Free Enterprise Group- A New Beveridge

November 22, 2012

I have written a new report on welfare reform for the Free Enterprise Group- called A New Beveridge. It offers new ideas for the Welfare State, 70 years on from Beveridge’s original proposals.

A New Beveridge

Overseas Visitors and the NHS

September 10, 2012

My new report on the cost to the NHS of unpaid debts from foreign nationals is now available, including five steps that the government can take to reduce the problem.

The Missing Millions

I have also written a summary of the report for Conservative Home:

Two more articles on social care

July 11, 2012


Leading social care out of the long grass:

Ending the roulette wheel of care:

Labour’s Social Care Failure- 13 Years in the Long Grass

July 9, 2012

A new report that I have written, dealing with Labour’s appalling record on social care since 1997:

Labour’s Social Care failure

Recent articles

June 27, 2012

In reverse chronological order.

PFI: Labour’s NHS landmines:

On encouraging a savings culture in social care:

Health tourism and the NHS:

Personal health budgets:

Free Enterprise Group report on social care:

The Social Care Market- Fixing a Broken System:

Europe and the NHS

April 30, 2012

From last week’s Westminster Hall debate on the European Working Time Directive:

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Following my hon. Friend’s two-year campaign, the exact financial cost and burden on the NHS caused by the directive is becoming clear. On 18 March, The Sunday Telegraph published a freedom of information request about the cost, and some of the figures have been read out, but I want to read out a few more to place them on the record. Of the hospital trusts that provided figures, 80% admitted spending more than £1,000 per shift on medical cover as a result of the EU working time directive. In total, £2 billion has been spent on that since 2009, which is roughly equivalent to the wages of 48,000 nurses or 33,000 junior doctors.

We have talked about inequalities. It is worrying that some trusts are clearly suffering more than others, and some are in extreme financial difficulties. Yet North Cumbria University Hospitals Trust spent £20,000 on hiring a surgeon for one single week. Mid Staffordshire NHS Foundation Trust—my hon. Friend the Member for Stafford (Jeremy Lefroy) referred to this—spent £5,667 for a doctor for just one 24-hour shift in a casualty unit. The Christie NHS Foundation Trust in Manchester spent £11,000 on six days’ cover for a haematology consultant. Scunthorpe general hospital offered £100 an hour for one month’s work in a temporary post. Princess Alexandra Hospital NHS Trust in Essex paid more than £2,000 for a locum doctor to work a 12.5 hour shift last October.

I could go on, but I want to come back to that £2 billion in two years, and to relate it to the Nicholson challenge, which is a cross-party issue, of saving £20 billion to reinvest back into front-line services. The challenge was set in 2009 by the previous Government to take place over three years. As a result of the comprehensive spending review, that has now been extended to four years. No MP can claim that that is a cut by one Government or another, although some MPs have tried to. It is a cross-party approach, and we in the Chamber are responsible and understand that if the NHS is to remain free at the point of use, regardless of ability to pay, we need to make savings and to reinvest them into front-line care.

The coalition Government have already done a fantastic job in making savings of about £7.5 billion on the way to the £20 billion figure. But the reality is that, if this £1 billion a year cost to the EU working time directive remains, that will be a £4 billion cost over the period of the comprehensive spending review. Therefore an extra £4 billion will need to be found in efficiency savings. We are moving from a 20% efficiency gain, therefore, to almost a 25% one. [Interruption.] It appears that the Minister disagrees, but it is just a back-of-an-envelope calculation.

Charlotte Leslie: My hon. Friend is contextualising this debate in an important way, in respect of wider finances and the Nicholson review. Reverting to the question of evidence, does he agree that simple figures, such as these, on the cost of a directive that has been introduced are also evidence? The first-hand reports of clinicians on the ground are perhaps more reliable than the evidence gathered from sources that might not always be willing to tell the truth about the situation, for fear of not meeting compliance targets.

Chris Skidmore: Absolutely. On the figures I mentioned, only 34 hospital trusts responded to the requests for information, so the data were incomplete. Only 83 out of 164 responded with any data at all.

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Debbie Abrahams: Is that not the point? This is about ensuring that we have quality data to inform policy development. It may not be working as it should be—I will accept that—but we cannot use incomplete, poor data to propose solutions. We need to ensure that we have quality data to inform that process. What if I made a statement now and that was regarded as evidence? Surely we are not going to base policy on just one person or on poor data.

