department’s world-class commissioning, saying:
“It is a ground-breaking and ambitious programme that... will help PCTs deliver better services, which are more closely matched to local needs, resulting in better quality of care, improved health and well-being and a reduction in health inequalities across the community.”
We have heard similar claims before in such responses.
If my hon. Friend looks at the Government’s response to the Committee’s inquiry on dental services, he will see that such claims were made at that time, too. The Government also stated that practice-based commissioning would be supported and extended, even though it had not proved popular with many GPs. Is that improving now? I saw some statistics last week that showed that, in respect of the measurement of practice-based commissioning, practices were doing it, but not for everything. There are issues with that.
The Government also accepted our recommendation that incentive schemes for improving quality, such as PROMs and commissioning for quality and innovation, should be properly trialled and evaluated before their widespread implementation. I understand that, strategically speaking, there is a pilot scheme taking place in your constituency, Mrs. Anderson, in respect of the quality up in the north-west of England. I met the chair of the SHA for the north-west at a gathering and said that I might spend one of my days in the recess not lying on a sunbed in a country off the Indian ocean, but going over the Pennines to have a look to see what is happening with that trial. Although this report is now gone, I have no doubt that hon. Members would be interested in how that SHA is measuring quality, how it proposes to do so and the likely effect of that on other parts of the NHS.
The Government reiterated their commitment to extending choice and personalisation in health care and said, again, that this would be piloted. I welcomed that earlier.
| Next Section | Index | Home Page |