GP Extended Access Services: Privatisation

Alex Cunningham Excerpts

Wednesday 17th October 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

I beg to move,

That this House has considered privatisation of GP extended access services in Stockton, Hartlepool and Darlington.

It is a pleasure to serve under your chairmanship, Mr Hosie, as we explore the important issue of the privatisation of local health services. Before I begin, may I bring to your attention my entry in the Register of Members’ Financial Interests? I have worked in the local extended access service. I have been employed as a GP since my election to Parliament, and before that I was chief executive of Hartlepool & Stockton Health, which is a GP federation established by all local GPs as a non-profit-making venture to allow collaboration between practices and other parts of the NHS. I resigned my position when I was elected, and I served my notice. My partner, Vicky, is a nurse in the local NHS and she derives some income from the GP federation.

As the Minister will know, the Government’s ambition is for all patients to be able to access evening and weekend GP appointments, which is a good thing. It is difficult for each individual GP practice in any area to open every evening and weekend, but it is achievable if GPs work together. In Stockton South in April 2017, Hartlepool & Stockton Health started to deliver extended access appointments between 6.30 pm and 8 pm on weekday evenings, for three hours on a Saturday, and for two hours on a Sunday. Local GPs did that as a collective through their federation.

The federation was set up as a private company—there is as yet no NHS GP federation organisation that it can belong to—but it was designed as a not-for-profit organisation because local GPs insisted on it. They did not want to make any profit out of collaboration. All the money earned by the organisation is reinvested into local primary care—I know the detail of that because it was my job before I came into Parliament to set up and run the organisation.

Evening and weekend GP services have now run for 18 months and they have been a success by all measures. Patients like it:

“Every aspect of my visit was excellent…it was prompt and professional…a lovely experience”

are three of the many comments received as feedback. During the past year, there have been 26,000 extra GP and nurse appointments for routine care. That has not just been good for patients; it has also reduced pressure on local practices. Teesside has one of the highest patient-to-GP ratios—we are an under-doctored area.

Down the road in Darlington, Primary Healthcare Darlington has run an extended access service in the evenings and weekends since 2015 when it received Prime Minister’s Challenge funding. According to all the reports I have received, it has run an equally good service for the people of Darlington. So far, so good. However, in September this year the local clinical commissioning group launched an invitation to tender with two lots—one to run an extended access service in Darlington, and the other in Hartlepool and Stockton. The tender documents requested that organisations bid to run one and a half hours of general practice each evening and a bit longer at the weekends. The bidding process is under way and I am sure the Minister will not want to say anything that might prejudice the process.

I have initiated this debate to ask some big questions. Biggest of all is this: how does privatising this service benefit local patients—the acid test for any NHS change? When local GPs work together to deliver this service, and when the local NHS has all partners collaborating so well, how can it possibly be right to bring in a new private sector provider?

[Alex Cunningham (Stockton North) (Lab)]

I congratulate my hon. Friend, my next-door neighbour, on securing this debate. One thing that concerns me is the potential loss of good will from GPs across the Tees valley who are currently delivering the service. Does that concern him too?

[Dr Williams]

I will come later in my remarks to some of the reasons why the system works well at the moment, and to some of the potential threats that could arise from introducing a private sector provider.

Before I expand my point, let me establish my position so that there can be no confusion or misinterpretation. As I said, extended access services are a good thing. I worked hard before my election to establish them, and they are good for patients and for the NHS. I congratulate Hartlepool and Stockton-on-Tees CCG and Darlington CCG on delivering extra GP services for local patients over the past few years in Darlington and for the past 18 months in Stockton. They have done a good job. I also know that most GP practices are technically private organisations with a contract with the NHS, but there is an important difference between a local GP who is doing the work and making money from that, and a private corporation whose shareholders profit from the NHS.

Having said that, I am on the record as having said that GPs should be employed by the NHS, and I believe that the time has come for the NHS to set up community providers to integrate GPs, community nursing, social care and community health services. GPs should be offered employment in those organisations. The farce that I am describing today makes the case for that type of organisation stronger.

While setting out my credentials, I am also pragmatic and not dogmatic about private and voluntary sector provision within the NHS. Our local counselling services in Stockton are better for having multiple providers. Patients like getting hearing tests on the high street at Specsavers instead of going to the hospital audiology department. What I am describing today, however, is privatisation for privatisation’s sake. It is privatisation because the “rules” say privatise, and not because anyone thinks that privatisation is good for patients. It is probably even privatisation by accident.

For me, the most important test of any change in the NHS is: how does this benefit patients? The NHS is there to improve health. I have huge respect for all the staff who work in our NHS, and I thank everyone for their efforts, but fundamentally local health services must meet the needs of local patients. How could bringing in a private GP company for an hour and a half each day possibly make things better for patients in my constituency? If there were a list of 101 things to do to improve the NHS in Stockton South, finding a new provider for GP extended access would not be one of them.

Children’s mental health services are in crisis and health inequalities in Stockton are the most stark in the whole country. Our local authority is struggling to deliver effective public health services because of the cuts, and waiting times for autism diagnosis for children have been four years, even though our health and wellbeing board, council and CCG have good plans to reduce that. For general practice, in some parts of Stockton South patients tell me they have to wait four weeks for a GP appointment. Fixing those things should be the priority for our CCG, not being forced to spend time and money on an unnecessary privatisation.

GP extended access is one part of the local NHS that is working well. The model has energised local GPs and, to an extent, local nurses. Eighty-five doctors and 25 nurses have worked in the service. Three years ago, before I was in Parliament, I led a workshop for GPs, and the No. 1 thing they asked me not to introduce was an extended access service. However, working together with the CCG, a model was created that people wanted to work for—one that works for staff and patients. Since GPs own the organisation that they work for, the things that matter are prioritised. The GP federation has a culture lead—an employee of the federation whose job it is to promote a happy, healthy working environment and reduce the pressure on frontline GPs. GPs working in that service are not motivated by profit. They are working as a collective and taking responsibility.

Extended access has also allowed new models of care to be tried, and pharmacist, physiotherapist and counsellor appointments are directly bookable at the weekend. The scheme is popular with patients—96% of GP and 70% of nurse appointments have been used. In short, the service works well. Although most people said at the start that it would not work, the service is popular with patients and well led. Why privatise it? What on earth could be gained? One and a half hours a day of private general practice—it is ridiculous.

More good collaborative things are happening in Hartlepool and Stockton. The local GPs are already working in partnership with the local hospital and the local ambulance service to run the local urgent care centre. Local services are integrated, everyone is talking to each other and most people are happy. Most areas would be delighted to have such a level of engagement and co-operation and such leadership. The service has been put out to tender simply because of the law. The Health and Social Care Act 2012 mandates competitive tender for certain contracts worth more than £615,000 a year.

In this case, I contend that the law is not working. It does not work for patients, it will not work for doctors or NHS leaders and I suspect it is probably not even what the Minister wants. There is hypocrisy here—a fundamental difference between what the Government are saying and what they are doing. I will quote from NHS England’s “Next steps on the NHS Five Year Forward View” document, published in March 2017, which says that it will:

“Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care…hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access.”

That is what the NHS five-year forward view says will happen: GPs will work together to pool responsibility, which is exactly what is happening in my area. If private companies are invited to competitive tender for that, every GP has something to fear from the collaboration. They will do the work of setting up the services and somebody else will then come in and run them.

The Minister’s colleague, the Minister for Health, the hon. Member for North East Cambridgeshire (Stephen Barclay), recently gave evidence to the Health and Social Care Committee inquiry into integration in the NHS. When he was asked about privatisation, he said that

“there are a number of checks and balances in the system in the requirement for CCGs to consult their local populations, their health and wellbeing boards and their oversight and scrutiny committees. On top of that, there are safeguards at a national level of CCGs going through the integrated support and assurance process. Actually, there are a lot of checks and balances as to the fact that this is not privatisation.”

I ask where the checks and balances were to stop the CCG having to put these services out to tender. Why did the Minister not intervene, when it is plain to everybody that it is a ridiculous idea to bring a private company in for an hour and a half each day?

[Alex Cunningham]

What concerns me is that this tender document sounds as though it will lead to a reduction in service, and the working people who access those extra clinics and appointments will not have the same level of service that they currently do. The Minister must intervene to ensure that we at least have the level of service that we have now.

