This week: Karin Smyth MP
Why she matters?: Karin Smyth is the Labour MP for Bristol South; shadow Northern Ireland secretary; and a former NHS manager – both as a commissioner and a non-executive director. Her effective and forensic pursuit of various NHS issues in Parliament has discomforted ministers and Department of Health and Social Care officials.
“When we’re asked to support [NHS financial] estimates here in Parliament, the numbers bear no relation to what is spent or how in my local economy”, says Ms Smyth.
“There is a disjoint in my role as an MP in Parliament and my role in the local community because there is no local financial accountability. NHS management looks to the national, which is the traditional source of financial bailouts and career opportunities. So, you don’t get many NHS managers standing up to say to the national level saying that we should close unsafe local services or overflowing accident and emergency departments because there is no reward for that.
“We need real honesty locally about what’s going on. In my conversations with local MPs, they’re saying the national bodies have just approved redevelopment funding but it’s just not happening locally. That’s the effect of capital-to-revenue transfers.
“So how would I know if something in my patch had been approved for that national money and then got pulled to support revenue funding. Who will challenge them to stop doing this, other than Robert Naylor?”
She suggests her fellow MPs should ask clinical commissioning group and trust chairs ‘have we lost out?’ “We don’t even know what capital money [was] planned but not spent or released in year. This adds to the C-DEL issue for foundation trusts. The incentive on those fixing the roof is not there.”
The issue of local accountability is one the Labour MP returns to time and again during her interview.
Ms Smyth suggested in an article for HSJ that local people must have a say in NHS spending – and it is a theme she expands on in the interview.
NHS commissioning arrangements, she says, have moved away from a sensible division of planning for local health needs from “day-to-day operational staffing and firefighting”.
Changes have taken “what should be a community process so far away from the public that I think [it] is a failure and a problem.
“At a local level major NHS service change needs some governance around it to allow local people to influence it. Now while the NEDs of PCTs were not elected, there was a formal process and screening and interviews, and we had regular formal appraisal, but yes, it still didn’t involve the public. There was a token patient on the board”.
A licence to offend
What about other approaches to involving the community? In the old days, Community Health Councils proved so effectively troublesome that former health secretary Alan Milburn abolished them.
“I’ve been in favour of involving the public more for the last 30 years, and the NHS is still not good from that perspective. HealthWatch are simply not set up to do that”, says Ms Smyth.
Ms Smyth regrets the lack of a public champion. “When I worked in Enfield Health Authority in the late 1990s, the local CHC was an important critical friend at health authority meetings. As all organisations are, CHCs were variable in attitude, helpfulness and quality, but as a young NHS manager, when service changes were being planned, it was made very clear to me from directors that the CHC and indeed local politicians were important players to talk to - formally and informally.”
CHCs had a licence to offend and tell the truth, to an extent that no part of the system has enjoyed since. Ms Smyth feels that while CHCs did not represent a golden age, “there were those formal links to the general public, and their board papers were public. Others argue that that made things take a long time to get done, but I’m unclear that it’s quicker now with the decisions made in secret.”
Questions of local accountability also led the Bristol MP to oppose the competitive tendering of £1bn worth of community services in her constituency.
“Having one main [community services] provider in this way seems to be meant to [financially] support Bristol’s two main acute trusts. Do we think community services exist to support acute trusts, or local health needs, which diverge across South Gloucester, North Somerset and Bristol?
“If our direction of travel [is] a focus on communities, and the local value of public health [measures], why are we upending community services [many, she notes, run by social enterprises] to have a single provider? You hear people talk about ‘consistency of service’ and standardisation, but community and local health needs aren’t standard.
“Local people are absolutely not involved in this change to the provision of their local services.
“This is a massive contract for 10 years, worth £1bn, and that should cause quite substantial debate in city and local NHS. But as the MP, I have to struggle and work through public papers to find out what is happening and when.
“We don’t know the cost of this community services re-procurement, because there’s no published business case [and] if we don’t know the true cost of what we have at moment, we won’t know if what replaces it is better value, let alone better quality.
