I remind hon. Members participating physically and virtually that they must arrive for the start of debates in Westminster Hall. Members are expected to remain for the entire debate. I also remind Members participating virtually that they are visible at all times to each other and to us in the Boothroyd Room. If Members attending virtually have any technical problems, they should email the Westminster Hall Clerks’ email address. Members attending physically should clean their spaces before they use them and as they leave the room, and take the wipes with them and bin them. I also remind Members that Mr Speaker has stated that masks should be worn in Westminster Hall. Members attending physically who are in the later stages of the call list should also use the seats in the Public Gallery and move to the horseshoe when seats become available.
That this House has considered waiting lists for elective surgical operations.
It is a pleasure to see you in the Chair, Ms McVey. Covid-19 has had a “calamitous impact” on patient access to surgical care. That is the view of the Royal College of Surgeons of England and it is what I want to focus on today. The Government need to receive that a message loud and clear. It is a message that needs to be repeated time and again, that cannot and should not be ignored, and that resonates with millions of people. I look forward to the response from the Minister, who I know takes this matter seriously.
The Government are not responsible for covid, but it is the Government’s responsibility to mitigate its effects through a variety of interventions. The question is whether they have fulfilled that responsibility. I imagine that the independent public inquiry will help us pin down that particular question. Let us hope that, as and when it happens, it is independent and full. The Royal College of Surgeons represents about 30,000 members in the UK and worldwide and, in this respect, it has a pretty good insight into the current calamitous situation facing millions of people, as it puts it.
I am sure it will be helpful if I contextualise the current situation facing patients. The most recent waiting time statistics published by NHS England on 15 April 2021 are worrying, but if taken with the hidden statistics, the position becomes almost overwhelming in magnitude. That is the challenge for the NHS, the Department of Health and Social Care, NHS England and, of course, for the Government’s commitment to ensure that the NHS gets all the resources it needs, as promised by the Prime Minister. I know that trusts and clinical commissioning groups, as well as NHS England, Public Health England, the Department of Health and Social Care and other NHS-related bodies have worked hard over the past year to ensure that services are being delivered as best they can, notwithstanding the unprecedented circumstances. My reason for initiating this debate is to highlight issues of concern. It is a challenge for us all.
I take my hon. Friend’s point about the Government not putting their head in the sand, but I think he referred to the need to plan. Is the real issue that while perhaps they are not putting their head in the sand they need to demonstrate that they are starting to plan right now?
That is a fair point, and I will touch on it later. I know that the Minister is well aware of the situation and has his own challenges in getting the point home to his colleagues in the Treasury, among others. We will give him the support that he needs when he has those conversations.
In terms of support to weather this crisis, the Government cannot put the brakes on this vital area of public expenditure. Given the figures I have outlined, it is better to pre-empt this tsunami, because once it comes, it will be all the more damaging. Putting it right after the fact will be more expensive, more difficult and lives will be in danger, not to mention the ongoing economic impacts for the nation. If we have learnt anything from the covid-19 crisis, it is the point made by my hon. Friend the Member for Bristol South (Karin Smyth) that assessment and planning, followed by focused, comprehensive action, are required.
I have set out the issues as many in the health field have them set out. They are not my figures, they are not made up, they are in the public domain. The Minister knows the organisations concerned, as do hon. Members, so I will not list them.
I have attempted to be as concise and factual as possible and to set the scene, but there is a second element: how the issue can be tackled. The rest of my time will be spent on that. Again, this is not me making this up—is is not the hon. Member for Bootle’s version. It is, in a sense, the health organisations’ view. In this respect, the Royal College of Surgeons has set out a clear way in a comprehensive fashion. Other royal colleges and health organisations have expressed their views too. I have no doubt that the Minister will listen to those voices, which will be helpful and constructive. However, they are also unambiguous in their view of the need for the Government to act now with specific proposals that go beyond a balance-sheet approach. I believe the time for details and proposals is fast approaching.
Before I call Back Benchers to speak, I remind Members that in this 90-minute debate we will be calling the Front Benchers no later than 3.40 pm, and obviously Peter Dowd will be winding up again after the Minister.
It is a pleasure to serve under your chairmanship, Ms McVey, and I congratulate the hon. Member for Bootle (Peter Dowd) on securing this very important debate. I fear many of us will end up repeating some of his points, but hopefully I shall be digging into one or two of those points in a bit more depth.
I start by paying tribute to and thanking our incredible NHS staff up and down the country—not least in my constituency—for their incredible commitment, resilience and hard work. Frankly, they have all gone well above and beyond what they are paid to do and what they signed up for throughout this pandemic, both in treating those with coronavirus and in rolling out the phenomenal vaccination programme. Also, despite what we are discussing today, we must not forget that urgent treatment, urgent surgery and A&E visits were still taking place throughout the pandemic. We must not forget that, so a heartfelt thanks to them.
We often hear that the NHS has coped throughout the pandemic. Indeed, we did not see those awful scenes that we saw in Italy of people being treated in corridors and makeshift tents. I would say, though, that the NHS has coped, but at what cost? We have heard the startling figures of 4.7 million people waiting for treatment. We know that about 2.3 million of those are for elective surgery, and there are all sorts of estimates, of anywhere between 4 million and 6 million or 7 million hidden patients, or those who have not yet necessarily presented. There is that pent-up demand for treatment. We know that two thirds of those waiting for treatment have been waiting for more than 18 weeks, and just shy of 400,000 have now been waiting for over a year. As has already been outlined, the impact on patients’ quality of life, in terms of mental health and excess deaths, cannot be overstated, but I would also like to touch on the workforce impact, before moving to solutions and finance.
It is a pleasure to speak in the debate. I intend to make some constructive comments and look forward to the Minister’s response. I thank the hon. Member for Bootle (Peter Dowd) for setting the scene so very well and reflecting the opinion that we all have. The Minister does not have responsibility for health in Northern Ireland, but I will give him a couple of examples from Northern Ireland as they are replicated elsewhere.