[Dr Williams]

I thank my hon. Friend for highlighting the potential risks to local patients. This is not about defending the interests of the staff who work in the service, however important they are; it is about ensuring that it is the best service for local patients.

Finally, I quote from the 2017 Conservative election manifesto; I am afraid I do not keep my own copy, but it is still available online. It says:

“We expect GPs to come together to provide greater access”.

It also says:

“If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes. This includes the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy. So we will review the operation of the internal market and, in time for the start of the 2018 financial year, we will make non-legislative changes to remove barriers to the integration of care.”

I ask, then, what the Minster has done and how he has acted to remove barriers to integration of care in Stockton.

GPs in the NHS in Darlington and in Hartlepool and Stockton are doing everything they have been asked to do by this Government and the NHS. They have organised themselves into collectives, and together they are delivering social prescribing and pharmacists in practices, promoting nursing in general practice, introducing new technologies, helping physicians’ associates and training. Those are all good things that I am sure the Minster would support. Integration works. Integration is the right strategy: collaboration, not competition.

Why privatise now, and what is the risk of a private company running this service? The tender encourages competition on price. The lower an organisation’s bid, the more likely it is to win the contract. Cutting costs means less money to pay for things such as the culture lead I mentioned, so the kindness, the looking after staff, the encouragement and the “thank you” cards go, and with them much of the goodwill they bring, which my hon. Friend the Member for Stockton North (Alex Cunningham) talked about.

Would local doctors and nurses want to work for a private organisation motivated by profit? Remember, I said that most local GPs were opposed to extended access only three years ago. Their participation has been carefully nurtured; they have ownership of the organisation delivering the service and they now really care about making it a success. How will the tender process take account of that? Today, we have doctors and nurses working in a service motivated by patient care. How can a for-profit company answerable to remote shareholders recreate that ethos? We have seen this Government’s privatisation failures over and over again, with Circle, Serco and Carillion. This Government are saying one thing about NHS collaboration, but doing another.

I have three questions for the Minister, and I will give him plenty of time to respond. First, why did he let this happen and why did he not intervene to stop it? Secondly, what is he going to do to stop this happening again in other parts of the country? What changes to the law does the Minister think would be helpful? Thirdly, how can he expect the public to trust the Tories on their new integrated care system idea if he cannot guarantee that these new multi-million pound contracts to run all the local health services will not be put out to tender in exactly the same way?

In the Minister’s response, I ask him to either defend this ridiculous privatisation of 1.5 hours of GP services a day, risking a great service being taken away from local GPs and given to a private company, or perhaps to concede that this type of privatisation—a consequence of the Conservatives’ 2012 Act—does not help patients and runs counter to the aims expressed in his party’s election manifesto, the stated aims of his ministerial colleagues and the strategy of NHS England. Maybe he will agree that the law needs to be changed. I look forward to his response.

--- Later in debate ---

[Steve Brine]

I might have to send the hon. Gentleman a note on that, but I will repeat what I said, just for the purposes of accuracy—I know he is seeing the relevant people later this week. Where the clinically led CCG decides that it is in the interests of patients and taxpayers to look at a range of potential providers for a service, it is able to do so. Those are the words I have for him. What we need and have is a sensible, proportionate framework that effectively balances the need of commissioners to secure the best-quality service at the best price with their need to ensure the security and sustainability of supply. It has worked that way and worked well for the past 12 years.

[Alex Cunningham]

rose—

[Steve Brine]

I will happily give way to the constituency neighbour of the mover of the motion.

--- Later in debate ---

[Alex Cunningham]

I wish to push this point. I know the Minister said that he might have to send my hon. Friend a note, but in putting the service out to tender, the CCG either is acting within the law or is not. Did it have the option within the law not to put this particular service out to tender? We need a very clear understanding of that.

[Steve Brine]

Let me repeat that the local, clinically led CCG absolutely decided that it was in the interests of patients and taxpayers to look at a range of potential providers for the service that they wanted to be provided. That is the process that it is going through. The hon. Member for Stockton South rightly said that he would not expect me to wade into the middle of the procurement process. I cannot do that, but I will say that sensible, dynamic commissioning will be central to the NHS meeting the challenges that it faces today and in the future despite the commitment to increase the funding by £20.5 billion a year. That is vital to ensure that the NHS delivers on our triple aim of improving quality of care, cost control and population health which, as I am the Public Health Minister and absolutely focused on prevention, is one of my and the new Secretary of State’s key priorities. It is central. To achieve that triple aim, NHS commissioning will need to continue to develop as it has done since its inception. NHS England has designed a new commissioning capability programme to support commissioning systems. The programme provides tailored support delivered through place-based solutions to equip NHS commissioners with the skills they need to deliver on the challenges of today and the future.

Let me stress one of the fundamental principles of the 2012 reforms of the NHS—I served for many weeks on the Standing Committee that considered the Bill. That principle is delegating power away from Whitehall and Ministers such as me, who come and go with political cycles, to local clinical commissioning groups. They are led by fantastic GPs and other local health experts, who are best placed to make the important decisions that matter to local people. Darlington CCG and the Hartlepool and Stockton-on-Tees CCG are rightly making the decisions about how best to ensure that people in their areas have access to a GP when it suits them. Bids for local extended access GP services are currently being closely assessed with a view to the contract starting in April 2019. I have faith that those local commissioners will award this contract in a way that, as I have set out, improves access and quality for patients. Let me say that very clearly: I have faith that those local commissioners will award the contract in a way that I think the hon. Member for Stockton South will find satisfactory.

Tobacco Control Plan

Alex Cunningham Excerpts

Thursday 19th July 2018 Commons Chamber

[Steve Brine]

I agree with the right hon. Gentleman. Those of us who have secure estates in our constituencies and go in and visit them regularly will be aware of just how much of a challenge this is, given how ingrained smoking is within the cohort. That relates to the point I made about specific groups. I think that the Prison Service deserves great credit. Suffice it to say that it has a lot of pressures on it, and in some ways it probably felt that this was the least of its worries and the last thing it could deal with, but it is actually very important. That is why I say we are working well across the Government, and the Prison Service is really pulling out the stops in its area. I thank him for that intervention.

To finish on the protocol, HMRC will continue to lead on it on behalf of the Government, working with my officials at the Department of Health and Social Care. Through the protocol, we are sharing our expertise as a leading tobacco control nation; this is not just about what we are doing domestically. We are funding the FCTC secretariat with £15 million over the spending review period to support tobacco control in 15 low and middle-income countries. I am very proud of that work, and I am pleased to say that we are already having an impact. Georgia introduced smoke-free legislation and a ban on advertising on 1 May. It seems strange to talk about banning advertising as a new measure, given how long a ban has been in place in our country, but it shows that other parts of the world have a long way to go to catch up. I am very proud that we are using our experience and our evidence-based experience to help countries such as Georgia to do so. I want to place on the record my congratulations to Georgia.

Domestically, Her Majesty’s Treasury continues to maintain high duty rates for tobacco products to make tobacco less affordable, which is absolutely right. Public Health England, for which I am responsible, and NHS England are working on a joint action plan to reduce smoking in pregnancy. A key part of this is helping midwives to identify women who smoke and help them to quit and to support the implementation of National Institute for Health and Care Excellence guidance on reducing smoking during pregnancy and immediately following childbirth.

PHE has been encouraging the use of e-cigarettes to help people quit. As part of this, the most recent Stoptober campaign for the first time highlighted the role of e-cigarettes in quitting. The best evidence suggests that e-cigarettes are helping thousands of people to quit and that they are particularly effective in the context of a smoking cessation clinic. PHE’s data website, “Local tobacco control profiles for England”—another snappy title I dreamed up—is helping local commissioners and service planners to identify where they are succeeding, where they face the greatest challenges and how they compare with their neighbours and the rest of England.

[Alex Cunningham (Stockton North) (Lab)]

I very much welcome the Minister’s comments in The Guardian newspaper this morning about the activities of one tobacco manufacturer that has been contacting or at least trying to ingratiate itself with NHS staff by helping them to quit smoking. Will he write to all trusts and clinical commissioning groups telling them that they should have nothing at all to do with this initiative?

[Steve Brine]

I already have and NHS England already has: we have already done so. We think that Philip Morris International’s move is totally inappropriate and totally contrary to the protocol. I do not think I could have been clearer either in the press or at the Dispatch Box today, and I thank the hon. Gentleman for giving me the chance to say so again.