Chris Skidmore: I agree. I am sure that all hon. Members would echo such a call. We should have complete data. The complete data, if we had them, would show that the situation is far worse and that, instead of the £1 billion a year cost, the hidden cost is, according to the data that I have, perhaps £2 billion. We do not know.

My hon. Friend the Member for Bristol North West, almost like a Cassandra, warned that this would be a problem back in 2010, and started the campaign with no data at all. Two years down the line, we find what she said to be true, in respect of data from individual trusts. We will know more, probably, by the end of this year and there will be more stories in the Sunday papers and it will become an ever bigger issue. That is why it is so important to have this debate now, because when the public and patients who use the NHS ask, “What were you doing about this, as MPs?”, we can say, “We’ve had this debate. Okay, it’s not come up with all the solutions just yet”—we are interested to hear what the Minister says about possible solutions—“but we are on the case.” That is important, because an avalanche of cases will come forward in the near future. It is important to recognise that.

There is a challenge from Nicholson and we need to make those savings. The problem is that this matter is standing in the way of the Nicholson challenge being effectively delivered. Either we have to push harder to gain those efficiency savings—the problem now is that we have inefficiencies of the worst kind and are essentially having to make more efficiencies elsewhere to reinvest in front-line care—or the money will not be reinvested back into front-line care. Working time directive costs are classed as front-line care, when clearly they are not, so money is being removed that could be spent on nurses or on alternative equipment for the NHS that would have benefited patients.

Mr Simon Burns: My hon. Friend might find it helpful to know—he is talking about the Nicholson challenge and asking, “What were we doing during this”—and might take some comfort from the fact that, since May 2010, the cost of locums has fallen by 11%.

Chris Skidmore: I appreciate that information. I only have pre-coalition data from 2007-08 and 2009-10, although they are not inaccurate. It is interesting to note that, before the coalition came in, the cost of locums was rising enormously, from £384 million to £758 million. The coalition’s inheritance was enormous. It is good to hear that there has been an 11% saving, which is roughly £75 million.

Mr Burns: Let me give my hon. Friend the precise figures on the savings. The number of people employed as locums by the NHS has fallen by 11% since May 2010, and the number of doctors in the NHS has increased by about 4,000.

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Chris Skidmore: I welcome those figures. The coalition Government clearly recognise that front-line care is in danger of becoming atomised. We want continuity of care and front-line doctors, and we want full-time doctors and nurses rather than locums. Over the past couple of years—I am not blaming any one Government in particular—we have seen a sort of fragmentation and atomisation so that we now have 50 agencies delivering locum services, one of which has a turnover of £100 million a year. We need to look at that issue. The working time directive has been blamed for the rise of locum doctors, and it is good to hear that the coalition Government are making strides to change that, and we must recognise that in this debate.

The issue of training has been raised, as well as the fact that 400,000 hours of surgical time are lost every month—that is 4.8 million hours every year. My hon. Friend the Member for Hastings and Rye (Amber Rudd) was very informative about the impact that that will have on surgery as a craft, and I appreciate that. Professionalism is an issue, and the clock on, clock off attitude is not what any of us wants to see in the NHS. We want professionals to be in charge of their services in the NHS, and such an attitude clearly puts them out of charge.

On the timeline, the Secretary of State for Health claimed that the “Time for Training” report by Sir John Temple reinforced his,

“determination to support efforts to resolve these difficulties and be ready to work constructively with the European Commission and other member states on radical, creative approaches to gain additional flexibilities.”—[Official Report, 9 June 2010; Vol. 511, c. 14WS.]

The Prime Minister responded on the Floor of the House to a question from my hon. Friend the Member for Bristol North West:

“My hon. Friend raises an important issue about the working time directive and its effect on the NHS. Nobody wants to go back to the time when junior doctors were working 80 or 90 hours a week, but I think we all see in our constituencies that the working time directive has sometimes had a bad effect on the NHS…The Health and Business Secretaries are committed to revising the directive at EU level to give the NHS the flexibility it needs to deliver the best and safest service to patients. We will work urgently to bring that about.”—[Official Report, 18 January 2012; Vol. 538, c. 745-6]

My hon. Friend, and others, have spoken about other countries such as Spain, the Netherlands, Ireland and Portugal, which all somehow manage to get around the directive. I was interested to read my hon. Friend’s article in The Times where she wrote about what happens in the Netherlands and stated that Dutch trainee doctors are categorised as autonomous workers because they earn more than three times the national minimum wage. Being classified as working for themselves exempts them from the directive. There is a similar situation in Ireland where training has been exempted from the definition so that work done by trainee doctors falls outside the directive.

