Below is the transcript of my debate in the House of Commons earlier today on NHS rationing in Devon, and which has forced a u-turn on some of these rationing decisions, although the fight is not over yet.
Mr Ben Bradshaw (Exeter) (Lab): Last week, on 3 December, the Northern, Eastern and Western clinical commissioning group, responsible for commissioning health care on behalf of the population of Devon, excluding Torbay and south Devon, announced a package of cuts, restrictions and the ending of some treatments and operations altogether. The decisions included denying all planned operations to smokers and people with a body mass index of more than 35, the issuing of hearing aids to be restricted to one ear, and cataract operations to be restricted to one eye. Some treatments and operations were to be stopped completely, including certain varicose vein treatment, shoulder surgery and earwax removal.
In her letter to me, the chief officer of NEW Devon CCG, Rebecca Harriott, indicated that this was just the start. She wrote:
“Other measures are still being considered. Some will be for the longer term, but some will be announced in the coming months. We anticipate that there will be further measures for a full or partial suspension identified during December and for implementation from January.”
This constitutes the wholesale rationing of health care in Devon—rationing in the NHS on an unprecedented scale, as well as a return to the worst ever postcode lottery. It means that people in Devon—or most of Devon—who have paid and still pay their taxes in exactly the same way as everyone else in England will not be able to get the operations and treatment they need because of where they live. People over the border in Somerset, Dorset and Cornwall still will, as will those in Devon who are registered with a GP in Torbay or south Devon.
This is how the Royal College of Surgeons, the professional body that represents hospital doctors, reacted to Devon’s announcement:
“Access to routine surgery should always be based on an individual’s clinical need. The Government has been clear that restricting clinically necessary treatment on the basis of financial considerations is unacceptable. We urge the Department of Health and NHS England to review the situation in Devon.”
So my first question to the Minister when she responds is: will she review what is happening in Devon, as the Royal College has requested?
The professional bodies and charities representing the hard of hearing and partially sighted have also responded with outrage. Britain’s main deaf charity, Action on Hearing Loss, said that it is appalled by what is happening, pointing out that the decisions were made without any consultation with local people, health care professionals or the wider hearing loss sector. Paul Brecknell, its chief executive, said:
“This is a service that’s been available since the birth of the NHS. Hearing loss is a serious health issue, which, if unmanaged can lead to isolation, dementia and mental health problems”.
My constituent, Mark Worsfold, was born profoundly deaf and works as a radar scientist at the Met Office in Exeter. He e-mailed me describing the new policy as
“morally, legally and financially indefensible”
and he went on:
“I rely entirely on lip reading for communication. What many people don’t realise is how much of lip reading is guess work. Hearing aids can make the difference between highly educated guesswork and incomprehension. Having just one hearing aid doesn’t mean your lip reading ability is halved, it can destroy it completely.”
The National Deaf Children’s Society told me that the decisions made are “unthinkable and entirely unethical”, and called for their immediate reversal and the publication of the evidence on which the decisions were based. That leads me to my second question to the Minister. Will she publish, or will she require the CCG to publish, all the clinical evidence on which these decisions have been based?
The Royal College of Ophthalmologists condemned the decision to ration cataract operations to just one eye. A senior consultant told me that it is likely to cause people who are losing their sight to fall, particularly on stairs, and will lead to a big increase in hip fractures, one of the main reasons for pressure on hospitals, again costing the NHS more in the end.
On the proposed weight restriction, I was contacted by a constituent, Kate Bolsover, a former NHS nurse and care assistant, who said the following:
“I’m overweight due to having arthritis and severe issues with my spine that require heavy medication that increases weight gain. I’m doubly incontinent because of abuse from my ex-partner and I need an operation to fix that, but because of these cuts I won’t be able to have my operation, and without it I won’t be able to go out. I feel doubly discriminated against by an NHS I worked so many hours for with passion.”
Medical experts and health care professionals have told me that they believe the cuts and rationing announced in Devon breach the NHS constitution and Devon’s own CCG guidelines. These state that access to services should be governed by the principle of equal access for equal clinical need. They also believe that the cuts and rationing breach the clauses on discrimination in the NHS constitution, and the duty contained in it and the CCG’s own local framework to reduce health inequalities.