All our local activity has the overall goal of helping people to quit smoking and stopping others starting in the first place, so how are we doing? Here is the score card. Publications by the Office for National Statistics and NHS Digital earlier this month show that we are making progress. Since 2011, the number of adult smokers has dropped by a fifth to the lowest level since records began, and we are fully on track to achieve our 2022 ambition for adults. Among 15-year-old smokers, there is good progress, and figures published last year showed that the prevalence of smoking has reduced by a further percentage point from 8% to 7% since the publication of the plan. The number of e-cigarette users in that group is also falling. Latest figures from the ONS annual population survey reveal that smoking rates among 18 to 25-year-olds are falling faster than in any other age group. Considering that that age is when most smokers start smoking, I am particularly pleased with that.

We are also making progress on inequality. Although routine and manual workers continue to have higher smoking rates compared with the rest of the population, the gap has narrowed slightly, from 26.5% at the publication of the plan to 25.7% as reported by the ONS earlier this month. Those are achievements to celebrate. Nevertheless, I must be honest with the House and say that progress on tackling smoking in pregnancy is disappointing, and in truth the figures have barely moved in the past year.

What shall we do in year 2 of the plan? First and foremost, I am determined to redouble our efforts to support pregnant smokers to quit. That will be best for them and for their babies, and we need people to understand that. Secondly, we will use the opportunity of the Government’s investment in the NHS, which the Prime Minister announced last month, to embed prevention and cessation more firmly into the culture of the NHS. Last month, the Royal College of Physicians, which has a proud record of groundbreaking reports on tobacco, published “Hiding in Plain Sight: Treating tobacco dependence in the NHS”. That weighty report calculated that the cost of current smokers needing in-patient care is £890 million a year. It points out that smokers are 36% more likely to be admitted to hospital at some point than non-smokers, and it makes the powerful argument that smoking cessation repays the cost from year 1. I welcome that report, and I will be making that case loud and clear as we engage with NHS England on the content of the 10-year plan that the Prime Minister has asked it to produce.

Thirdly, we will continue to engage with local authorities —they are now top-tier public health authorities up and down the land in England—on promoting smoking cessation as the best evidence-based means of quitting smoking. Encouraging the NHS to do more on cessation is emphatically not about removing responsibilities from local authorities. This is about creating a whole-system approach in which addicted smokers can access the support they need to quit. Public Health England will continue to provide local councils up and down the land with facts and advice on tackling smoking—for example, it will work with sustainability and transformation partnerships, which should be leading that whole-system approach in the constituencies of all English Members.

Fourthly, as I have mentioned, we will continue to raise tobacco duty to make tobacco less affordable, while also taking action to tackle the illicit trade in tobacco. Fifthly, we will maintain a careful watch on so-called novel tobacco products. The Government are keen to use the opportunity of newer products, such as e-cigarettes, to help smokers to quit, without undermining the key message that the best thing someone can do for their health is quit completely. As I said in the Science and Technology Committee’s inquiry into this subject, we will continue to keep the harms of products such as heated tobacco products under review and continue to hold the industry to account. We have been explicit that the promotion of tobacco products is unlawful, as my recent letter to Philip Morris International makes abundantly clear—that letter was written before the one I mentioned in response to the hon. Member for Stockton North (Alex Cunningham).

Last but not least, we will continue to make the case for tobacco control internationally, building on our reputation as a leading tobacco control nation with credibility in that space. We have such credibility because our consistent work in this area goes back to the coalition Government, the previous Labour Government and the Conservative Government before them, and such consistency means that we are highly credible around the world. More than 7 million people a year across the globe die from smoking-related disease, and the UK Government can help make a dent in that toll by sharing knowledge and skills.

[Steve Brine]

I think cigarettes cause the most damage, because of the tobacco and the nicotine. The carcinogenic properties of the former are lethal. That link was proven with the lung cancer study that started the ball rolling. I pay tribute to my hon. Friend as the chair of the all-party group for the work he has done in this area. There are a lot of things that we know and there are a lot of things that we still do not know. Some people say that I do not go far enough to promote e-cigarettes and novel products, and some people say that maybe we go too far—I mentioned Stoptober. That generally suggests to me that we are in the right place. What I would say—I think that I said it earlier—is that an awful lot of research is still needed on e-cigarettes. One Member once told me that we should make e-cigarettes free on prescription to all pregnant women. The reason I did not say, “Yes, I think that’s a good idea” is that I still think there are risks to that product. I still think that the best thing people can do is to stop chuffing on anything, whether traditional cigarettes or so-called novel products. I thank him for his intervention, and I look forward to hearing what he has to say during the debate.

[Alex Cunningham]

I thank the Minister for giving way a second time. I join the tributes to both the Minister and the chair of the all-party group. There has been tremendous cross-party work on this issue—that has always been the case. The Minister mentions the role local authorities have to play. We all know the pressure they have been under in recent times. I wonder whether he could see a mechanism that would provide and ring-fence the funds to enable local authorities to fulfil their role. Currently, they are struggling to do so.

[Steve Brine]

I thank the hon. Gentleman for that intervention. On providing support to help smokers quit, as I said, we have moved from the national context of legislative work to local application. The challenge is that adult smoking rates vary considerably across the country—for example, they are 8% in Wokingham and 23% in Kingston upon Hull—so it is right that local councils have the flexibility to spend that money. There is some £16 billion in the ring-fenced public health grant during the spending review period, so there is a lot of money in the system. But am I happy with patchy services in areas where smoking rates are too high? No, I am not. That is why I have said that the Government have not made a decision on full business rate retention. I would be concerned about the impact that that might have. I would want all sorts of reassurances from local councils if I were to make that change. Do I think it right that local authorities can design services for their local area? Yes, I do.

The new Secretary of State and I have already discussed prevention, which is one of the three main pillars he wants to focus on. I have told him that the new investment of £20 billion that we are putting into the NHS is fantastic. Bluntly, we could have the money on the side of the bus three or four times over, but unless we get serious about prevention, in this space as much as any other, the NHS will continue to be under enormous pressure. Local authorities are a key partner for us.

I would also say, not least because the chair of the all-party group on community pharmacy is sitting behind the hon. Gentleman, that community pharmacists and pharmacies have a key role to play. They are an NHS centre on street corners up and down our land. Some of them provide really good work. The healthy living pharmacies I have seen help people to access the services they need. They provide a little bit of mentoring and support, using their experience to say, “Yes, you can beat this,” and signposting them to services, whether through the public sector or the third sector.

There is an awful lot that we can still do. That is why the 10-year plan will have prevention embedded at its heart, as the five year forward view said it would—and it did, but I do not think that it lived up enough to the ambition on that. Perhaps people would expect the Minister responsible for prevention to say that, but I am nothing if not consistent.

Tobacco remains the single biggest avoidable killer in our country today, causing a third of preventable cancers. It contributes to around half of health inequalities between rich and poor in our society and is a potent symbol of the burning injustices that the Prime Minister spoke about, which I think affect the life chances of poorer people up and down our land. The tobacco control plan represents the Government’s continuing commitment to tackling this epidemic. It was never presented as a panacea and it is still not a panacea, but it is a cracking good start.

Over the past year, we have seen some impressive progress, but I am absolutely not complacent. In World cup terms, I would suggest that we have made it through to the knockout stages, but nothing more. I hope to be able to demonstrate further progress in a year’s time, and no doubt we will discuss that again in the House. I look forward to hearing hon. Members’ contributions, and I am happy to introduce this important debate.

--- Later in debate ---

[Alex Cunningham (Stockton North) (Lab)]

I appreciate being called at this stage of the debate. I declare my role as a vice-chair of the all-party group on smoking and health. This was going to be a Backbench Business debate on a motion that I put forward to consider further action necessary to deliver the vision set out in the tobacco control plan for England 2017 of a smoke-free generation by 2022.

I am grateful to colleagues across the party groups for working with me to secure the original debate. I am also grateful to ASH and other organisations for assisting with my preparation today. I will read the original Backbench Business motion into the record so that the Minister can take it on board. It reads:

“That this House welcomes the Government’s Tobacco Control Plan published in July 2017; notes its ambition to create a smokefree generation and to reduce the prevalence of 15 year olds who regularly smoke from 8% to 3% or less; notes the slowing rate of decline in youth smoking prevalence and risk to progress; and calls on the Government to develop new strategies to ensure that it allocates the resources and the funding necessary to deliver on that ambition.”