As the hon. Member said, the figures, which we are all aware of, were clearly in the press last week. I had the opportunity to ask the Secretary of State about them yesterday. I did so because of the backlog of operations—I mentioned tonsillitis and children waiting for their adenoids to be removed—with waiting lists growing not just here in the mainland but indeed across the whole of the United Kingdom of Great Britain and Northern Ireland. Those who have spoken have mentioned the concerns and pressures that I have, and they will be reiterated by those who come after. The Secretary of State in replying said that £7 billion would be made available—the hon. Member for Twickenham (Munira Wilson) will be interested in that figure—and through the Barnett consequentials we in Northern Ireland will get some benefit.
The Secretary of State did acknowledge that there is an absolutely massive backlog, but I think that as we slowly get out of covid-19 through the vaccine roll-out—we put on record our thanks to the Minister and the Government for all they have done on that—we need a strategy in place that addresses the backlog of those waiting to be seen. From waiting lists to see consultants to surgery dates being pushed back, coronavirus has brought us from teetering on the brink of surgical collapse to being under the rubble. It is as serious as that, certainly in Northern Ireland, where the waiting lists are gross. The Secretary of State referred to how it is a problem not just in England but in every region in the United Kingdom. We welcome how he and the Government recognise the problems, but we look to the Minister, with no pressure whatsoever, to tell us what is going to happen and how the strategies will address the backlog.
It is a pleasure to speak with you in the Chair this afternoon, Ms McVey. I extend my thanks to my hon. Friend the Member for Bootle (Peter Dowd), who opened the debate so well.
Once more the NHS has been pushed to its limits these past few months, and once more it has delivered an unprecedented response. Every single person working for the NHS has strained every sinew at every hour of every day and night to support as many people and save as many lives as they could. I know how staff in York’s NHS services have stretched their known capability, skill and knowledge, have extended their capacity to care and support, and have served our community without complaint or restraint. For that reason, I echo hon. Members who have said that those staff need to be justly rewarded with a well-overdue pay rise.
At York Teaching Hospital, 1,974 covid-19-positive patients were treated between September 2020 and the end of March 2021, in a very challenging clinical environment, where infection control measures tested staff and the system. The hospital is already a challenged site, and that experience indicates that conversations must commence on the future of the hospital estate in the city. It serves a growing population, and I hope that the Minister would clock that and be open to early discussions about how, over the next decade, we can develop plans to meet the health needs of our city. Already, year in, year out, over the winter crisis it is challenged, but covid-19 has really pushed it to its limits.
As the latest phase of the crisis abates, the next mountain must be conquered. The pressure it causes is relentless. Elective surgery, which was stood down at the beginning of the pandemic, continued through the rest of the period. However, we know that the number of cases has built up.
In York, the independent sector is used to provide some of the cancer care. Good cancer networks were built with the local establishment. It would be good if the Government would publish the amount they have spent on contracts with the independent sector throughout the pandemic. Has it been at cost or at an escalated cost to the state? We need that information so that we can understand the extent of the use of the independent sector and so that lessons can be learnt about the need for national contingency in public health facilities, and about how the private sector is drawn on and whether there are better models out there for procuring services.
It is a pleasure to see you in the Chair, Ms McVey. I congratulate my hon. Friend the Member for Bootle (Peter Dowd) on securing this important debate. I agree with much of what has been said. I am particularly happy to follow my hon. Friend the Member for York Central (Rachael Maskell), who has spoken so well about assessment, diagnostics and rehabilitation from a clinical perspective—a crucial factor to bear in mind.
The hon. Member for Strangford (Jim Shannon) talked about Northern Ireland. In my own work in Northern Ireland looking at health visiting services, the unique circumstances of Northern Ireland history and the ability to make difficult decisions about reconfiguration and so on and to move services on, as well as the legacy of the conflict, meant that there were some severe challenges making it more difficult for people working in Northern Ireland health services to catch up, even before the pandemic.
I pay tribute to the remarkable job done by the NHS, particularly my colleagues in Bristol, and the way that new pathways and new ways of working have been adopted so quickly. We must maintain and build on the innovation and flexibility that we have seen. As a former manager, one of my previous tasks was to try to get digital technology into the service some 10 years ago, looking particularly at dermatology. It was a gargantuan task. It was not bureaucracy and it was not people not wanting to do it that stopped it happening—it was the way the money works. The way the money works in the system does not always reward innovation. That is one of the things we need to learn from this particular crisis.
I also worked a lot with primary care to try to improve telephone communications, in the days before we had all heard the name Zoom. There is quite a lot of evidence about primary care telephone consultations and how they could help meet the demand for primary care, and about clinicians being willing to undertake them. Patients are often a bit reluctant to undertake them. The evidence has not always been clear. What a massive amount of research opportunity we have now to enable us to understand when people like telephone conversations, when they are helpful, how they support primary care and how we can have new levels of resource.
As a fellow Cheshire MP, it is a pleasure to see you in the Chair, Ms McVey.
Every Member who has contributed to the debate has spoken with great knowledge and sincerity about the challenge we face as a society. I pay particular tribute to my hon. Friend the Member for Bootle (Peter Dowd) for securing the debate and for his excellent introduction. As every Member has pointed out, he was right to say that we have record waiting lists. We should never forget that we had already seen a huge rise of over 40% in the decade before the pandemic. As some Members mentioned, it is possible that covid is masking an even worse situation. We know that the number of referrals plummeted around this time last year, as the NHS rightly focused all its intention on the pandemic.
As Members have said, we know that the NHS aims to ensure that no more than 8% of patients wait more than 18 weeks for treatment. That is a target that has not been met for five years, so this situation cannot be laid entirely at covid’s door. Indeed, just over a year ago, in February 2020, 17% of people on waiting lists had been waiting longer than 18 weeks. It is clear that the past year has had an impact, because the figure has now doubled to 35%.
Sadly, it is now the case that over a million people have waited longer than six months for hospital treatment. There are now 388,000 people waiting more than a year. Again, that is the highest number on record. That is nearly 400,000 people waiting for things such as knee and hip replacements. As Versus Arthritis points out, they
“are in extreme distress, with many struggling to cope with pain which is impossible to ignore, worsening mental health and reduced quality of life.”