A number of people have told me that they are preparing legal challenges. The weight restriction alone, according to figures provided by the CCG, could affect as many as 11,000 people a year, and the smokers’ restriction even more than that. One smoker from Exeter e-mailed me this morning to say:
“I am a smoker yet I could be denied an operation here in Devon if I don’t give up. As a taxpayer, surely this must be illegal. I can’t refuse to pay my taxes, yet I can be refused to use a service I help fund. This is so wrong.”
Even the Minister’s own Conservative colleague, the Secretary of State for Communities and Local Government, stung perhaps by suggestions that he might fail Devon’s new weight criteria, has told my local newspaper, the Express and Echo, that he believes that what is happening in Devon is “anathema and un British”. Simon Stevens, head of NHS England, told the Health Committee this week that he had “reservations” about what is happening in Devon. He said that all health organisations need to abide by the NHS constitution, and that the Government could step in if they do not.
So my next question to the Minister, which I have repeatedly asked in letters to Ministers and NHS England but to which I have had no reply is this: what assessment has she made of the compliance of what is happening in Devon with the NHS constitution? It requires equal access based on clinical need, it forbids discrimination and it requires health inequalities to be addressed. If when she studies what is happening in Devon in full she or Mr Stevens agree with me that it does breach the NHS constitution, will she or NHS England intervene? Perhaps she already has, because less than an hour before this debate was due to start, a letter pinged into my computer inbox from Devon CCG announcing that it was dropping the weight and smoking proposals. That is right, Madam Deputy Speaker. Who says Parliament counts for nothing? However, this is no way to run our precious NHS.
I pay tribute to all those who have helped me and others with the campaign against this rationing, although the battle is not over yet. The rest of the rationing proposals remain in place, and that brings me to the underlying financial crisis facing the NHS in Devon.
In February, NHS England, Monitor and the NHS Trust Development Authority jointly announced they were sending in consultants to examine and analyse the mounting financial crisis facing Devon NHS. Devon was one of 11 so-called “financially challenged” NHS organisations to be investigated in this way. The work was supposed to find out the underlying reasons for the particularly serious problem that we have in Devon. Was there something that the Devon NHS was doing wrongly? Were there areas where it could work better or more efficiently? Were there other underlying factors, such as the cost of caring for Devon’s disproportionately large and growing elderly population, which meant that Devon was underfunded in comparison with other parts of the country?
In spite of asking for months now for details of that investigation, Ministers and NHS England have failed to provide it. They still have not done so. Instead, the Minister’s fellow Minister, the Liberal Democrat right hon. Member for North Norfolk (Norman Lamb), had the gall to go on BBC Radio Devon this morning and blame the £430 million deficit and resulting cuts and rationing on our local NHS spending money unwisely. When the Minister replies, will she explain what he meant by that? Where has Devon been spending money unwisely? Is she really saying that unwise spending decisions have caused a deficit this huge? This is exactly what the consultants’ investigation into Devon and the other financially challenged trusts was supposed to tell us. Will she now publish the detailed findings of that investigation so that we can know the truth?
As well as the cuts and rationing to treatment and operations that I have already outlined, Devon faces the closure of community hospitals and the highly successful and extremely well used walk-in centre in Exeter is threatened with closure. The Prime Minister and the Health Secretary keep claiming that they want better access to GPs, but things are getting worse. The Sidwell street walk-in centre in Exeter is a fantastic and vital resource for hard-pressed patients who find it difficult or impossible to see a GP at a time that suits them. Its loss would simply add to the pressure on already overstretched local GPs and my local A and E department.
That leads me to the impact of the NHS funding crisis in Devon on the acute sector. My excellent local hospital, the Royal Devon and Exeter, has during the last 15 years or so been one of the best managed and best performing hospitals in England. It recently and unusually missed the Government’s own watered down maximum waiting time for accident and emergency. It is also running a large deficit for the first time ever. When announcing the hospital’s intention to go into the red, its first-class chief executive, Angela Pedder, implied that if it did not, she would not be able to guarantee safe care.
