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NHS Reorganisation — [Mike Gapes in the Chair]

Part of the debate – in Westminster Hall at 3:38 pm on 12th December 2018.

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Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour) 3:38 pm, 12th December 2018

Before we were interrupted by important business in the Chamber, I was referring to contributions from other hon. Members. Jim Shannon gave his perspective from Northern Ireland, and set out clearly what a proper consultation should look like—a standard that, as we have heard, is not really being reached by the NHS at the moment. He also raised issues with the GP out-of-hours service. That is slightly beyond the scope of the debate, but he is right to say that the issue covers the whole United Kingdom. Indeed, recently there have been numerous newspaper reports about people having to wait for many weeks to get a GP appointment.

Looking at current NHS performance, it is clear that, on all key performance measures, as my hon. Friend the Member for Warrington South said, the NHS is struggling to keep up with demand. A&E performance is at a record low this year. More than 4 million people are stuck on waiting lists, and cancer targets are being repeatedly missed. This has led to the Government effectively giving up on trying to meet the NHS’s constitutional targets. As my hon. Friend said earlier, waiting lists for operations are likely to hit 5 million people within the next three years. While the eight years of a financial plan that has failed to keep up with demand have clearly been a driver of that failure, it is also clear that the 2012 top-down reorganisation has exacerbated the issues that the NHS faces.

We have been left with a fragmented, marketised system, which prevents the kind of transformation and integration of services that we would all like to see. At a time when everyone is calling for various parts of the health and social care sector to work together, we remain bound by legislation. As my hon. Friend said, it is this legislation that enforces a siloed, market-based approach, which imposes statutory barriers to integration.

Against this backdrop we have seen a whole series of acronyms encapsulating a range of reorganisations to health services, including STPs, ACOs, ACSs, ICPs, ICSs and so on—all part of what the Health and Social Care Committee has described as a culture of

“changing titles and terminology, poorly understood even by those working within the system.”

It is all clearly an attempt by NHS leadership to reverse the impact of the Health and Social Care Act 2012 by any means that do not require primary legislation or parliamentary oversight. These reforms could have wide-ranging impacts, from causing walk-in centres, cottage hospitals, maternity centres and A&Es to relocate or close altogether, to introducing a new form of 10-year contract, which raises the spectre of private companies once again running our local health services.

I know the Government are not particularly fond at the moment of testing the will of the House, but something as fundamental as transforming our most treasured asset clearly should not be taking place without parliamentary consent. Ministers and NHS leaders are tiptoeing around the 2012 Act, but if we are to have meaningful proposals and an effective integration process, we need an admission that that legislation has had its day. To all intents and purposes, the 2012 Act is no more; it has expired and gone to meet its maker. Yet the Government refuse to acknowledge that central fact.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others a vast and unwieldy network of commissioners and providers with completely different approaches was put together at very short notice. The only beneficiaries of that process seem to be the private consultants who were drafted in to complete these hastily arranged plans. Professor Chris Ham has pointed out that

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Despite the fact that plans were designed to cover the period from October 2016 to March 2021, NHS England and NHS Improvement said in a letter to local leaders last month that sustainability and transformation partnerships and integrated care systems will be expected to develop and agree their plans during the first half of 2019-20. Will the Minister update us as to how many of the 44 STPs developed as part of this process have, as NHS Providers puts it, had no further work done? What was the cost of developing those plans? Can the Minister justify forcing the entire health and social care sector to stop what it was doing and embark again on a hasty and expensive process to come up with new five-year plans, only to be asked to do the same again a few years later? In the few local areas that have proceeded to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean.

The accountable care organisation—now rebranded as integrated care provider—process has the potential to radically alter the entire health and social care landscape, but, again, it is continuing without any parliamentary legislation. One of the primary concerns about that new model is that it would be compulsory to advertise the contracts to the market, and commissioners are forbidden from discriminating between NHS and non-NHS bidders. Bids can be made by a group of organisations, so an NHS trust or a group of GPs could partner with a private company. Previous high-profile attempts to do this kind of thing in Staffordshire and Cambridge collapsed spectacularly with millions of pounds wasted. As my hon. Friend said, it is also deeply worrying that one of the criteria used to assess bids will be whether they are able to deliver value for money. That marks a significant change to the status quo, and one that I do not believe should be countenanced without new legislation.

I have heard Ministers speak on several occasions to assure those of us who have concerns that this will not see mass privatisation. However, during the debate on integration in September, the previous Health Minister, now the latest Brexit Secretary, was asked four times by Conservative, Scottish National party and Labour Members to expressly rule out new organisations being run by the private sector. He failed to do so on every occasion he was asked. Is the Minister now prepared to give that kind of assurance, and if not, why not?

It is also less clear what will happen in the event that an ICP ends up in deficit, particularly if a private sector organisation or a charity has won the contract. While the consultation document sets out that efforts will be made to ensure that ICPs are financially viable, the same assurances have been offered about the existing configurations, and almost half of all NHS providers were in deficit last year. That has led us to the disastrous situation where, according to the 2017-18 accounts published by NHS Improvement, NHS providers owed the Department of Health and Social Care more than £11 billion, up from £8.1 billion in the previous year. That sharp increase was a result of bail-outs given to trusts that ran into deficit as a result of underfunding. Borrowing from the Secretary of State now exceeds private finance initiative liabilities. In 2016-17, £1.3 billion was repaid from trusts to the Department, of which £161 million was interest. Can the Minister set out what will happen if an ICP reaches financial deficit or collapses?

One thing that is clear from the draft ICP contract is that if the annual budgets provided are not sufficient to deliver the current levels of service, the ICP will be responsible for “managing changes in demand.” While there are merits in a system that incentivises keeping people well, there is a clear danger that demand will be managed by accessing patients to treatment. Will the Minister rule out unilateral rationing of services by ICPs if they cannot keep to their budgets? What safeguards are in place to prevent further rationing of services, and who will be accountable in the event that patients want to challenge such a situation? It is far from clear who will ultimately make these decisions and who will be accountable for them. Where the split between the legal commissioner and provider is technically maintained, it is impossible to see in practice how an ICP would not be taking on core commissioning functions.

All this raises the spectre of a new postcode lottery, where patient experiences are uneven depending on who was contracted by an unaccountable panel of commissioners. The whole approach is farcical, and none of this has come before the House for what could be described as a meaningful vote. Experts from across the health and social care sector, and even the chief executive of NHS England, have all acknowledged not only the desirability, but the inevitability of new legislation. Will the Minister commit as part of the NHS long-term plan to set out in full the direction of travel for NHS reorganisation, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for the necessary primary legislation?