My hon. Friend the Member for Bootle set out clearly some of the implications not just for physical pain, but for mental health and uncertainty about job prospects. My hon. Friend the Member for York Central (Rachael Maskell) eloquently set out the reduced outcomes and difficulties we will face if the process is not followed as well as we would like and patients enter the system at a later date.
I call the Minister, mindful that we will have a winding-up speech from Peter Dowd at the end.
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What do the statistics say? A record 4.7 million patients were waiting for hospital treatment in February 2021. There were nearly 400,000 patients waiting for more than a year, which compares with just 1,643 people waiting for more than a year in February 2020. That is a significant rise, if ever there was one. Only 64.5% of patients waiting for hospital treatment were treated within 18 weeks in February against the Government’s target of 92%, which was last achieved five years ago. In total, 387,885 people are now waiting for more than 18 weeks. Those patients are our constituents. Each and every one of us will have numerous patients or would-be patients affected by this dire situation.
In my clinical commissioning group area, which covers my constituency and that of my hon. Friend the Member for Sefton Central (Bill Esterson), there were 1,374 people who had been waiting a year or more to be seen in February, compared with eight in April last year. It is a huge increase. All specialities are affected, but notable ones are ophthalmology, trauma and orthopaedics. It is important to note that what is not included is the impact on overdue follow-up activity and routine surveillance outside referral treatment.
We cannot overestimate the strains and stresses that such waiting puts on patients and their families, who do not know whether they will get the operation that is needed, or when it will happen. That point about what the situation means for patients was clearly made by the Royal College of Surgeons. There is a breakdown from NHS England, by specialty, which illustrates the situation that we and, more importantly, millions of our constituents face. In the trauma and orthopaedics surgical specialty that I have mentioned, more than 600,000 people are waiting, including 288,000 who have been waiting for 18 weeks or more and 84,000 who have been waiting a year for treatment. The percentage treated within 18 weeks, compared with the 92% target, is 52%. The figures are much the same for general surgery: 394,000 people waiting, with 60% treated within 18 weeks. I will not go through all the figures—I think hon. Members get the gist.
Such waits affect people in a variety of ways, mentally and physically. There is the obvious issue of pain that can be persistent, draining and debilitating for month after month. Also, of course, there are psychological effects such as distress or worry about deterioration in health, and concerns about the impact on a person’s employment status and the financial costs that might follow from the loss of a job, and subsequent loss of income. Of course, there will be an impact on family members or carers, who in turn have to cope or deal with the impact on the patient. There is the worry that an extended wait for surgery will bring more risks of deterioration in the patient’s condition. In certain situations the patient might need more complex surgery later. Moreover, there is always the concern that in certain circumstances a patient might die while waiting for an operation or other intervention. Those are serious, substantive and worrying issues that we, and particularly patients, must all face.
The parlous state of pre-covid waiting lists has made the covid situation worse, but it is not just a question of the impact of covid on lists. There is also the matter of underlying issues faced by the NHS, which covid has greatly exacerbated. In November 2020, making a comparison with 2019, the Health Foundation estimated that there were 4.7 million “missing patients”, as it calls them, who have not been referred for treatment. In other words, if 75% of those patients were included, the waiting list could grow to 9.7 million in 2023-24. That simply reaffirms the point that I made earlier about the need to plan now.
Many people have not referred themselves during covid to their GP. Getting a slot has often been challenging, to say the least. That element could become a significant factor in relation to cancer surgery: it has been estimated that the number of patients with suspected cancer referrals fell by 350,000 compared with the same period two years ago. That point was made not only by the Royal College of Surgeons but by other health-related organisations. The Royal College of Surgeons is not an outlier, and if the Government do not recognise the calamitous situation that patients now face, they will be ill-equipped to resolve it. I do not suggest that they are in danger of putting their head in the sand; but they are, if they are not careful, in danger of underestimating the scale of the crisis facing the country.
I want to highlight four recommendations. The first is increasing NHS bed capacity. For many years in the run-up to the pandemic, the NHS was far too close to capacity. It was running hot, to use that phrase. International comparisons, which I acknowledge do not tell the full story, but do give a partial story, show that the UK has 2.5 hospital beds per 1,000 people, which is well below the OECD average of 4.7, and behind countries such as Turkey, Slovenia and Estonia. Remember, beds have been reduced from 108,000 in 2010-11 to 95,000 in 2021.
Secondly, during the pandemic the Royal College of Surgeons of England called for the setting up of green or covid-light sites with a separation of elective surgery from emergency admissions. As the college says, there is, “evidence of the risks to patients if covid-19 is contracted during or after surgery, including a greater risk of mortality and pulmonary complications”. In this regard, covid-light sites are critical to process ongoing planned surgery, given that patients and staff are segregated from situations where those who have the virus are treated. In addition, there is a regime whereby patients self-isolate and test negative before any surgical intervention is in operation. Meanwhile, staff without symptoms are regularly tested.
The third recommendation is for surgical hubs. During the pandemic, professionals have worked in partnership to provide mutual aid during periods of intense pressure, thereby enabling a seamless process of surgical intervention. Because of the multi-agency, multidisciplinary co-operation, trusts have also been able to designate certain hospitals as surgical hubs. As such, a capacity for particular types of elective procedures has been facilitated through skills and resources coming together in one place in covid-secure environments. While this hub model, as it is called, is not a total solution, it is none the less a practical way to enable many geographies and surgical specialities such as orthopaedics and cancer to work together.
The fourth recommendation is support for patients, and I touched on that earlier. Again, the Royal College of Surgeons has welcomed the prioritisation of patients in NHS England’s 2021-22 priorities and operational planning guidance. None the less, I agree that we need to go further and provide more guidance about how to develop and expand the options to address those waiting longest, and to ensure that health inequalities are tackled throughout the plan.