We cannot debate the current situation in the NHS in Devon without mentioning mental health. The problem of inordinately long waits and the shortage of beds for young people has been raised by me and others in this place for the past three years. It was highlighted again recently when the deputy chief constable of Devon and Cornwall police tweeted his frustration at having to accommodate a young girl with mental illness in a police cell for two nights. When I asked the Health Secretary about that last week, he blamed poor communication. He was wrong. The girl was taken into police custody from a general hospital paediatric ward, where she should never have been in the first place, because there was no appropriate children’s mental health bed available for her. The reason it took several days to find her a bed is that she had been turned down for one by private sector providers who, under their contract, do not have to accept patients.
That case is not an isolated example. In the last year alone for which figures are available, 30 children with mental health problems in Devon were taken into police custody while suffering a crisis because there were no beds available. When beds have been found, young people have been sent as far away as Newcastle because there are none closer to Devon. I would be grateful if the Minister could outline in full exactly what the Government are doing—not in the future, but now—to address the scandal of mental health provision for children in Devon. In researching for this speech, I learnt that at any one time there are between two and five children with mental health problems on the paediatric ward of the Royal Devon and Exeter hospital in my constituency because there is nowhere else for them to go. That is totally unacceptable.
I would also like to ask the Minister about concerns I have picked up about how well the various NHS bodies in Devon are working together. There seem to be particular concerns about the relationship between Northern Devon Healthcare NHS Trust and other NHS organisations in Devon. That was illustrated recently when Northern Devon decided to centralise stroke services in the rural market town of Ottery St Mary, rather than near the acute provision in Exeter, which is what the clinicians and all of the other organisations involved wanted.
Until a few moments before this debate, I had not received a reply to any of my letters, but several came pinging into my inbox just before. It is simply not good enough for MPs to have to go through the lottery of securing an Adjournment debate before they can get reasonable responses from health organisations and Ministers. I have now received a response to my letter to the head of the Trust Development Authority, David Flory, but it not particularly reassuring. He states:
“The relationship between Northern Devon Healthcare NHS Trust and North, East and West Devon Clinical Commissioning Group has been strained over the last two years. In 2013, arbitration was required to agree the 2013/14 contract and both parties needed mediation to address in-year issues.”—
it sounds like a divorce—
“The need for formal dispute resolution is often a symptom of deeper issues with local relationships.”
I have been raising concerns about that for months. What have the Government being doing about it?
I asked for this debate because of my growing frustration about the fact that the people of Devon, other Members of Parliament and I were not getting answers to the basic questions we were asking. As I have said, my computer has been pinging all afternoon with sudden responses to letters I sent weeks or even months ago, for which I am grateful. Of course, the most dramatic of them has been the climbdown by NEW Devon CCG with regard to banning operations for people who are obese or who smoke. The Minister, when she replies, might like to tell the House what role, if any, she has played in helping it to reach that climbdown.
However, the underlying financial crisis that I have spoken about today has not been addressed. If the CCG is now not going to do the things that it had already announced it would do, what is it going to do instead? It has already said that this is just the beginning and that more proposals for rationing and stopping treatment will be set out this month and next. Until the underlying financial problem is addressed and we know why there is a particular problem in Devon, it will not be resolved to the satisfaction of my constituents. I hope that the Minister can give answers to me and to the people of Devon now.
The Parliamentary Under-Secretary of State for Health (Jane Ellison): I congratulate the right hon. Member for Exeter (Mr Bradshaw) on securing this debate. He is right to say that Parliament is intended to bring these very important topics to the fore. In securing this debate, he rightly brings a very important subject to the Floor of the House, and I welcome the opportunity to respond. It is a matter of great importance to him and his constituents, but also to other Members in the area. My right hon. Friend the Member for East Devon (Mr Swire), as a Minister in the Foreign Office, and my hon. Friend the Member for Central Devon (Mel Stride), as a Government Whip, are unable to speak in the debate, but let it be noted for the record that they are here in attendance, representing their constituents, and have shown a keen interest in the matter and discussed it with me, as has the right hon. Gentleman.
I start by commending the work carried out every day by those working in our NHS, particularly in the area of Devon that we are discussing. At every opportunity in this House, we should, particularly as we approach the Christmas season, pay tribute to the fantastic work of our front-line NHS workers.