Financial discipline forces you to be more accountable
Instead of a tendering process, Ms Smyth says: “The right way to develop community and primary care services is to work better with the local authority on public health to keep people supported at home. This is about sorting out housing, heating, transport; boosting citizens’ ability to support themselves. It’s about creating cultural and social capital in our own communities, that the NHS then augments.”
Local government, she suggests, could provide a good model for involving the community in planning and prioritising health services – particularly when it comes to tricky financial trade-offs.
“[Councils] are very resource-savvy as to how much money there will be at the start and end of year. When I was an NED, our trust chair had been chair of social services and he could not believe the annual NHS planning cycle. Social services know their budget and by law, can’t overspend”.
“That financial discipline forces you to be more accountable to your local population.”
Ms Smyth adds that it would also create much more awareness of trade-offs that have to be made in health economies which run into trouble through, for example, the local trust running up a big deficit.
“If we’ll be asking [the public] to pay more money in tax, which we in Labour are, we have to allow them a say. There have been various attempts at citizens’ juries, and we need to give people more credit for their ability to make grown-up choices and trade-offs”.
The Labour MP suggests that if we “arm the public with knowledge of why acute X has been in deficit for so long and acute Y up the road isn’t, it could frame a good conversation for local people about trade-offs, if [for example] they don’t want to see GP or community nursing services closing. Until people understand the NHS’ money locally and how services are set up and run, it’s hard to ask that sort of question. I don’t underestimate the [impact of the] financial squeeze of recent years, but some trusts are in permanent [systematic] deficit.
“If we really want the promised better mental health services and community services and primary care, then to get local people’s consent, they’ll need to really understand where the money goes and why”.
The emphasis on local needs would be developed under a Labour government led by Jeremy Corbyn, she says.
“There would be renewed focus on working with local government – a number of people leading the party are of and from local government.
“Social care is important as the most deprived have so much difficulty with disability and caring. It continues a vicious cycle of low income and poverty. They have high levels of physical and mental disability”.
Getting the NHS back into deprived communities
Ms Smyth wants the NHS to play a direct role in tackling these inequalities, by offering employment opportunities for people with disadvantaged backgrounds.
“When I talk to acute providers, they’re keen to support this. If we give [local people NHS] jobs, we get a much better workforce in those communities. Many roles can be flexible to allow for caring, and NHS jobs are relatively well-paid and have good benefits and can be suitable for people with disability”.
Echoing a developing theme among health policy influencers, she says economic and social factors should be considered when planning new NHS services.
“Getting the NHS back into these deprived communities,” she says, would be an effective way to deal with some of the “stark divisions in our society”.
Having been an NHS manager for much of her career, how does Ms Smyth think MPs could effectively learn more about the service?
The Labour MP cites the police force Parliamentary scheme (in which she has just taken part), which has been going on since 1990.
“You do 18-20 days with various parts of the police service. It’s very instructive, and a great way to build relationships between the police and MPs as legislators, and that might be something NHS could think about copying.
“The NHS is not a single organisation; it’s hundreds of organisations. And you [would] get some insight and empathy, [which is] a good thing”, she concludes.
What are the main lessons Ms Smyth learned from her time planning NHS emergency care? She smiles wryly.
“We spend a lot of time telling people not to go to the place that it seems would sort their needs out most effectively (A&E) and [instead] go to an urgent care centre. [Yet] no clinician can define ‘urgent’, so how do we expect the general public to understand what it means?
“My experiences taught me that even when [we knew] we were trying to push water uphill by managing demand we’d still do it. I remember trying to get leaflets signed off [explaining] who [shouldn’t] go to [the] walk-in centre, the urgent care centre, the GP 8-8 APMS, the A&E or the GP. Five places to go, and no clarity [on] which patients should go where!
“Maybe an A&E ‘water towers’ speech is needed!”
The Bedpan is now going on summer recess. It will return in September
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