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.

Reform and the NHS

February 15, 2012

Alan Milburn’s strident article on health reform presents the urgent need for further reform of the NHS in years to come. Unlike another former Health Secretary, Andy Burnham, who seems to have sacrificed his credentials for opposition for opposition’s sake, having once embraced the reforms to GP commissioning and private sector involvement that he now dogmatically opposes, Milburn accepts that reform cannot be an issue simply left to party-politics.

The rise in chronic illnesses, such as diabetes, together with a rapidly ageing population which will see the number of over 85-year olds double by 2030, means that the NHS is facing a perfect storm. As a result, reform is not an option, it is a must: without it, we will not be able to achieve better outcomes at lower costs, or in Milburn’s words, ‘the new holy grail in health policy’.

What is striking about Milburn’s article is its commitment to the understanding that reform is not an event, but must be a continual progress driven by a quest for excellence, productivity and efficiency. This includes a need for integrated budgets for health and social care, advocated by the Health Select Committee last week, increasing payment by results for healthcare providers, ensuring the frontline take ownership of their services, and above all more competition: ‘Monopolies in any walk of life, whether private or public, rarely deliver operational efficiency or respond well to customer demand … competition may not be appropriate for every service, but if the NHS is to meet the challenges of the next decade it will need more of it, not less.’ Andy Burnham would do well to reflect on this.

The most radical of Milburn’s proposals is his insistence that we have to make patients ‘active participants’ in their healthcare. Stating that studies in the US and the UK have demonstrated that giving patients themselves direct personal control over their budgets, as the government has begun to do with personal budgets in social care, ensures that levels of satisfaction rise and public spending fall. He concludes that ‘hundreds of thousands of patients, particularly those with a chronic condition, should have their own personal state-funded healthcare budget.’

These are ideas which Milburn is right to look at- as he suggests, the evidence and experiences in the US demonstrate individual health savings accounts are revolutionising healthcare and delivering better care at better costs. For instance in Indiana, the introduction of Personal Wellness and Responsibility Accounts, which provide the first $500 of preventative care and encourages enrolees to take responsibility for their healthcare, have allowed 40,000 previously uninsured Indiana residents to register with the plan- all of whom are on incomes below 200% of the federally-set poverty level. Health outcomes are up, and costs are coming down.

Obviously the US is a very different case, but if we are to ensure that the NHS remains able to deliver the best possible care to its most vulnerable patients with chronic illnesses, we need to ensure that personal responsibility becomes the watchword within the service. As other evidence from the US shows, by focusing on those with chronic conditions, so-called ‘super users’, often with high rates of obesity, diabetes, or alcohol dependency and addiction, estimated to be around 15-20% of the population who cover 80% of all healthcare costs, healthcare dependency can be reduced and huge savings can be made- to be reinvested in a better service .

With an older population that will be more dependent on care than ever before, tackling the issue of personal responsibility, neglected for too long, is today’s challenge to ensure the NHS’s survival for tomorrow.

The perfect storm that threatens the NHS

January 24, 2012

New article on the NHS for the Telegraph, on the problems implicit in an ageing population:

Foreign Nationals and the NHS- Unpaid Bills

January 16, 2012

Following on from my article on Conservative Home yesterday, here are the full results of my Freedom of Information requests:

Foreign Nationals Final

Sunday Times 4th December- Mapping out a future for the NHS

December 6, 2011

When it comes to the NHS, there is one certainty all commentators can agree upon. By 2050, the NHS will face unprecedented demand: with an ageing population which will see us living longer, pressure on its services will be immense. The status quo cannot hold. Change, as every political party knows, is not only necessary but vital if we are to ensure that the NHS remains free at the point of delivery, regardless of the ability to pay.

Each day, 1.5 million patients are treated by the service; in a month, 23 million will visit their GP surgery. Yet it remains startling that we do little to record who in particular is coming through the NHS’ doors and how frequently they do so. The truth is that, until we begin to seriously analyse who is using the NHS and why, the service will struggle in future to deliver targeted high-quality healthcare within the constraint of its current resources.