I turn to the service changes to Northern, Eastern and Western Devon—NEW Devon—clinical commissioning group. As the right hon. Gentleman set out, the CCG is facing significant financial pressures, with an end-of-year deficit of £14.5 million for 2013-14 and a similar deficit predicted for this financial year. To address these pressures, the CCG proposed some changes, which it described as “temporary”, to some of the services it commissions in the area. On 3 December, as he said, it announced that it was taking urgent measures to prioritise essential services and the requirements laid out in the NHS constitution.
We recognise that CCGs have to take resourcing decisions based on the needs of their local community, but blanket restrictions on procedures that do not take account of the individual health care needs of patients are unacceptable. Decisions on treatments, including suitability for surgery, should be made by clinicians, based on the individual clinical needs of patients. The Deputy Prime Minister made that point in response to the right hon. Gentleman at Prime Minister’s questions, and I reiterate it now. The right hon. Gentleman has given some very serious and moving examples of patients who would be affected by such blanket restrictions. National Institute for Health and Care Excellence guidelines represent best practice, and we expect NHS organisations to take them fully into account as they design services for their local populations and work towards full implementation over time.
With regard to the latest position, things have moved quite rapidly in the past 24 hours, as the right hon. Gentleman outlined. NEW Devon CCG announced today that it will no longer compel patients to undergo weight loss or stop smoking ahead of routine surgery. It confirmed that patients will instead be offered evidence-based guidance, as we would expect, on the benefits of weight loss and smoking cessation as part of their health care. As a former Health Minister, he would, like me, draw attention to the fact that both those things are generally desirable in terms of good health and the efficacy of treatment. The CCG also confirmed that it would not be restricting in vitro fertilisation treatment or caesarean sections on non-medical grounds.
In announcing its decision on weight loss and stopping smoking, the CCG confirmed that it will continue with a series of other measures that have already been announced, but those will be subject to public consultation in the new year, where appropriate. Discussions are under way to confirm the extent of that consultation. Today I had a telephone discussion with some of the key people involved, including the chief officer of the CCG and the NHS area lead. I know that the right hon. Gentleman and my right hon. and hon. Friends will want to take a full part in that consultation. Indeed, the right hon. Gentleman indicated some of the areas that he will wish to explore in that consultation process.
NHS England has confirmed that it is currently scrutinising the CCG’s proposals and is in close dialogue with it. That has been confirmed to the right hon. Gentleman, with a good level of detail, in a letter to him from the chief executive of NHS England, which I have had sight of. I hope that he has had that letter; I think he has.
Mr Bradshaw indicated dissent.
Jane Ellison: If not, I apologise on behalf of NHS England. I was informed that the letter had been sent to him. I very much hope that it has pinged into his inbox by the time he returns to his office. If, by some chance, it has not reached him, I will certainly make sure that my office passes him a copy. I will also make sure that other right hon. and hon. Members who would want to have sight of the sentiments in the letter do have sight of them.
NHS England has confirmed that it is currently scrutinising the CCG’s proposals. They are in close dialogue and I confirmed that myself in my conference call today. NHS England is seeking assurance that the proposals are in the best interest of patients, which we would all echo; that they are based on sound evidence, to which the right hon. Gentleman alluded; and that they are subject to a well-planned process, including, if appropriate, public consultation.
On the next steps on financial issues—the right hon. Gentleman put this in the context of a longer-term concern—the CCG has stated that its financial projections are being updated in the light of the current pressures and the five-year system-wide assessment of a potential finance gap between resources and the cost of health demand, which the CCG considers will be £430 million, which is a considerable sum.
Devon was one of the 11 financially challenged health economies to be provided with intensive support by NHS England. I understand that the report of that work is due to be published shortly, along with planning guidance, which will be a joint publication with the NHS Trust Development Authority, Monitor and NHS England. The right hon. Gentleman does not have long to wait to see that detailed piece of work on the broader, long-term picture.
Mr Bradshaw: Does the Minister have any idea why it has taken quite so long? Did the CCG drop its smoking and obesity proposals before or after her telephone conversation with it?
Jane Ellison: I will write to the right hon. Gentleman with a response to his first question, as I am not abreast of the detail. The letter to him from the chief executive of NHS England is dated the 10th, so I think that answers his second question. I apologise that he has not received notice, but discussions were under way prior to my phone call with the local NHS leads, during which we touched on the issue.