I very much welcome what the Minister had to say today and the 66 recommendations that are coming forward to move things along. I want to summarise the key points that I had originally hoped to make in much more detail.

This is an important issue for me in relation to my home area, the borough of Stockton-on-Tees. The smoking rate has come down considerably: 15% of the adult population in Stockton are currently smokers. Some 31% of the households that have a smoker are below the poverty line. If they quit, 1,991 households would be lifted out of poverty, and residents of those households include 1,342 dependent children. Smoking costs Stockton-on-Tees approximately £37.4 million, it costs the NHS £8.5 million, and £24.1 million in lost productivity. Some 15.3% of pregnant women in our area smoked at the time of their baby’s delivery.

Furthermore, the analysis of the most recent youth smoking data by Cancer Research UK finds that more than 350 young people started smoking every day. That is the equivalent of 17 secondary school classrooms. At the current rate of decline in smoking cessation, we will fail to achieve the ambition for England that, by 2022, 3% or less of 15 year olds are regular smokers.

Health inequalities are growing: one in four people in routine and manual occupation smokes compared with one in 10 in professional and managerial occupations, and that gap is widening. The key points of the Backbench Business proposal were the need to do more to reduce smoking initiation in young people and to encourage quitting among adults. We must reduce young people’s exposure to smoking in film, television and other media. That issue was raised by the hon. Member for Linlithgow and East Falkirk (Martyn Day) a few minutes ago.

There is substantial peer-reviewed evidence that shows a causal link between exposure to smoking in the media and starting to smoke and that young people are being exposed to smoking on screen in the UK. Government have a role to play in encouraging media regulators to take smoking seriously and to act in this area. The Government need to urge Ofcom and the BBFC to revise their guidelines with respect to smoking on screen in entertainment media viewed by under-18s to discourage any depictions of tobacco use and to require action to mitigate any remaining exposure. We can make it more difficult for young people to obtain cigarettes by increasing the age of sale to 21, introducing retail licensing for the sale of tobacco and properly funding regional activity to support enforcement.

In the UK in 2014, 77% of smokers aged 16 to 24 began smoking before the age of 18. Evidence from the US shows that raising the legal purchase age to 21 reduces the number of young people who start smoking, reduces smoking-caused deaths and immediately improves the health of young people. More than one third of under-age smokers buy their cigarettes from shops without a licence, which can be revoked if they continue selling—so tobacco retailers can continue to sell tobacco to minors or to sell illicit tobacco. A retail licensing scheme covering all levels of the supply chain from manufacturer to retailer would also help to protect the business of legitimate retailers who obey tobacco control legislation.

As others have said, Government need to do much more to support and enhance enforcement where there is illegal activity, but funding cuts have led to significant reductions in the capacity of trading standards departments, which are responsible for seizures of illicit tobacco and prosecutions for tobacco fraud. From personal experience, I know that the capacity simply does not exist. Time and again, I have alerted Her Majesty’s Revenue and Customs to tab houses selling tobacco illegally in Stockton, but those very same tab houses continue to sell. HMRC is the beneficiary of enforcement activity, as it protects tax revenues, so surely it should be required to fund the activity, which could be organised at the regional level, which is the most cost-effective way of doing it.

One of my principal concerns is the much higher incidence of smoking in disadvantaged communities and how we de-normalise it and tackle health inequalities by funding mass media campaigns, which the hon. Member for Harrow East (Bob Blackman) talked about in detail. Some 83% of children who smoke regularly have family members who smoke, and this is magnified in disadvantaged communities, such as the town centre ward in Stockton. Public spending on these campaigns, however, has fallen from a peak of £23.38 million in 2008-09 to only £2 million last year. We need to reverse those cuts, as such campaigns are highly effective and can be targeted at poorer and more disadvantaged groups, which have the highest rates of smoking.

The “polluter pays” levy on tobacco manufacturers, which the all-party group on smoking and health supports, could help to fund mass media campaigns as well as other important tobacco control measures. It is time to consider the greater role for social media to amplify the impact of mass media campaigns. There is now the capability to target individual postcode districts with specific messages using, among other things, the promote tool on Facebook. We could help the 60% of smokers who say they want to quit smoking by funding stop smoking treatment and including inserts in tobacco packets encouraging quit attempts.

In 2017, the budget for stop smoking services was cut in half by local authorities in England. The NHS and local authorities need to collaborate more effectively to ensure that smokers, particularly vulnerable groups who tend to be more addicted and have greater difficulty quitting, have access to the help they need. I think the Minister alluded to that in detail—if one can allude to anything in detail—in his speech. Simon Stevens told the Health Select Committee a couple of weeks ago that local authority stop smoking services were not sufficient and that NHS England needed to do more to treat vulnerable groups of smokers under its care. He said:

“It is pretty clear that we will have to keep pushing harder on smoking, and smoking cessation is part of that. That cannot all be done through local authority commissioned services; we are going to have to look at whether the NHS can embed smoking cessation in more of the routine contacts that we have with vulnerable groups who are still smoking. ASH and the Royal College of Physicians have put out an important set of proposals in the last 10 days, which we will take a very careful look at.”

I very much welcome that, and I hope the Minister does too.

On the subject of pack inserts, research from Stirling University has shown that smokers of a variety of ages, gender and social grade support their use as an aid to encourage them to quit. The Minister said earlier that we did not need more legislation. Well, perhaps we do. We need legislation mandating pack inserts, which would provide an inexpensive and highly targeted means of supplementing on-pack warnings.

People with mental health conditions are being left behind in all this. Approximately 40% of people with a mental health condition smoke. Smoking is the main reason that people with mental health conditions die 10 to 20 years earlier on average than the general population. They tend to smoke more heavily, be more heavily addicted and find it harder to quit. It is not that they do not want to quit, but that they need more help to succeed. The Minister mentioned this in his opening remarks, but I hope that he will say a little more when he winds up the debate. I can help a wee bit—at least the people who are briefing me can.

To reduce smoking among people with a mental health condition, we need to ensure that all mental health trusts treat tobacco dependency alongside implementing smoke-free grounds; to have improved data on smoking rates and service provision for people with a mental health condition who smoke; and to empower and inform people with a mental health condition to take control of their smoking and to include them in the development of services. We need specific national targets for reducing smoking rates in people with mental health conditions, and shared plans between local authorities and the NHS to ensure that smokers get support and help in the community as well as when they are being treated as in-patients. We need to train all mental health staff in smoking cessation and to offer a range of alternative nicotine-containing products, including e-cigarettes, to those struggling to quit. Furthermore, as called for by the Royal College of Physicians and ASH, we need treatment for tobacco dependency to be embedded throughout the NHS, not just in NHS mental health trusts. This would improve treatment outcomes. The Minister knows all this.

Smoking exacerbates as well as causes disease, and helping smokers to quit can reduce NHS treatment costs and improve quality of life for patients. This includes pregnancy, chronic obstructive pulmonary disease and other respiratory diseases, cardiovascular disease, mental health, surgery, diabetes and HIV/AIDS, not to mention 16 different types of cancer. Advice and treatment can increase patients’ chances of quitting up to fourfold. It is about the cheapest and most effective healthcare intervention around, costing hundreds of pounds per successful quitter. But despite these impressive results, only 24% of patients diagnosed with lung cancer are offered advice to quit by their GPs, and only 13% are prescribed stop smoking treatment. The RCP has calculated that if all smokers were provided with help to quit, the NHS could save £60 million annually in hospital readmission costs and A&E attendances alone from year one onwards, once the cost of the treatment is taken into account.

There are many other aspects to this issue. My hon. Friend the Member for Harrow East—I call him my hon. Friend, despite the fact that he sits on the Government Benches—talked about other nationalities living in the UK. We could talk in great detail about people from eastern Europe and the extremely high levels of smoking in those communities, but I want to finish with just two simple questions for the Minister. Will the Government seriously consider all the recommendations that I have outlined in the debate today? Will he commit to asking Simon Stevens, as chief executive of the NHS, to confirm that tobacco dependency treatment for all smokers, as recommended by the RCP and ASH, will be included in the plan for the NHS to be published in November? He knows, as we all do, that lives depend on it.