In my view, there should also be cross-departmental work on more comprehensive support for those directly affected by covid isolation requirements and people whose livelihood is threatened by longer waiting lists. Before I go on to summarise the four recommendations I have just put to Members, I emphasise that I am aware, and appreciate, that NHS England and NHS Improvement have been working on an elective recovery frame- work covering workforce logistics, clinical prioritisation, patient focus reviews, waiting list validation and patient communication. I welcome that, as will other hon. Members. I acknowledge that the NHS has completed almost 2 million operations and other elective care in January and February this year, and non-urgent surgery times have begun to recover.
In summary, there are four recommendations arising out of the narrative. Recommendation one: the Government should urgently invest in increasing bed and critical care bed capacity across England. Recommendation two: the Government should consolidate covid-light sites in every integrated care system region, and ensure that at least one NHS hospital acts as a covid-light site in each integrated care system in England. Recommendation three: the Government should widen adoption of the surgical hub model across all English regions for appropriate specialities, such as orthopaedics and cancer. Recommendation four: all integrated care systems should urgently consider what measures can be put in place as soon as it is practical to support patients facing long waits for surgery. I would like to put on record my thanks to the Royal College of Surgeons for its advice, information and support in relation to this matter.
Finally, the whole question of workforce-related issues—numbers, pay, conditions at work—needs a comprehensive, fair, equitable and inclusive review. The Secretary of State can initiate a wholesale review of organisational structures in the NHS in the middle of this crisis, which is causing angst and concern across the NHS—we cannot pretend that is not happening. He can therefore initiate a review of the terms that I have suggested.
Many lessons need to be learned from this crisis. I stress the value, commitment and professionalism of all staff in the NHS. Staff across all professions, disciplines and sectors are feeling drained after a year of hard, unrelenting work and we need to thank them for that. Without them, in particular, this country would be in an even worse social and economic predicament than it already is. We owe it to them to ensure that they get all the support they need to support the rest of us. Who could disagree with that?
As the hon. Member for Bootle has stated, it is estimated that approximately half of those with cancer did not contact their GP in the first wave. In fact, I heard a story the other day, via a friend of a friend, about somebody whose cervical smear test was cancelled last year. She was trying to contact her GP with symptoms earlier this year, and was fobbed off. She has now been discovered with stage 4 cervical cancer. I suspect that those stories will be replicated up and down the country. Macmillan Cancer Support has estimated that there are 15,000 missing diagnoses. We all know the importance of early diagnosis. I used to work for a cancer charity and in a pharmaceutical sector that had a big interest in oncology. We all know that surgery, often combined with early chemotherapy and radiotherapy, is absolutely critical in improving life chances and sometimes in being curative.
On the subject of hip and knee replacements, we know that the second and third most common operations are hip and knee replacements. The vast majority of patients needing that kind of surgery have osteoarthritis. Again, waiting lists in those areas have gone up exponentially. It is clear from talking to health service leaders on the ground that these cases are not necessarily in the priority category, which is understandably where cancer resides. As we have heard, though, there is an impact on quality of life, in terms of pain and reduced mobility. A survey by Versus Arthritis found that over 50% of those waiting had increased pain and reduced mobility, and more than three quarters experienced a deterioration in mental health and wellbeing. The longer-term impacts on the NHS and, critically, the social care sector, which was already struggling and on its knees, will be huge. The direct and indirect cost implications, therefore, will be huge, not to mention further complexity from late surgery.
Although this debate is about surgery, it would be remiss of me not to mention mental health. The Minister knows that I have a personal interest in and passion for mental health. We all know that mental health waiting times were pretty dire before the pandemic, particularly for children and young people. Now they are worse still. I am hearing from parents week in week out about not just children, but young people—often those who have crossed from the CAMHS age to being young adults—who cannot access services and are waiting a year or more for treatment. Again, without early intervention and action on these problems now, we are storing up problems further down the line. We know from the Royal College of Psychiatrists survey that two fifths of those waiting for treatment have ended up contacting crisis services. That is not the best way to treat people with mental health conditions. The hon. Member for Bootle mentioned excess deaths, and modelling from the Scientific Advisory Group for Emergencies suggests that we could have 18,200 or so excess deaths that are not covid-related. I implore the Minister to make sure that we start to count excess deaths that are not covid-related. At the moment they are hidden by the covid figures, but I suspect that these delays to treatment are causing a huge number of excess deaths.
The other big issue that I want to talk about is the workplace impact. We know that staff morale is through the floor at the moment. I recently had a meeting in south-west London with other south-west London MPs, organised by the local Royal College of Nursing branch, at which we talked to nurses. I heard from one after the other about how they are struggling in terms of their mental wellbeing and morale. We know from an RCN survey that a third of its members are considering leaving. We already had huge numbers of vacancies in nursing and other parts of the NHS before this pandemic, and the turnover will increase. I have made the case, as have many Opposition Members, for a better pay settlement for our NHS workers—1% is frankly an insult and a pay cut, as we keep hearing again and again. I implore the Minister once again: pay is important, but so is greater support for NHS workers’ mental health and wellbeing. I know that local NHS leaders are trying to do what they can, but further support and a commitment from the Minister would be welcome.
Finally on the impacts, I want to touch on health inequalities. Covid has massively exposed the health inequalities in our country. The thing that I fear most is that those who know how to shout the loudest and navigate the system, and have access to the sort of remote technology that is being increasingly used, will be able to access the treatment they need. I say that as the MP for a relatively affluent part of London, where I suspect a higher than average number of people have access to private healthcare and health insurance, and will be able to get treated through that route. Those who have been worst hit by covid will be worst hit by these waiting lists.
On solutions, I have touched on the need to treat our staff better in terms of pay and mental health support, and reduce the turnover. Importantly, we need to give staff time to recover. That is what I keep hearing from the chief executives of hospital trusts and community trusts on the ground: they need time to recover.