We must either look at the EU angle—many Members have raised the issue of the European Union—or at what the British Government can do within the NHS. GPs are self-employed. Can we not think radically and ask to what extent doctors working in hospitals could also be classed as self-employed so that we can get round the regulations? That is worth thinking about, although I am not sure what the consequences would be.

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Mr Burns: I really do not want to be a clever clogs. My hon. Friend has accurately described what happens in the Netherlands, but even with the opt-out, weekly hours in that country are limited, in that case to 60 hours.

Chris Skidmore: Sixty hours would be a start—65 is what most people seem to be calling for. It is about getting a balance. We do not want to go back to the 80, 90 or 100-hour working week, but nor do we want to face the consequences of the 48 or 56-hour working week. There is a balance to be struck, and I would be very interested to hear what the Minister thinks can be done. This debate is obviously an interesting one because it can go down a European direction, which I know a Health Minister cannot say very much about today. However I would be interested to hear what he has to say about the NHS in his capacity as a Health Minister.

Ian Paisley: There is also the issue of bean counting. We must be very careful, because this debate is about delivering something to the patient and ensuring that the team around the patient, including the doctors, co-ordinate their work to meet the needs of the patient. If we get into very strict bean counting—whether we are talking about 48 hours, 60 hours or whatever—and do not recognise that this is about a patient-centred service, we will keep having more and more of these problems that we have discussed. That is the critical issue, and why we need the flexibility.

Chris Skidmore: I entirely agree with the hon. Gentleman. Patient-led care is where we must get to. That is why we are all here; that is what the Health and Social Care Act 2012 will deliver. I am sure that we will all be working further to ensure that the patient is placed at the heart of the NHS.

Social Care Debate- House of Commons 8th March

March 9, 2012

Chris Skidmore (Kingswood) (Con): I start, like others, by congratulating my hon. Friend the Member for Truro and Falmouth (Sarah Newton) on securing this debate, bringing out the urgent need to tackle the issue of the future of social care, and ensuring that we face up to the responsibilities of looking after the elderly of today and tomorrow. We have heard humble messages from the Minister and the shadow Secretary of State about their willingness to work together. The spirit of cross-party agreement is encouraging.

As the right hon. Member for Leigh (Andy Burnham) said, these issues go right back to Beveridge in 1942, when the average life expectancy was 69 and social care was not an issue to be considered within the realms of the state. The right hon. Gentleman mentioned the “sixth giant”, and he is right that we need to revisit Beveridge for the 21st century and perhaps to look again at what Beveridge considered to be most important—the contributory principle. The contributory principle for social care will be all-important when we look at how to deliver social care reform.

As we know, reform is desperately needed. The arguments over the funding of our social care system are well practised, but let us rehearse some of the statistics, which are becoming more familiar with every debate we hold. The number of those aged over 85 will double by 2030, and during the course of this Parliament alone, more than 1.4 million people will turn 65—one in 10 of whom will have a long-term care need that will cost more than £100,000. We should also make it clear that this problem is not unique to the UK. Germany and Japan have recently taken radical action to reform their systems. However, the UK has a specific problem that makes finding a solution to the ever-growing problem of social care particularly difficult: most people simply do not understand the system. They do not understand that social care and the associated costs of getting older are not free, as the Minister stated, and nor have they ever been.

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That point was made in the Dilnot report, and it cannot be stressed enough. I wish to highlight two of Dilnot’s recommendations. First, he states:

“To encourage people to plan ahead for their later life we recommend that the Government invests in an awareness campaign.”


“The Government should develop a major new information and advice strategy to help when care needs arise.”

The acknowledgement that more needs to be done to inform the public is welcome. In reality, until one is forced to interact with the system, there is a serious lack of information compounded by an assessment procedure that is often unrealistically complicated. For many elderly people, part of the shock that comes from being forced to sell their house to pay for care is the unexpected nature of that situation. In some respects, we are facing a problem of responsibility and of planning ahead. Although people are now accustomed to the idea of preparing for their old age with regard to pension provision, there remains an aversion to preparing for the eventuality of future frailty and ill health. Few of us wish to admit that we will grow old and frail and need help and support, before it is too late.