--- Later in debate ---

[Steve Brine]

With the leave of the House, I will also respond to the debate, Mr Deputy Speaker. I am aware that I am standing in the middle of the A14—almost literally—which is tonight’s Adjournment debate, but I will respond to the points that have been raised in this short and small but perfectly formed debate.

The shadow Minister—my good friend, the hon. Member for Washington and Sunderland West (Mrs Hodgson)—rightly mentioned the issue of pregnant women and smoking, to which I referred in my opening remarks. Public Health England and NHS England are working on a joint strategy at the moment, setting out recommendations for how local areas can work together to achieve our ambition on smoking in pregnancy. In a way, I guess that is given a greater impetus in the light of the flatlining figures—I suppose that is the accurate way of putting it. This work is part of the maternity transformation programme, which started in 2016 and which I know she is aware of. Public Health England will look at how its mass media campaign can more effectively reach young people, especially working-class women of reproductive age and their families and friends. I wanted to put that on the record.

The hon. Lady returned to the subject of smoking services. I repeat what I said during the debate: there are varying rates across the country, so it is right that local councils have the flexibility to respond. I will touch on the point that the right hon. Member for Rother Valley (Sir Kevin Barron) mentioned about this being all the responsibility of local authorities. There is a third way, he will pleased to know, as a Blairite—that has finished his career, I apologise. I put on record again that councils will receive £16 billion of the public health funding until the next spending review, when the spending plans will be announced. We expect them to use it wisely.

My hon. Friend the Member for Harrow East (Bob Blackman) talked about the Back-Bench debate and the general debate. I will leave that matter for the usual channels, but the important thing is that we are having the debate, which is very welcome.

The shadow Minister spoke about smoking cessation training and those services. The success of our plan hinges on all manner of professionals offering help that works, which is why effective training on supporting smokers to quit is central to the tobacco control plan—from doctors and nurses in the NHS to physiotherapists in the community, to pharmacists, who I have mentioned, and to the health professionals who need to equip smokers with the capability, opportunity and motivation to quit for good. It often involves very brief advice and there is a lot of online training out there. Twenty minutes or so of online training can teach a professional how to have a short conversation with somebody with a smoking challenge, with proven results. I wanted to put that on record.

My hon. Friend the Member for Harrow East mentioned Philip Morris International and its kind proposal to help NHS trusts, which has been in the newspapers today. I thought I would place on record for the House that what it talked about in its offer to trusts was “operating a scheme that allows employees who do not quit to trial one of our range of smoke-free alternatives”. We have to give them 10 out of 10 for effort, but it is totally inappropriate and that is why we have written to all trusts to make it clear.

I understand my hon. Friend’s Budget 2018 proposal for the Chancellor of the Exchequer on the need for the money in respect of the polluter pays principle. I know that the Chancellor will have heard that. My hon. Friend talked about the need for hard-hitting campaigns. We do have them, of course, and they are an essential part of tobacco control. In England for several years now, we have sought the balance between hope and harm. Every January, we have the Health Harms campaign and in the autumn, we have our more upbeat Stoptober campaign, and 2018 will be no exception.

The hon. Member for Linlithgow and East Falkirk (Martyn Day), who spoke for the SNP, talked about the illicit tobacco trade protocol, and I thank him for putting on record that we indeed ratified the protocol on 27 June to eliminate the illicit trade in protocols. The first meeting of the members of the protocol will be in Geneva from 8 to 10 October.

The hon. Gentleman talked about track and trace. The tobacco products directive contains a commitment for member states to provide the track and trace system by May 2019 for cigarettes and roll-your-own tobacco. The European Union has published draft recommendations on the track and trace proposals, and we voted in favour of implementing the regulations. I would say that the EU measures go beyond the requirements of the framework convention on tobacco control, but many of its benefits arise from the exchange of information between nations, so it seemed sensible to us for the UK to align with the EU after exit in this respect.

Both the hon. Member for Stockton North (Alex Cunningham) and the hon. Member for Linlithgow and East Falkirk talked about smoking and the media. The Government do not interfere in editorial decisions. I think it right that content makers decide what to include in their programmes, provided that they comply with the broadcasting code, and I ask them to take their responsibility seriously. Obviously, as Members have said, they are regulated by Ofcom. Last month, it published a note to broadcasters reminding them of the rules in this area, and advising them on the depiction of branding and health warnings. The last time Ofcom found a breach of the broadcasting code related to smoking was in 2015, so I think that broadcasters take the code seriously.

Many Members mentioned the British Board of film Classification, which I know well and which is a well-managed organisation. Its guidelines were last updated four years ago, in 2014. Consultation on the new guidelines began late last year, and they are expected to be published early in 2019.

There was a lot of talk about e-cigarettes, which were partly dealt with at the beginning of the debate. Public Health England will update its evidence report on e-cigarettes and other novel nicotine delivery systems annually until the end of the current Parliament in 2022, and we will include that in our “quit smoking” campaign messages about the relative—I underline “relative”, if Hansard can underline—safety of e-cigarettes. I enjoyed the comparison that the right hon. Member for Rother Valley made with Ireland: I thank him for that.

The right hon. Gentleman also said that not everything could be done by local authorities. We have not said that it should. I have made it very clear to Public Health England that where we have more work to do is where they should target their help and support, but there is also a new grant to support the tobacco control plan. The Government have launched a competitive scheme whereby organisations can apply to undertake work to support the plan’s ambitions. The grant is £140,000 a year for three years, from 2018-19: a total of £420,000 is available. Applications are currently being assessed, and we will contact the successful applicants in the autumn. I will find out some more details and send them to the all-party group.

The hon. Member for Strangford (Jim Shannon)—as always!—asked whether we would introduce vaping areas in hospitals. Public Health England advises that the smoking of e-cigarettes should not be routinely treated in the same way as smoking tobacco, but it is true that it is for NHS trusts to make their own policies. Some, including the Maudsley, have designated areas both indoors and outdoors.

[Alex Cunningham]

Will the Minister give way?

[Mr Deputy Speaker (Sir Lindsay Hoyle)]

It is up to the Minister. He said that he wanted to speak for only one minute.

[Steve Brine]

I will give way.

[Alex Cunningham]

The Minister has 12 minutes left.

[Mr Deputy Speaker]

It was the Minister who suggested that he wanted only one minute in which to sum up. The fact that we are late does not matter to me.

[Alex Cunningham]

Let me tease the Minister on three matters. One, what are we going to do about the “tab houses”? Two, what is his position on cigarette pack inserts? Three, what is he doing to do about the fact that mass media campaign funding has been cut by 90% in the last 10 years? We need that funding in order to be effective.

[Steve Brine]

I will write to the hon. Gentleman about his first two points. As for the mass media point, the hard-hitting campaigns that we conduct through the mass media are incredibly powerful. Last year’s campaign showed a gentleman rolling a cigarette with roll-your-own tobacco made of blood and gore. That was very hard-hitting, and it had an incredibly good response mechanism when we tested it and when we rolled it out. In this year’s campaign, “between hope and harm”, I think the hon. Gentleman will see a good balance of that mass media campaign that he talked about.

I realise that that was more than a minute, Mr Deputy Speaker. There is so much to say about this subject! It is so exciting.

Let me end by reaffirming the Government’s commitment. What everyone has said today has been very kind. Yes, I am committed to this subject, but ultimately we will be judged on our record. We are committed to making further sharp reductions in smoking prevalence, not so that we can meet the ambitions of the plan, although that is all very nice, but so that we can make a difference to people’s lives, because as the right hon. Member for Rother Valley said, if our constituents were dying in these numbers in road accidents we would be calling for crossings.

We want to make the smoke-free generation a reality to help people’s lives and to make a difference. Tobacco control is a key priority for us, and it will be a key priority for the 10-year plan that the Secretary of State and I will be working on with NHS England. I was interested to hear the comments of Simon Stevens at the Select Committee, and I agree with Simon, not for the first time.

I thank all Members who have spoken for their contributions—and it is amazing how far a minute can go, Mr Deputy Speaker.

Question put and agreed to.

Resolved,

That this House has considered the Tobacco Control Plan.