The problem of measuring demand is nothing new. But we can learn important lessons from elsewhere. Camden is one of the poorest cities in the USA, with nearly 95% of the population eligible for Medicaid assistance. By 2007, its hospitals were facing a crisis of overcrowding in accident and emergency departments. The situation became unsustainable, yet it took police reform to begin a healthcare revolution. Jeff Brenner, a physician in Camden, joined the board of a new police reform commission. It opened his eyes to new ideas, such as former New York Police Commissioner William Bratton’s Compstat approach of mapping crime and focusing resources on hot spots.

Brenner transferred this approach to Camden’s healthcare, creating his own Healthstat maps.  387,000 records for 98,000 patients were analysed. For the first time, the location of where patients were coming from were revealed. The results were startling. 80% of the total healthcare costs were generated by just 13% of these patients. One patients was even admitted to hospital 113 times in a single year. Taking the top 1% of patients who were most frequently admitted to hospital, Brenner’s team, the ‘Camden Coalition’, were able to reveal that this tiny group of 1,035 patients made 39,056 hospital visits over five years, accounting for 10% of all admissions, generating charges of $375 million- 30% of Camden’s total medical costs.

It became clear that if these so-called ‘super users’ were effectively treated, preventing their readmission, then costs would also fall. The mission was clear: find the patients with the highest medical costs. If Brenner could improve the quality of total care, he could limit the dependency on emergency room use, reducing costs to the system. In 2007, Brenner launched the Citywide Care Management System with this objective. A software programme was purchased, linking the three hospital databases using name, address and date of birth. To begin with, he gathered together social workers and A&E doctors and revealed the patterns he had found, explaining the cost statistics of that most expensive 1%.

What kind of patients were the Camden Coalition seeking out? The first person the team treated was a man in his mid-forties, with severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds. In three years, he had spent as much time in hospitals as out. When Brenner met him, he was in intensive care with a tracheotomy and a feeding tube, having developed septic shock from a gallbladder infection.

Brenner visited him each day. As he began to learn his life-story, which included a combination of poor health, alcohol and drug addiction, living in a welfare motel, Brenner had figured out a few things he could do to help. Some of it was simple. He realised that the plans and prescriptions the specialists had made for the patient’s many problems did not always fit together. Teaming up with a nurse practitioner who could make home visits to check blood-sugar levels and blood pressure, he taught the patient, who had little clue about what medications he was taking, what he could do to stay healthy.

A lot of what Brenner had to do went beyond treatment. He enlisted a social worker to help the patient apply for disability insurance, so that he could leave the chaos of welfare motels, and have access to a consistent set of doctors. The team encouraged him to find sources of stability and value in his life. They got him to return to Alcoholics Anonymous. Above all, the greatest challenge the team faced was not ill-health, but hopelessness.

But change did come. Four years on, the patient had gone without alcohol for a year, cocaine for two years, and smoking for three years. His diabetes and congestive heart failure were brought under contro. He lost two hundred and twenty pounds. If he falls, he can now get up by himself rather than calling for an ambulance. There is no miraculous turnaround to primary care. But through care, and perhaps most importantly patience, results do happen.

Now the team actively seeks out clients- unlike most healthcare systems, including the NHS, where patients simply present themselves, often when their condition is already advanced. The Camden Coalition was able to work with 36 super users in its original programme, who alone averaged $1.2million in costs each month. After the intervention programme, charges fell by more than 56% while the number of hospital visits fell by 40%. And for every dollar spent on the intensive case management programme, monthly hospital costs in Camden fell by $55.

We need a similar ‘care revolution’ in the NHS, creating our own health maps to identify where help and care is needed most. For cost is directly linked to care. The effects of bad care can quickly be measured and defined by the number of patients admitted to A&E. Brenner himself remarked, “Emergency room visits and hospital admissions should be considered failures of the heath-care system until proven otherwise.”

The lesson for our NHS is simple. If we can deliver better care to those that need it most, the overall cost to the system will come down. With demographic changes stimulating ever greater demand, the case for a revolution in care needs to be made now.

How data could improve our experience of the NHS

December 6, 2011

The Prime Minister’s announcement yesterday about opening up access to medical data will help drive future innovation in the NHS, and bring about greater opportunities for scientific research.

In the light of this, I have written an article for the Daily Telegraph on the benefits of extending the use of technology and data in the National Health Service: