NHS and Social Care Commission

Part of the debate – in the House of Commons at 1:51 pm on 28th January 2016.

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Photo of Andrew Murrison Andrew Murrison Conservative, South West Wiltshire 1:51 pm, 28th January 2016

I rise to support the motion, and I hope in my contribution I will be able to explain why. I should first declare my interest as a licensed medical practitioner, albeit one who is in awe of my colleagues in the Chamber who regularly see patients, which is something I thoroughly commend. I think most of the people out there—apart from those who write for some of the more scurrilous parts of our national press—appreciate the fact that there are people in this place who are still engaged in medical practice of all sorts. It makes us relevant, it makes us current and it gives us some authority, as we have heard already today, when we talk about areas of expertise.

There are some omissions in the motion, however. I suspect that its magisterial generality is probably by design; nevertheless, it fails to mention public health directly, which is an important part of the piece. If we are to consider the entirety of health and social care in this country, we need to talk about public health, which I think, if I am honest, has been neglected by consecutive Governments, largely because nobody fully understands what public health is. There is not really an accepted definition of “public health”. It means many things to many people. Some of us still believe, I suppose, that it is a rather old-fashioned thing, to do with the pre-1974 vision of medical officers of health, who dealt exclusively with infectious diseases. It is much bigger than that. Public health pervades all elements of the public service and needs to be addressed head on if we are to deal with some of the pressures we face in the acute sector, as well as ensuring that we meet some of the imperatives that apply to health in this country, which, as my hon. Friend Dr Lee has pointed out, should mean being focused pretty much exclusively on healthcare outcomes.

Norman Lamb mentioned outcomes almost in passing. Let me gently suggest that outcomes, mortality and healthcare experience throughout life are absolutely what we must be remorselessly focused on, and there the story is not a particularly good one, as the Commonwealth Fund made clear. Of course, the Commonwealth Fund report is quoted selectively by those who want to say that our system is the best there is, and that is fine: I trained in the NHS, I have worked in the NHS and I would be reliant on the NHS, so I defer to nobody in my admiration of the national health service and all that it stands for and does. However, it is naive to suppose that it is perfect in all respects, which is what I suspect really lies at the heart of this motion, as we look to the distant future.

The Commonwealth Fund says that outcomes in this country are not good, and I think our people deserve much better. I want outcomes in this country to be among the very best in Europe, not, frankly, in the lower quartile, as is too often the case with common forms of disease. We are betraying those who put us here if we demand anything less than that. The motion is relatively modest, because it tries to work out how we will square the gap towards the end of this decade. I think that, in the minds of those who wrote it, they are worried about the £30 billion—that will apply in five years’ time—but we are perhaps not looking forward to improve on where we are at the moment. There is too much talk, really, of marking time. The concern we have about the gap in funding makes us think that what we have now is good enough, but frankly it is not. We need to be much more ambitious, as we look ahead, about how we improve our health service right across the piece, including public health, to ensure that our health outcomes approximate the very best in Europe and not, in too many cases, the very worst.

Liz Kendall mentioned the Barker report, and she was right to do so. The Barker report was useful. The hon. Lady will not be surprised to hear that I did not necessarily agree with all its conclusions; nevertheless, Kate Barker produced some figures that were useful. She pointed out that spending on health in this country is less than in some of the countries with which we can reasonably be compared. She talks of Canada, France and the Netherlands, and suggests that by 2025 we will need to spend a great deal more of our national wealth on health and, by implication, social care, and I agree with that. She suggested 11% to 12%, which, given the demographics, is probably reasonably modest.

The dispute is about how we would deal with that, because £30 billion does not really come close, given what is happening. It does not come close even if we stand still, let alone seek to improve outcomes in the way I have suggested we must. The question then is how on earth we close the gap—whether we do it through general taxation, national insurance, some sort of hypothecated system or a mutual, as applies in France, for example, or whether we go for co-payment. I suspect there is pretty much a consensus in the House that we can discount some of the options fairly easily, but it is important that the commission that the right hon. Member for North Norfolk seeks to set up should examine all options, even if there is a general understanding that some of them will not be palatable, for a variety of reasons, be it fairness, efficiency or not being geared sufficiently well to the lodestar of outcomes. Nevertheless, we need to examine all options if we are to do this for the very long term, as I believe is the intention.

My hon. Friend the Member for Bracknell was right to focus on structure—something on which I believe there is a need for cross-party discussion and, I would hope, consensus. It is all very well talking about the NHS estate in general, but although what he described from his personal experience was terribly brave, I know from my personal experience that when that is translated into the specifics of our constituencies, for many Members it becomes extraordinarily difficult. It is the local that inspires many people in their love of the NHS. They would love to have their local hospital and local services that they identify with. When it comes to talking about the NHS estate, what we are really talking about is change.

Sometimes change is great locally, because it means a spanking new hospital, but too often it means at least a perception of loss, and people feel that acutely. One of the first things I did when I was elected here 15 years ago was to introduce a ten-minute rule Bill called the bed-block Bill. I find to my horror that, 15 years on, the issues remain. In essence, my Bill was designed to promote community hospitals—cottage hospitals. I had four in my constituency at that time and I felt that each was, for different reasons, under threat. I was a strong advocate for them, and the bed-block Bill, which was designed to promote them and unblock acute hospitals, was duly presented and, like all these things, duly drifted into the sand.

The issue remains relevant, but at the higher level we also need to talk about whether we are right-sized for acute or district general hospitals, and whether we should have these relatively small institutions across the country—far more than there would be in France, for example—offering, or attempting to offer, pretty much the same stuff. An example would be gastroenterology. The British Society of Gastroenterology has produced reports on this issue, pointing out that in many district general hospitals people are not guaranteed to have out-of-hours upper gastrointestinal endoscopy services available to them. I put it to the House that in the 21st century, not being sure that someone is going to be scoped if they have an acute upper GI bleed is simply not acceptable. That is bound to translate into poorer outcomes for a relatively common set of conditions.

It seems to me that the only way we can achieve better outcomes in that kind of situation is to think about whether we need to move towards regional and sub-regional specialist centres rather than continue with the pretence that we can mirror those services in each one of our district general hospitals. More commonly, people talk about stroke and heart attack—and the same applies. It is simply not the case that people will get the same treatment regardless of the hospital they go to.

This is professionally driven. It is the specialists themselves who are saying that we need increasingly to specialise. The day of the generalist is pretty well coming to a conclusion. In order to get that level of specialisation, we must have critical mass, and the only way of achieving that is by having a smaller number of what might be seen as “clinical cathedrals”—large centres offering highly specialist services, geared towards improving outcomes.

The downside is obviously where the cuts then come. Right-sizing the NHS estate inevitably means some will gain and some will lose in the process—in terms of the immediacy of services. Nobody wants to have to travel miles and miles to access services. We get complaints from our constituents about this all the time. There is a process of education for the public to go through. They need to make a choice. They have either immediacy of service just down the road to an institution that will give them sub-optimal care, or better outcomes of a sort that might reasonably be achieved in a regional or sub-regional centre. That is the choice.

Part of the work of the commission suggested by the right hon. Member for North Norfolk will encompass that work of education. That is one reason why, however, I think his 12-month timeframe is very ambitious. I would certainly not want to have a commission reporting in five or 10 years’ time, but the right hon. Gentleman will have to be more realistic about how long this will take if it is going to be an iterative process.

At a lower level, we need better step-up and step-down care. That is at the heart of our ability to unblock some of our acute centres. It is important to look at this issue again. The reason why community hospitals went ever so slightly out of favour relates to the costs of the services they provided, which occurred because the case mix was all wrong. Too often, this became a convenient way of relieving social pressures, admitting people ostensibly for medical reasons to a medical bed when those people primarily needed social care. It always comes back to social care, and if we put people requiring social care into what remains a medical bed, it will of course become impossibly expensive. That is why it did not add up. I am afraid that the onus is on the practitioners and the controllers of those places—general practitioners—to ensure that the case mix is correct. If we do that, community hospitals will become both effective and efficient.