Use of Chamber (Women MPs of the World Conference)

Resolved,

That this House welcomes the events organised to celebrate women’s suffrage and to mark the centenary of the Representation of the People Act 1918; recognises that the Women MPs of the World Conference provides a unique opportunity to gather parliamentarians from across the world to engage in discussions about equal representation and bring about social change; and accordingly resolves that parliamentarians who are delegates participating in the Women MPs of the World Conference should be allowed to hold a debate in the Chamber of this House on a day in November other than a day on which this House is sitting or a day on which the UK Youth Parliament is making use of the Chamber.—(Mims Davies.)

NHS Outsourcing and Privatisation

Alex Cunningham Excerpts

Wednesday 23rd May 2018 Commons Chamber

[Alex Cunningham (Stockton North) (Lab)]

For now, NHS trusts remain the sole shareholder in their wholly owned subsidiary companies—yes, just for now—but those subsidiary companies will be easier to sell in future. The trusts have established those subsidiaries with long contracts under the misguided impression that such contracts protect the trust and the employees. What the trusts do not acknowledge is that the current Government, or a future Government, could order them to sell off a subsidiary company, contracts and all, and, if necessary, could change the law to make it happen.

We have already seen how these new subsidiary companies make their margins off the backs of now former NHS staff who face the prospect of less favourable contracts with no access to the NHS pension scheme, yet some trust executives claim they are transferring employees to protect them. That is absolute rubbish. We all know that when staff are transferred by TUPE, the receiving employer can have a reorganisation. It can create new roles and axe old ones, and it can require people to apply again for what looks like their old job with some subtle changes, with the terms and conditions varied, putting an end to the protections they once enjoyed. This creates the two-tier workforce many others have spoken about today. It means that some people are being treated better than others, with more rights, better pay and better working conditions.

I have even heard that some of these executives believe the changes could be in the best interest of the workforce. None of these executives faces the prospect of being reorganised out of their job or out of their final salary pension scheme with a 15% employer contribution. The executives will continue to get that pension, yet the people they have shifted into new organisations will get a 3% employer contribution to their pension.

In a few years’ time, it will be interesting to see just how many of the original staff are still in these organisations and how many of them are on the same terms and conditions enjoyed by NHS staff who are still employed directly.

I am proud that, just a week ago, one of the teams at the North Tees and Hartlepool NHS Foundation Trust in my Stockton North constituency was shortlisted for the NHS 70th awards, but a few months ago even this trust succumbed to temptation and set up one of these wholly owned subsidiary companies, despite the accounts for an existing subsidiary company showing it needed a bail-out from the trust to survive.

Wholly owned subsidiary companies are not working. They are a mechanism to rid employees of their NHS pension and of collective bargaining. The companies are damaging to employees, and they are damaging to the service in the longer run. What they are really doing is severely damaging the morale of our staff.

[Mr Speaker]

For a maximum of two minutes, I call Hugh Gaffney.

Oral Answers to Questions

Alex Cunningham Excerpts

Tuesday 8th May 2018 Commons Chamber

[Steve Brine]

The new ambulance standards are designed to do exactly that. I note the hon. Lady’s welcome for that in her area. That is critical, but of course it is critical that people get to the right place and get the right treatment. That is why I said at the start of these exchanges that centralising stroke treatment is not always popular but is often the best thing for clinical outcomes.

[Alex Cunningham (Stockton North) (Lab)]

15. How many people have accessed NHS dentistry services in the last 12 months for which data is available.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

Access to NHS dentistry remains consistently high. The most recent figures show that 22 million adults were seen by an NHS dentist in the 24 months from January ’16 to Christmas last year and 6.9 million children visited a dentist last year.

[Alex Cunningham]

Twelve thousand of those people in my constituency were left without a dentist when the Queensway practice in Billingham, in common with many dentists across the country, ditched NHS work. People are trying to build capacity there, but the funding system for dentists is a major impediment. What plans do the Government have to address the crisis in NHS dentistry, encourage dentists to stay with the NHS, and make dental health a priority?

[Steve Brine]

We have been in correspondence about the Queensway practice, as the hon. Gentleman knows. When a dental contract ends and patients need to find another dentist, NHS England has a legal duty, as he knows, to commission alternative services to meet local need. I understand that that is happening in his area and that he is being kept regularly updated on the situation. In answer to a previous question, I mentioned the dental contract, which is a key part of our reforms to keep people in, and attract people into, the dental profession.

Respite Care for Vulnerable Adults: Teesside

Alex Cunningham Excerpts

Monday 12th March 2018 Commons Chamber

[Alex Cunningham (Stockton North) (Lab)]

I am grateful for the opportunity to highlight an issue which is specific to Teesside, but which I am sure will have parallels throughout the country. Let me start with a well-worn quotation:

“If you’re one of those families, if you’re just managing, I want to address you directly. I know you’re working around the clock, I know you’re doing your best, and I know that sometimes life can be a struggle.”

Ministers are probably fed up with Opposition MPs quoting those words spoken by the Prime Minister just 20 months ago, on the steps of Downing Street. We keep mentioning them in many different contexts while we see our communities suffer as the promise that followed fails to meet their needs.

Parents of some of the most vulnerable people in our community believe that there is a respite care crisis in Teesside. No one works harder around the clock, doing their best and struggling to cope and care, than the parents and siblings of vulnerable adults, some of whom have the most complex needs imaginable. Those vulnerable adults, with some of the most extreme personal needs, may be in their 30s, 40s or even 50s, which means that the parents caring for them are in their 50s, 60s or 70s. We as a society owe those parents and carers a huge debt of gratitude. They choose to care for their loved ones at home. They do not hand them over to the state because they cannot cope; they get on with the job. They endure the sleepless nights, they clean up after their family members, and they give them the love and dedication that they need. To be honest, they do not ask for much in return for the huge burden they shoulder on behalf of us all, yet we often let them down by failing to provide the support they need, and on Teesside that appears to many to be getting worse instead of better.

I know that this issue is not exclusive to Teesside, but this evening I want to speak on behalf of the parent carers whose loved ones use the residential provision at Bankfields and Aysgarth on Teesside, and all those families who rely on residential respite care to give them a break from caring and have just a little bit of time for themselves.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on securing this debate; we have almost an hour and fifteen minutes to speak on the subject, which will be nice. One in 10 people in Northern Ireland are carers, and what the hon. Gentleman is describing is happening in Northern Ireland as well. Does he agree that short-term respite care must be provided to assist in securing the long-term benefit of keeping people in their homes and semi-independent, and that respite care should be offered, and should not have to be begged for?

[Alex Cunningham]

I thank the hon. Gentleman for his intervention, and I agree with him: the longer people are supported to stay at home, the longer they are not an even greater financial burden on the state. I will develop that theme later.

Such is the crisis in health and social care in our country that our NHS commissioners face difficult choices, and families are very worried that they could be facing a substantial cut in the provision offered to them as the local clinical commissioning groups seek to stretch the limited resources they have to meet an increase in demand for support. The CCG for north Tees and Hartlepool and the South Tees CCG are reorganising the way they provide residential respite care. When I met the north Tees chief executive on Friday, she told me of the need to have needs-based services and the plan to review exactly what each individual needs. I know, and so does the Minister, that we must have equity in the system and meet the needs of each individual, and I do not have a problem with that, but, sadly, the review is being interpreted by the families as a cut in provision, with some believing they could lose up to half their respite nights, which they are very anxious about.

I definitely agree that provision should be right to meet the needs of the individual, but this issue is much greater than that: it is also about the needs of the whole family, and perhaps the CCG should have conducted a needs assessment before deciding on the review. In fact, I have always thought that the respite care was very much for the family— an opportunity to take a break from their caring responsibilities, to recharge the batteries and to prepare to resume what they see as their duties.

The CCG has been at pains to stress to me that its proposals do not necessarily mean that there will be a huge reduction in the number of respite nights, but it recognises things will change for some people and is working with families and piloting different ideas to try and improve provision and reassure them. While I think the CCG could have handled this whole business better and understood more comprehensively the issues from the perspective of the families and the various local authority and joint health scrutiny groups who oppose the plans, I cannot say it is its fault.

[Fiona Onasanya (Peterborough) (Lab)]

In my constituency, a home providing respite care for very disabled and unwell children called the Manor is being closed, and I very much agree with my hon. Friend that this issue should be about the whole child, including the family, and the respite having that night provision gives to the family. In my constituency, that night provision is being entirely cancelled; does my hon. Friend agree that the impact of that must be assessed?