That leads me to my second point on the solutions. I would love to hear the Minister explain why the block contracts with the independent sector ended at the end of March. I would have thought that continuing to use independent sector capacity in the short term would help. A number of the stakeholders who briefed us for today’s debate have raised concerns about the fact that independent sector provision is largely concentrated in the south-east, London, the south-west and the east of England. That is not ideal and could exacerbate the inequalities that I have talked about, but something is better than nothing. If it helps to reduce the pressure on the NHS, it is important that it is looked at as a solution.
Thirdly, I would like to talk about transparency. We need an honest discussion with the public about these waiting lists, and clear reporting about the waiting times for the different waiting lists. We have talked about support for patients who are waiting for treatment, and good, clear, regular communication is an important part of that. I mentioned the need for transparency about excess deaths as a result of people waiting for treatment. The Government need to level with the public if there are tough choices to be made around the prioritisation of what treatment people will get within a certain period of time, or if they will have to travel for treatment. They need to be up front and honest with the public, because that is the only way we will maintain public trust.
That relates to a point that I want to make about communication. We must continue to communicate with the public about whether it is safe to go to hospital for treatment, and we must look at how we engage hard-to-reach groups that might not be embracing some of the digital technology that is increasingly being used to improve efficiency, not just because of infection control measures.
There must be better local collaboration. I want to thank the two acute hospitals that serve my constituency: Kingston Hospital and West Middlesex University Hospital, which are part of South West London and St George’s Mental Health NHS Trust, and London North West University Healthcare NHS Trust respectively. I know they are working incredibly hard on community diagnostic hubs and the surgical hubs that we have talked about, and they are ensuring we have covid-light sites, and so on, in line with the NHS operational guidance. That is to be welcomed, championed and supported. We have touched on having greater support for patients waiting for treatment.
NHS providers have said that we need a bold, transformative approach to tackle these waiting lists, and ultimately that will need to be supported by cash. I will pre-empt the Minister, who will stand up and say, “We have committed £4 billion”—I am sorry to steal his lines. Yes, that is fantastic and to be welcomed, but last autumn the Health Foundation estimated that we will need about £10 billion to deal with the backlog.
We saw in the late 1990s and the early 2000s that the way to bring down waiting lists is huge injections of cash. The Chancellor said he would give the NHS whatever is needed. We know that a lot of these problems come from an underlying lack of funding in the NHS over the long term and that, for four years, the NHS has not met the target in the NHS constitution that 92% of patients should wait no longer than 18 weeks to start elective treatment. That was an underlying problem pre-pandemic, but it has been exacerbated. That is why at the last general election the Liberal Democrats suggested that we should raise income tax by a penny in the pound specifically for the NHS and social care.
I am sure that the Minister has the Chancellor on speed dial, just like the former Prime Minister does, and I know that the Secretary of State has the Chancellor on speed dial. I implore him to make the case for the cash injection needed to tackle waiting times and improve the health of the nation. I am sure he does not need my help, but I and the Liberal Democrats stand ready to help him to make the case, just as the hon. Member for Bootle has already offered.
The Secretary of State always tells me that he has regular contact with Health Ministers in the devolved Administrations. I know that he does, and I welcome that close contact, being on the phone every week—maybe two or three times a week—but I want to ensure that the strategy and the co-ordination are working across all the regions. I will give two examples to illustrate what the issues are.
One of those examples happens to be from one of my own staff, who has two wee girls. One of them is a five-year-old, Lily, who was choking on her food and her drink. After another bout, her mum looked into her throat and saw that her tonsils were the size of golf balls. Those are her words. For a wee girl of only five years old, one would panic right away. She rang the GP, was seen and got an urgent referral to ENT. She then paid to go private, which meant she had to borrow money. Not everybody can do that. She was told that the waiting list was over a year long just to get a consultation. She went to the consultant and was sent home with a sleep monitor, to see where the problems were, which would report back to the doctor. She gave back the monitor after three nights, as requested, and was contacted within two days to say that Lily needed urgent surgery, as her oxygen levels had dipped dangerously low during the night.
Lily’s mother rang the hospital and was told she would have to have surgery in the first urgent slot in April. We are more than two weeks in from the beginning of April, and it has not happened. Lily is still waiting for her surgery and her mother has installed a baby monitor, which speaks, with an on-and-off movement. What a way to live a life, heart in mouth, on eggshells over a five-year-old, listening to the baby monitor all through the night, almost afraid to sleep in case of missing something.
The stress to the family resonates across every one of them. Simple surgery would rectify that. Despite being first on the urgent list, Lily is still waiting. I know the Minister is not responsible for that. The hon. Member for Bootle, who set the scene and had lots of examples, did not go into them all. I suspect that he would have examples very similar to the one I am referring to. Lily’s mother has sleep-interrupted nights to ensure that her child is breathing. A simple procedure would be the solution but, for some unknown reason, the year has passed and we do not seem to be any further ahead.
My second example is a 42-year-old market trader who has worn kneecaps. His business employs 13 local people. He has told me that unless he gets his operation, he will have to close one of his shops, as he cannot physically load and unload the vehicles, and he is losing business. The impact of not getting an operation in time not only affects children but those involved in industry and the economy.
The hon. Member for Twickenham referred to cancer diagnosis. I know of people who had cancer in the past year and, unfortunately, because they did not have their operations, they are no longer here. That is a fact. When the hon Lady mentioned that, I could relate to it and understand, because I know people who are not here today because they were unable to get an operation. I understand that the Government have a responsibility to look after the covid situation, but the time is coming when we need to look beyond that. We need to have a strategy in place, and I look to the Minister for a response on that.
With regard to knee replacements, that 42-year-old market trader is an example of those who need it right now, not years in the future. I also make that point for cataract surgery. Lots of people are not just waiting for the surgery, they are waiting for the appointment to diagnose when it can be done, knowing that they are going blind. Simple cataract surgery can change their lives with real, dramatic and positive effect. We need to be on the ball with these things.