The solution to the funding crisis brought on by an ageing population will inevitably require individuals to pay more, and from an earlier age. Whatever we do to change the current system, it is absolutely essential that a much clearer picture of the relationship between contribution and entitlement—precisely as Beveridge set out—is at the heart of that.

Reform requires realism. Even if the Dilnot proposals are implemented in their entirety, they will not provide the full solution. Whatever cap on care costs is set, domiciliary care costs and annual living costs are not taken into account. A new system that is able to lever more private funding into the system will ensure that we can provide the best deal for the elderly, but it will require an understanding that we need to grow an insurance market to maturity that is then sustainable in the longer term. That will not happen overnight. This is a process that will take between 10 and 20 years.

The current Government have taken the first important steps to reforming the system. As hundreds of billions of pounds are being talked about in respect of the current euro crisis, it is easy to forget that the Government’s decision to give an additional £2 billion a year to social care in the 2010 comprehensive spending review was the greatest ever increase in social care funding, and will lead to a vast increase in resources. We are investing more than ever before in carers and respite care, recognising the huge contribution that they make to our country, selfless in their service to their partners, parents, families and relatives.

In addition, a greater focus on personalisation and individual budgets, combined with an increased use of resources such as tele-health, will put more control over care into the hands of individuals, ultimately allowing new providers to provide more tailored services, thereby driving down costs at the same time as improving quality. Placing the person at the heart of their care has the potential to transform social care services, which for too long have been led by inefficient monopolies.

The Prime Minister’s recent call for greater integration of health and social care is equally welcome. I am a member of the Health Committee, and we called for

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that in our recent report. If we fail to address the social care problem, the NHS will end up picking up the tab. Every unplanned hospital bed admission for the elderly is a mark of the failure of social care to prevent that from happening in the first place. We know that if we can reduce demand for hospital beds by just 10%, that could free up £1 billion that could then be redirected into community-based care services. We must recognise that hospital is not always the best place for care to take place and redirect resources to reflect that.

In preparing for the Committee’s social care report, we visited Torbay, and I was particularly struck by the experience of integrated care there. Torbay’s primary care trust and adult social services have been combined into Torbay Care Trust, following which five integrated health and social care teams were established. They seek to be proactive in managing patients and to work in partnership with GPs. In Torbay, a team was also introduced that was specifically charged with monitoring patients in hospital and discharging patients where there is pressure on beds—again, the team is working closely with clinical professionals. That has helped to cut out unnecessary lengthy hospital stays and delayed transfers of care. As a result, Torbay now has the lowest use of hospital bed days in the south-west region, as well as the best performance on the length of stay. The chief executive of the NHS, Sir David Nicholson, has said:

“I have seen the future and the future is Torbay”.

He did so because it is the elderly who will benefit most from integrated care. Complex long-term conditions complicated by age can be properly managed only with a collaborative approach.

John Pugh (Southport) (LD): Torbay has, for some time, been a model of good practice and the fact that this good practice has not spread much further than the confines of Torbay is something of an enigma. Would the hon. Gentleman care to comment on that?

Chris Skidmore: Torbay was one of the sites for the pilots set up in alliance with Kaiser Permanente, which came over in 2003. Interestingly, it is instructive that one of the problems the NHS faces as an institution is that, although it creates fantastic pilots and the NHS innovation centre is working hard on rolling them out across a wider area, that process encounters significant delays. Good models of care should be spread out far more widely and far faster.

What most elderly people want from their health care system is simplicity. They do not want to be moved around constantly from pillar to post, waiting for specialists to see them; they do not want to see a host of different medical professionals, each of whom is unfamiliar with their case; and they do not want to languish in hospital beds when they could be more comfortable at home. The most important change must be a cultural one. There may have been a tendency in the past for health care to be reactive, responding to medical crises as they arise, but the future must be very different. To paraphrase John F. Kennedy, we do these things not because they are easy but because they are hard. We know that we face a challenge that will define the landscape of health and care for the decades to come—it is a challenge that all in this House cannot be willing to postpone.