[Alex Cunningham]

I certainly do agree. I opened my speech by talking specifically about this being not just a Teesside issue, but an issue across the country, and it is a tremendous challenge to Government to plan for the future; I will also be developing that later in my speech.

I know that the team members at the CCG dealing with respite and wider provision are dedicated to their jobs and that they too have been distressed as we have gone through this process, and I for one appreciate the strains of dealing with such sensitive issues. They are trying to do their best within what they say are the ring-fenced resources available, although I personally could have hoped that they would have kicked the Government for failing to provide the resources needed.

Currently, respite is provided in two NHS centres of excellence, Aysgarth and Bankfields, but what are they planning to do now? The best of the options available to carers is this perceived reduction in residential care provided by the expert and nursing staff for their family members, and then the provision of a menu of alternative choices, largely without nurses. The choices include beds in care homes, hotel rooms, adapted caravans and even in carers’ own homes. Could we really see a vulnerable adult accommodated in a caravan somewhere and looked after by people in whom their parents may struggle to have confidence? What about the risk assessments for that menu of provision? Who is going to check that all the new people caring for these vulnerable people are both trained and suitable for this role and that the premises are suitable? What respite is it for a carer if they have the respite worker under their own roof? That is not much of a break for the carer or the family member.

To be fair to the CCG, it has promised that there will always be appropriately trained staff to offer the care and support required. Sadly, however, it is yet to provide the families with the reassurance they need, and the uncertainty is torture for them. So much more needs to be done to drive understanding. We also have to ask whether changes that cause such disruption are really appropriate in 21st-century Britain when carers do not know what the future holds. Our provision should be improving, not deteriorating in practical terms nor in the eyes of the carers.

[Susan Elan Jones (Clwyd South) (Lab)]

My hon. Friend is making a powerful case. Does he agree that this country needs to be doing a great deal more to support carers? I think back to the 1997 Labour Government, when national insurance contributions towards carers’ pensions were introduced. Is there not a case for looking at things in the round and doing more to support carers?

[Alex Cunningham]

I am a member of the all-party parliamentary group on carers, so I spend a bit of time on this subject. I do not know whether we will ever get to a point at which we are content that we have done enough, but we need to do much more.

I recently wrote to the Hartlepool and Stockton-on-Tees CCG regarding the consultation that was taking place at the time. It confirmed that it is committed to retaining the full £1.5 million fund for this provision, but it highlighted that the money will have to be spread further to reach more families. That confirms that provision is being diluted, and when provision is diluted, it is cut, and it will be the carers who will pick up the extra responsibility.

I accept the CCG’s point that more people need respite services, but the answer is surely to increase funding and provide the services that are needed, not water down what is available and provide a poorer-quality service. Demands for such services will continue to increase over the coming years as more vulnerable, high-needs young people grow into adults, live longer and need the kind of comprehensive support given by the people I have been speaking of today. The cost of meeting the services will therefore go up and, yes, although the cost may in some cases be shared between the NHS and local authorities, neither of them can sustain quality services for a growing cohort of people when the income simply is not there.

According to the National Audit Office, Stockton Council has had its budget cut by 52% since 2010 and spends around 57% of its money on social care. Does the Minister realise that we are facing a potential crisis? Does she understand the tremendous role that carers take on? Does she appreciate the need for comprehensive respite care to give them a few days’ break, or does she think that they will get by and manage? Well, while some may, others will not and will face the difficult decision to hand their loved one over to the health service full time because they simply cannot cope any more. What short, mid and long-term planning are Government doing to ensure that we have a strategy in place not just in Teesside but across the country to cope with increased demand and provide the increased resources required to deliver appropriate provision?

My colleagues on Teesside—my hon. Friends the Members for Stockton South (Dr Williams), for Hartlepool (Mike Hill), for Middlesbrough (Andy McDonald) and for Redcar (Anna Turley)—have all listened to carers’ stories and recognise that they are facing tremendous anxiety over what the changes will mean to respite care. Others have listened, too, including the scrutiny committees of our local authorities. The joint health scrutiny committee, a cross-committee of local councillors, stated that it could not endorse either of the two options or any other that would reduce provision. None of the councillors believe that the CCG has covered itself in glory in its handling of the matter, and they can see why those dependent on these services for a decent quality of life have lost all trust in the organisation, feeling that it has ignored their pleas and failed to understand their needs.

There is another dimension to this. I applaud the CCG for the comprehensive consultation exercise—and it has been comprehensive. Sadly, the CCG has failed to get its messages of reassurance across to these needy families, who interpret that as its having failed to recognise the anxieties created by the process. Carers tell me they have no understanding of any new criteria that will determine who gets what services. They feel that they are being left in the dark. Yes, I praise the public consultation by the CCG, but at the end of day the options were severely limited. I repeat that there is no extra cash to cope with increased demand.

I have heard that at one meeting with councillors, the CCG said that carers cheered when option 2 was chosen over option 1, which would have ended all provision at the two nurse-led residential units. Naturally, the carers cheered the better of two bad options. There was no option at all to extend the current provision or provide resources to cater for the additional needs of new adults coming into the system, which is something that Ministers need to reflect on. The CCG also stated that this was not a cost-cutting exercise. I know that the money is ring-fenced, but with the need to look after more people with the same money, there are fewer resources per person in the system. While I remain critical of the CCG and the way in which it has handled this issue I recognise that in many ways it has been backed into a corner. It know the demands on its service, but does the Minister? It knows that there are more people needing services, but there is no additional funding to provide that.

We all know that we have a health and social care crisis in our country, and while local authorities can shift the burden on to local council tax payers as Government cuts bite deeper, it is not something that our local NHS commissioners can do. They cannot tell local tax payers that they are sticking an extra 3% on their bills to try and alleviate the shortage of funds in areas such as respite care. That leaves the buck well and truly in the Chamber, with the Secretary of State for Health and Social Care and the Minister. My plea to her is simple. Will she take an interest in what is happening on Teesside with respite care for vulnerable adults? Will she examine the proposals, which parents see as a cut to provision for families in the area?

This is much bigger than Teesside. Yes, I know that there are CCGs up and down the country facing the same issues, so perhaps it is time for Ministers to consider the whole policy area of supporting carers such as those I have talked about this evening and find ways of providing the NHS and, for that matter, local authorities with the resources that are needed. Will the Minister instigate a much-needed policy review to see how we can do much better as a country to support carers?

Many families—I have talked to several—are living on the edge, struggling to cope with the needs of their loved ones. They have no intention whatsoever of handing them over to the state, but they need comprehensive respite care services to give them a little of their own time and space. We as a nation owe them no less.

--- Later in debate ---

[The Minister for Care (Caroline Dinenage)]

I am grateful to the hon. Member for Stockton North (Alex Cunningham) for raising his concerns this evening, and indeed to his colleagues, the hon. Members for Stockton South (Dr Williams) and for Redcar (Anna Turley). They have stated the justifiable concerns of their constituents powerfully and articulately. Whenever change is afoot, people have a tendency to feel concerned, and it is absolutely right that those concerns are articulated.

Supporting the most vulnerable in our society—those with complex needs, those with autism and those with learning disabilities—is one of the most important but exacting tasks that health and social care commissioners face. It is a task that must be undertaken with a genuine desire to get the very best outcomes not only for those who need support, but for those who care for them.

It is important to remember that many of the services that we are discussing today are focused on people with autism and learning disabilities—conditions that can manifest with very different requirements. They may need care and help ranging from routine, occasional help in the home to full-time personal support, with perhaps two or more people at a time providing that personal assistance.

Our mandate to NHS England includes a clear objective to improve outcomes for people with autism or learning disabilities. That means making sure that they are fully supported in the community, that hospital admissions are reduced and that they have the opportunity to live an ordinary life. Building the right support is our plan to use concerted local action to deliver that community support and to reduce the number of in-patients by March 2019.