I understand the reference the hon. Member for Twickenham made to mental health. I have seen in my constituency the effect on the mental health of children, some as young as primary age. Schools are suffering tremendous mental health problems. This problem does not only affect Northern Ireland. Just under 4.7 million patients are waiting for hospital treatment in England, as of February 2021. That is the highest number since the referral for treatment data series started in 2007. Although a relatively sharp decrease in numbers waiting was observed from April to June 2020, the numbers have since increased to that record level of 4.7 million in February 2021. It seems likely that the dip from April to June 2020 was due to limited new referrals during the first wave of the coronavirus pandemic.
I always try to be positive when I come to debates. We get the background and examples to set the scene and show what the problems are, but everyone who has spoken so far has very honestly and admirably put forward solutions. I think we are all in the business of solutions. It is about the glass half full rather than half empty.
We need investment. We also need access to private clinics—at some time we will have to look to them—and facilities, and we need action now. With every day that passes, more people are in need; more are in pain and more are in fear, and we must get a hold on the situation. The lists continue to grow as more people’s names are added.
We need a clear strategy that prioritises the backlog of elective surgery. We need the £7 billion that the Secretary of State referred to in the Chamber, which is extra money for this particular purpose. We want to see how that pans out. We need to employ more staff, and extra surgeons as well. What do we have to do to do it? There must be a plan. We have a responsibility. As my party’s health spokesperson, I am very keen to see these matters addressed. I know the Government can do it. If they put their minds to the issue, they can make it happen, but each and every one of us in the House wants to see it sooner rather than later.
While staff have had to be redeployed to respond to covid-19 and address clinical priorities, which is absolutely right, York managed to continue with its planned surgery through the national phase 3 elective services restoration period up until March 2021. It has done really well: it has delivered 96% of the planned elective in-patient activity—ordinary elective and day cases—and 108% of the planned out-patient activity. That equates to the delivery of nearly 3,000 ordinary electives, 36,000 day cases and nearly 400,000 out-patient appointments over the six-month period. That is an incredible feat, because of the constraints—indeed, due to the sharp rise in covid cases in York, particularly following the Christmas period, 564 elective procedures were delayed—but those figures dwarf into insignificance compared with the scale of what is needed now. Nationally, there is a reckoning that it could take about five years to clear the list. And of course the Minister is planning a reorganisation of health services in the midst of all that, which may have some implications. I trust that, in his response to the debate, he can say how that will be bridged.
As we went into the pandemic there were already significant backlogs in elective care, as a result of austerity measures—cuts—being applied to services. That has had its implications in York. We have a high level of recruitment and retention in York—the vacancy rate is just 6%—but clearly there are implications due to the rationing that was applied. As a result, our clinical commissioning group, Vale of York, has applied rationing to services, and I want to dwell on that for a moment, because many procedures are no longer available in the city, but also many involve restricted access for those with a BMI over 30—in the case of hip and knee replacement surgery, it has now been lifted to between 30 and 35—and for those who smoke. We know that that discriminates disproportionately against those who experience socioeconomic disadvantage.
I have debated the issue many times in the House, but to this day I hold, as does the Royal College of Surgeons, that these should be clinical decisions, and should not be based on algorithms to weigh the clinical risks. Of course we all understand that smoking and obesity lead to significantly higher risks in surgery, but far more needs to be done to support people with weight loss and smoking cessation. With surgery already significantly delayed because of the pandemic, to deny people access to a waiting list removes the clinical support that they need. They also need additional support to address the risk factors, not least because we know that, for many people who smoke or are overweight, that is the case because they are dealing with the presentation of their illness. For instance, they may not be able to exercise and mobilise because of pain, which makes them more susceptible to putting on weight—or perhaps because of stress and depression.
We need to see those issues addressed. We need to see far more intervention in the form of prevention at these points, but also it needs to be understood that people should not have to wait even longer for the elective surgery that they need. We know that, over the last 13 months, there has been a serious drop in the number of people accessing diagnostic tests, out-patient appointments and other clinical services, so they are set back even further. And of course it is not just those cohorts of patients who are affected; we know that the effects have gone to so many other areas. As we have heard, the impact on cancer diagnosis has been significant as well. We know that today there are many people living with undiagnosed conditions who will, when they present, have greater risk and poorer outcomes unless this situation is attended to urgently.
Altogether, the waiting lists could double—none of us knows exactly what will happen—for clinical procedures once community referrals catch up. That would just break the system and therefore we need to see more reparation being put in place. I know that the Minister is looking at those issues, but by the time someone receives surgery they are likely to have more complexities, more underlying health conditions and a poorer prognosis. As we have heard in the debate, approximately 18,000 people could also see premature mortality as a result of this. Of course, there is a significant loss to the economy, loss of jobs, loss of income, loss of lifestyle and loss of social connections, leading to mental health challenges as well. We need to make sure that during this period people have access to social prescribing and support for wider needs as well as their clinical needs.
Bearing that in mind, I want to dwell on the issue of diagnostic testing and the fact that attendance in some areas was already low. Will the Minister look at how specialist clinics and testing centres could be set up to screen the population? Just imagine if everyone who had their covid-19 vaccine had a thorough health MOT at the same time. That would have been transformative. I ask the Minister: what can be learned from the vaccine roll-out to be applied to screening programmes and out-patient backlogs, to ensure that the NHS gets back on track with the provision of services as they are needed, and perhaps as a model for the future, too?
I want to raise one more point before I return to elective surgery; that is the issue of research. Research has been significantly shelved over the last year. We know that surgical advances will assist by cutting waiting lists, reducing the risk of procedures and reducing the need for surgery in the first place. I urge the Minister to ensure that there is significant investment in clinical research, and that it is stepped up, not cut back.
To return to elective surgery directly, first, on staffing, we know that we have an ageing workforce and many of those who have stepped up this year are now stepping back. Other staff members are exhausted and, frankly, shattered by their experience over the past year, so we need to ensure that we see that growth in the workforce. I trust that NHS planning and commissioning of training will increase, and not just to ensure that we address the current crisis; that could be extended into the future shape of healthcare. We need to get those figures right and not see the famine and feast that we have often seen in the past—although I cannot quite remember a period of feast. However, we certainly need to see proper provision of staffing.