As part of the work I was just referring to, an extensive, detailed analysis of services and costs in the NEW Devon health economy was undertaken. The NHS England area team director of finance has given significant support and challenge to the CCG to understand its financial position and to support the development of a financial recovery plan. The area team has also been engaged with the CCG through the quarterly assurance process and agreed a set of actions with time scales to improve the financial position.
I stressed in my conversation today the urgency of the matter and the clearly enormous public and parliamentary interest in it. Parliamentarians have a very important role to play in being a bridge between health officials and the public and the constituents they represent, as reflected by the interest shown in this debate by Devon MPs. The CCG and NHS England will meet next week to consider the CCG’s medium to long-term financial plans. It is an important meeting and I have asked to be kept abreast of those developments.
I will ask the Minister of State, Department of Health, my right hon. Friend the Member for North Norfolk (Norman Lamb), to write to the right hon. Gentleman with more detail on the mental health issues he has raised.
The right hon. Gentleman has also raised concerns in the House and elsewhere about the walk-in centre. That is dealt with in some detail in Simon Stevens’s letter to him—I repeat my regret that he has not had sight of it—so if he has further concerns after reading it, he might want to raise them with the chief executive. However, he is, of course, always welcome to raise them with Ministers.
To return to the central part of this debate, I reiterate that policies providing for blanket restrictions on treatments for particular classes of patients based on lifestyle characteristics are unacceptable, and various Ministers—including, as I have said, the Deputy Prime Minister at PMQs this week—have made that clear. Any general policy on prioritisation of services must be robust, evidence-based and justifiable. In addition, any general policy must take account and make provision for an individual’s clinical situation, an example of which was given by the right hon. Gentleman.
CCGs have statutory duties to consult, inform or otherwise engage with the public about commissioning decisions, and duties to promote the involvement of individual patients in decisions about their care and treatment. We fully expect that the CCG will be mindful of those obligations when making any decisions. As I have said, I have stressed the importance of good communication, which is absolutely vital. I have had personal experience as a constituency MP, as well as a Health Minister, of communication not reaching the right people at the right time, resulting in confusion and sometimes distress for constituents and patients. It is therefore very important to get such things right, and I expect all local health economy leads to be extremely mindful of the need to involve local parliamentarians and other democratically elected people.
Mr Bradshaw: Does the Minister accept the importance not only of good communication, but of functional relationships? The letter from David Flory about the dysfunctionality of the relationship between Northern Devon and the rest of the heath economy in Devon is very worrying.
Jane Ellison: Functioning relationships are absolutely key to long-term planning. We have all recently seen the “Five Year Forward View” from NHS England, and the Government have expressed their support for the plans and intentions in that document. Co-operation and close working are at its heart, as they are at the heart of any local plans for the short, the medium and particularly the medium to long term. Functioning relationships between different parts of the health economy, as well as between the elected Members in the area, are therefore vital.
I feel confident that the right hon. Gentleman will continue to draw attention to that need. Indeed, throughout the debate my hon. Friend the Member for Central Devon and my right hon. Friend the Member for East Devon have nodded in assent in relation to the importance of good communication.
Important meetings are coming up imminently, and I expect there to be good communication on their outcomes. I have asked to be kept abreast of them. Engagement with the public and others, including MPs, will take place next year on the issues that have to be consulted on.
Mr Bradshaw: I want to put it on the record that the obviously very important and long-awaited reply from NHS England is not one of the many e-mails that have pinged into my inbox today, so I would be grateful if the Minister ensured that I get it as soon as possible.
I feel sure that someone is already working on that, but as I say, we will try to get it to the right hon. Gentleman as soon as possible, and to let other interested colleagues have sight of its sentiments.
I urge all right hon. and hon. Members to engage with the consultation process, and to bring all their constituents’ communications to bear by feeding them into the consultation. I have asked to be kept abreast of those matters. As the right hon. Gentleman will see from the chief executive of NHS England’s response, this important matter is being taken extremely seriously both by Ministers and at the very top of NHS England, as well as by local health leaders.
I hope that the outcome of the discussions and consultations will be a good one—as we require it to be—for the right hon. Gentleman’s constituents and other members of the public in the area. We look forward to seeing how matters progress, and I again congratulate him on bringing this important matter to the Floor of the House.