As for facilities, we cannot dismiss the fact that over the past decade, about 12,500 beds have disappeared from our NHS. Cuts do have consequences and we have paid heavily for that. This is an opportunity to look again at how we configure our services, both on the acute side and in rehabilitation, to ensure that facilities meet needs. All surgery carries risk, so critical care support must be available, but we also need to ensure that more is done to support rehabilitation centres of excellence. Often we see patients being discharged far too prematurely, only to bounce back into the system or not fare as well as they could have done, had they had more rehab before going home. I speak as a former physiotherapist, so obviously I am passionate about that, but it really does make a difference.
In the past, patients undergoing hip, knee and other orthopaedic procedures have often gone to rehabilitation centres. Some of those centres no longer exist. For us in our profession to put people through their paces and gain the confidence they need, we need to make sure that they have those skillsets before they are discharged home. That is because we know that when people get home, the biggest risk from those procedures is that they just sit in a chair and do not mobilise at the level that they could, which of course undoes all that has been achieved. What a waste of money, but also what a waste of opportunity in somebody’s life.
Community provision is still patchy and we know that the sufficiency is not there to give people the time and investment that they need in a domiciliary setting. Following elective surgery we need to optimise not just acute care but the rehabilitation process, and make sure that post-operative care is at an optimum.
Just before I close: as many have said, the numbers are significant, they have risen sharply and the situation requires significant investment. We are moving into a new model of health provision over the next period. It is really important that we get it right and that we ensure that, before the legislation comes to the House later this year, we have the levers in place to address this form of care, locally as well as nationally. It cannot be business as usual. The next crisis is here and needs as much attention as the Minister and his team have given to the last.
I know from older members of my family that, despite receiving a lot of phone calls—I have a lot of respect for GPs who have been making those calls—people still want to see people. They want that reassurance. So much of healthcare is about reassurance and making people feel more in control of their healthcare and that they understand what is happening. We need to bear that in mind as well.
We know that we have a large backlog, but we do not know how large. Others have given some estimates. I met leaders at the Bristol, North Somerset and South Gloucestershire clinical commissioning group last week. They are meeting NHS England this week to talk through the levels of backlog and the size of the recovery. My message to those leaders last week is the same as my message for the Minister: locally, we must have very honest, clear conversations about what that backdrop means. Figures of 5 billion, 7 billion and 10 billion mean nothing to local people. We want to understand the impact on our own healthcare system and what the size of the problem is. That openness and transparency—and involving local people in the difficult decisions that are now with us—is absolutely crucial. It is the only way forward.
I have long advocated open, transparent conversations with the health service, and a more locally accountable NHS. When the Minister is looking at his White Paper in the next few months, he might think about having locally elected leaders on the new integrated care partnerships, to bring some of the local democracy that we need, and the accountability of health services, to local people. Local people understand priorities. They understand what has happened. They understand that there is a huge cost and that difficult decisions have to be made. We need to involve them in those decisions. The answer, unfortunately, for some of this recovery is a huge uplift in staffing, facilities and, of course, money, but that must be offset against what happens if we do not ensure that. I know we are all keen to help the Minister do that.
I was a non-executive director during those days of the Labour Government in the early 2000s, when the effort needed to tackle waiting lists was absolutely phenomenal. There was an enormous effort at both strategic and operational level. The clinical and clerical assessment of the lists required control both from the centre and locally. I am told that regular assessment of the lists is being done in Bristol, but it requires more managerial, administrative and clinical staffing models. When phoning patients to see whether they still require treatment, sometimes people will have died. The people who are making the phone calls and contacting people on those lists need to be hugely sensitive. They need to have experience, and they need to be skilled.
Doing this sort of work is not a basic, low-level, ad hoc and temporary admin job. We need to train people properly to do it. They will be communicating difficult decisions and trying to secure an understanding of the level of need in a community. Sadly, during the covid crisis we have seen poor communications around “do not attempt cardiopulmonary resuscitation” decisions. It is problematic having difficult conversations with people, but we have to trust patients and involve people, so let us learn some of those lessons.
I am old enough to remember the Tory Prime Minister who proudly told us in the late 1990s that we would not have to wait more than 18 months—imagine—for our treatment. We in the Labour party thought that we had banished those days to history. We do not want to go back. Our constituents deserve much better, and I am worried that we will go back to those days and to those terrible lists.
As my hon. Friend the Member for Bootle (Peter Dowd) said, we know that there is a resource issue. We will support the Minister in making those text messages, phone calls and emails—however he decides to communicate with his colleague in an up-front, honest and legal way. We will support him in those discussions with the Treasury. He needs to assure us that he understands the size of the problem, that he will be working with leaders locally, and that when those conversations are happening with NHS England and NHS Improvement, we as local Members of Parliament will have full access and an understanding of the level of need, demand and resource in our communities. That has been my challenge to my local leaders of the Bristol, North Somerset and South Gloucestershire clinical commissioning group. If they turn around and tell me they cannot tell me that because someone at NHS England tells them they cannot do so, I will get straight back to the Minister, whose phone number I have, by text message and email to demand answers.
As my hon. Friend the Member for Bootle said, this is an issue that cannot and should not be ignored. He described the challenges as possibly overwhelming—an apposite description, given that the Government’s strategy for the last year has been to avoid the NHS being overwhelmed. As that challenge was met, we hope that this challenge will be met as well. He also made the important point that, if we do not get this right, it will cost us more in the long run and will have economic and as well as physical and social impacts. The lessons learned from the pandemic ring true in that respect as well.
When we look very closely at the figures, we see that around 18,000 people are now waiting longer than 18 months. The figures we have relate to people waiting more than a year. Obviously, I have discussed this with the Minister on previous occasions and we hope that we will get the official figures shortly. We must remember that at the moment, we only have details for people waiting over a year, but the information I have suggests that more than 175 people have been waiting for more than two years. Those figures are slightly out of date, as they are from January, but that is a horrendous situation and I hope it has got better in the last few months. If it has got worse, I hope and expect that the Minister will be on the phone to those trusts inquiring exactly why people are waiting over two years to receive their treatment.
The importance of dealing with the backlog quickly cannot be overstated, because of the likely pressure that will manifest itself over the coming months. As my hon. Friend the Member for Bootle said, the Health Foundation has estimated that there could be as many as 4.7 million missing patients. If only three quarters of those are referred to treatment, that would lead to a waiting list of 9.7 million people by 2023-24. Obviously, that is an estimate, but if the Minister has done his own calculation, can he tell us what it is?
Over the last year, the NHS has adapted fantastically to the challenges of covid in a way that has rightly won the respect of everyone in this place and in the country. That has meant decisions have been taken about how treatments should be prioritised. We have seen appointments cancelled, operations postponed and staff redeployed, but even with those challenges, the NHS managed to carry out 1.9 million operations in January and February this year, which Stephen Powis, NHS England’s medical director, said is
“a testament to the hard work and dedication of staff”.
I join him in paying tribute to those staff for delivering that. However, even with that fantastic effort—to put into context the challenge that we face—the number of routine operations in January was down 54% on last year and in February it was down 47%.
Thankfully, I think we are past the peak of the third wave and there are only just over 2,000 patients with covid in hospital, which is the lowest since last September. However, the NHS is still under enormous pressure, with so many people now waiting for treatment, stricter infection control measures and, as many Members have referred to, an exhausted healthcare workforce. We have to be realistic: this could take years to address unless there is a credible and costed plan in place at the earliest opportunity.
Modelling by the NHS Confederation suggests that the sustained impact of the pandemic will leave a backlog of care in excess of anything seen over the last 12 years and that to maintain any sense of control over its waiting list, the NHS will need to increase capacity considerably above levels that have previously been sustained. My hon. Friend the Member for Bristol South (Karin Smyth) referred to the huge efforts that were made by the previous Labour Government to get waiting lists down. It seems that a strategy at least on a par with that will be needed.
The NHS Confederation has said:
“Without a comprehensive new plan, the government faces the…legacy of hundreds of thousands of patients left with deteriorating conditions”.
It warns that the additional £1 billion agreed in the spending review will not be enough to clear the backlog. The chief executive of the NHS Confederation Danny Mortimer said:
“health leaders are clear that the NHS will be recovering for years to come, and this must be appropriately resourced in the long-term.”
He called for
“investment in growing and maintaining the workforce”.
NHS Providers has said that the situation could take three to five years to resolve. Its chief executive, Chris Hopson, said:
“Trusts believe they can clear the backlog within a reasonable period of time”,
but that treating this like another waiting list initiative, relying on overtime and private sector use, will be insufficient. He said that the NHS will need to transform “how it provides care” and that the Government will need to provide
“the extra funding required to enable that transformation.”
As my hon. Friend the Member for Bootle set out, a number of practical steps can be taken to deliver transformation, but they come with a price tag. The Prime Minister was quick to pledge that the Government will ensure that the NHS has the funds it needs to beat the backlog, but how can we have confidence in him when he has already gone back on a promised pay rise for NHS staff? NHS England said that although the £1 billion fund will help, it will not be enough. Of course it will help and it is welcome, but helping is not the same as solving. Nobody, probably not even the Minister, believes that what is on the table represents a solution.
There is no doubt that the NHS has a monumental task ahead of it to restore services, meet demand and reduce the care backlogs, but it also must support staff and take steps to reduce inequality in access, experience and outcomes. Now is the time for the Government to deliver on their promise to deliver to the NHS whatever it needs. It certainly is not the time for another expensive reorganisation, as my hon. Friend the Member for Bristol South said. If that is the road we go down, it is important that patients’ voices are put front and centre of those new bodies, particularly if they are forced to deal with some of those extremely tricky issues.
As many Members said, 10 years of underfunding have left us in this precarious position. The challenge is there for the Minister. The experts say that we can tackle the backlog, but it will need funding. If the Minister can confirm any specific figures, that would be wonderful. I suspect we will not get that today, but at the very least will he confirm on the record that he agrees that the £1 billion that has been allocated so far is insufficient?
To pick up on what Chris Hopson, chief executive of NHS Providers, said about relying on the private sector, we know that huge sums were provided last year. As my hon. Friend the Member for York Central said, we have never had transparency about what that money was spent on. Can the Minister tell us how many NHS patients were seen in the private sector last year, and how many procedures were carried out using taxpayers’ money? I am sure that he is as keen as all of us to ensure that the best value has been achieved.
Many Members said that none of the backlog will be tackled if we do not have the staff to do it. A recent Institute for Public Policy Research report based on a YouGov poll of 1,000 healthcare professionals said that a third more nurses and midwives are leaving the NHS than a year ago. Those figures are scaled up across the workforce—that means 100,000 nurses and 8,000 midwives leaving. With 40,000-plus vacancies already, we cannot afford to lose one more, never mind 100,000 more.
Dame Donna Kinnair of the Royal College of Nursing said that that is
“The reality of a failure to properly invest in the nursing workforce”
and must be a
“wake-up call to the Government.”
It should indeed, especially when we are still waiting for the publication of the substantive long-term workforce plans to deliver a lasting solution to recruiting and retaining the workforce and ensuring there are enough skilled staff to provide safe and effective care now and in the future. That is why it is vital that Ministers bring forward a fully funded plan to tackle the backlog—we have been calling for that for a long time: an NHS rescue plan that will bring down waiting lists and ensure that patients can receive the quality of care that they deserve. As my hon. Friend the Member for York Central put it, we cannot carry on with business as usual.
Let me end with the important comments from Dr Rob Harwood, the chair of the British Medical Association’s consultants committee:
“Without further financial support and investment in increasing staffing numbers, patients will be waiting even longer for care, and there is a risk that patient care becomes unsafe the more exhausted staff become. The future of our NHS, already walking wounded, must not be put in jeopardy.”
The NHS is the jewel in our crown, but it needs protecting, sometimes as much as the patients it treats. We need financial support, a detailed people policy and a credible plan to deal with the backlog if we are to avoid coming back in 12 months to talk about an even worse situation.