We know that respite services are extremely important and a significant element of community-based support. They benefit not only the individual receiving that care, but their family and carers. Members have spoken very powerfully about that tonight. The hon. Member for Stockton North rightly points out that family carers in particular play an invaluable role—a role that is often unsung and undervalued. Often, they do so not out of a sense of duty or compassion, but out of pure love, and they deserve nothing other than our unbridled respect and our thanks. He asked me about the work that we are doing to support carers. They will of course be an integral part of our thinking in the Government Green Paper on social care that will be produced later in the year. In the interim period, we have a carers’ action plan, which I care passionately about and which will set out some short-term steps that we want to introduce to support carers and their valuable work more fully.

[Alex Cunningham]

It is very clear that the Minister gets this, and I admire the way in which she is putting her argument across, but this is also about resource. I am very concerned about the current problem on Teesside, but in the longer term young people in their 20s are coming through the system and approaching 30. These are children who in a previous generation would never have survived, and they are going to need more and more services. More children are becoming adults who will require more provision. What are the Government doing in terms of longer-term planning?

[Caroline Dinenage]

The hon. Gentleman articulates a real issue with which we have to contend. That is why we have increased NHS spending every single year since 2010, so that our NHS now has about £13 billion more to spend on caring for people than it had in 2010. That goes to the heart of the issue that he has identified. We need to ensure that care, particularly respite care, is responsive to the needs of individuals. That implies both a need to assess and determine the right kind of support, and a need for flexibility to allow for personal choice, as I believe is being looked at in Teesside.

Some needs may be best met through a stay in a suitable service that provides overnight beds, with appropriately trained staff to support people’s individual care needs, but that may not be true for everybody. Those with less severe physical or learning disabilities may find that action in the community is more desirable and appropriate for them—for example a visit, leisure activity or even visiting family members with the right personal support. We do not want those opportunities to be written off for them because we have a very restrictive system, which is why it is right that commissioners have the means to seek new approaches and to be flexible in how they meet people’s needs. I understand that the intention in North Tees is exactly that, but it must be based on suitable engagement, as the hon. Gentleman said, to assess people’s individual needs.

Having listened to hon. Members’ comments, I understand their concern that not everyone can currently access respite services and that these services may not be flexible enough. Local commissioners are rightly looking to change respite provision. The hon. Gentleman will understand that it is not customary for a Minister to comment in detail on specific commissioning decisions or on the extent to which there was appropriate consultation, unless that is part of a formal review process. I understand that the local CCG has consulted on the proposals for 10 weeks and is now in the process of designing the service.

[Alex Cunningham]

Does the Minister recognise that the CCG has acknowledged that it will have to get more people into the system, so the service will be diluted? Having recognised that, what can she do about it?

[Caroline Dinenage]

As I have already said, it is up to CCGs to commission the local services that they feel are appropriate in their local communities. It is not for the Government to force a top-down diktat on how they need to spend their resources. I understand that local councils are, quite rightly, scrutinising the proposals right now. This is an important means of quality assurance and is informed by local people with local knowledge. I hope that the hon. Gentleman will find some reassurance in that. However, although it is right that service reconfigurations are considered locally and are not driven from the top down, any significant changes to services are subject to the Government’s four tests. The changes should demonstrate support from clinical commissioners, strengthened public and patient engagement, clarity on the clinical evidence base, and support for patient choice.

There is a clear set of expectations in relation to the provision of respite care and the role of commissioners. Alongside provisions in the National Health Service Act 2006, all CCGs must secure services to meet the needs of their population to a reasonable extent. Respite care may be routinely commissioned or made available as part of a package of NHS continuing healthcare, and is often also provided as part of social care. The Care Act 2014 requires that where an adult or carer appears to have care and support needs, the local authority must carry out an assessment and meet any need where the person has met the eligibility criteria.

[Alex Cunningham]

The scrutiny groups on Teesside—at least some of them—are thinking of referring the matter to the Secretary of State. What happens when it is referred, and what can the Government do then?

Points of Order

Alex Cunningham Excerpts

Wednesday 7th March 2018 Commons Chamber

[Mr Speaker]

The hon. Lady has certainly been patient. Sometimes, raising a point of order in the Chamber and reminding those on the Treasury Bench of a promised meeting that has not yet been delivered can be a remarkably effective way of bringing about said meeting. The other device that I recommend to the hon. Lady, who is a new Member of the House, is the tabling of a written question. If she is interested in exploring historic copies of the Official Report, she will know that the former Member for Manchester, Gorton, our late and dear friend Sir Gerald Kaufman, was fond of highlighting unanswered correspondence to which he demanded a reply, unanswered questions to which he demanded a reply, or undelivered meetings that he had been promised and on which he still insisted by tabling written questions to remind Ministers of those matters and inquire when the promised reply or meeting would take place. In my experience, Sir Gerald was remarkably effective at obtaining such responses, as indeed was the former Member for Walsall North, Mr David Winnick. The hon. Lady may usefully learn from their and many other examples.

[Alex Cunningham (Stockton North) (Lab)]

On a point of order, Mr Speaker. In January, the Government announced plans to incentivise local communities to agree to explore the possibility of storing radioactive nuclear waste near their homes—an initiative that was widely reported in the media. I was anxious that it could revive proposals to store nuclear waste in the anhydrite mine under thousands of homes in Billingham in my constituency. I raised the issue at Prime Minister’s questions on 31 January. Sadly, the Prime Minister’s substitute that day, the Minister for the Cabinet Office, despite the publicity and it being Government policy, knew nothing about that initiative by his Government. However, he promised to investigate the matter and write to me. That was five weeks ago. Will you advise me whether it is unreasonable of me to have expected an answer by now?

[Mr Speaker]

I am grateful to the hon. Gentleman for his point of order and for his courtesy in giving me notice of it. It is not unreasonable for an hon. Member to expect a response from Ministers within five weeks. Ministerial correspondence is of course, as colleagues will know, the responsibility of the Minister concerned. The Minister for the Cabinet Office and Chancellor of the Duchy of Lancaster, the right hon. Member for Aylesbury (Mr Lidington), who happens to be my constituency neighbour, is normally most courteous. I am sure that his colleagues on the Treasury Bench, including the representatives of the Patronage Secretary, will swiftly alert the right hon. Gentleman to this outstanding action. The hon. Member for Stockton North (Alex Cunningham) certainly should have had a reply and he should now get one, sooner rather than later. Meanwhile, he has placed his concern on the record.

NHS Wholly Owned Subsidiary Companies

Alex Cunningham Excerpts

Tuesday 6th March 2018 Westminster Hall

[Liz Twist]

I most certainly do agree, not just for pensions but also for terms and conditions.

What is the problem with these companies? First, it is that they come at a price, which for the most part is met by the staff who work for them. Secondly, the VAT saved by trusts with these companies is not new money coming into the NHS—the money that trusts save will be lost elsewhere in public services. Already, the Department of Health and Social Care has reminded trusts by letter that they should not engage in any activities that may be construed as tax avoidance, and the loophole could be closed in the future. Thirdly, the establishment of wholly owned subsidiaries leaves the services open to privatisation in the future, continuing the fragmentation of our NHS.

[Alex Cunningham (Stockton North) (Lab)]

The North Tees and Hartlepool NHS trust set up a limited liability partnership last week. Even according to its own published material, it provides no guarantee of job protection beyond a few months and will create a situation with different employees on very different terms and conditions. Is this not all about Government cuts? Does my hon. Friend not agree that we could see even more staff transferred into this sort of arrangement in order to meet the Government’s cuts agenda?

[Liz Twist]

I most certainly do agree. I think this is the start of a very worrying process, not just for facilities management stuff but potentially for other staff.

--- Later in debate ---

[Liz Twist]

I very much agree. It is a very dangerous precedent that does not respect the rights of those staff.

[Alex Cunningham]

Further to that point, is my hon. Friend aware that the question and answer document produced by the North Tees and Hartlepool NHS Foundation Trust says that NHS staff transferred into the new company can expect a pay rise this year, but nothing is guaranteed in the future? They are already seeing their future conditions eroded, unless the new company awards them the pay rise they will get under the current system.

[Liz Twist]

That is absolutely correct, and I have raised with my local trust the potential move away from NHS pay rises.

The main way trusts can make savings is by employing the new staff on worse terms and conditions, which means lower pay rates, less holiday, inferior sickness schemes and no access to the NHS pension scheme. As colleagues said, even transferred staff may be moved on to the worse terms and conditions over time. Trusts are doing that to the lowest-paid workers, who are essential to keeping our hospitals going.

--- Later in debate ---

[The Minister for Health (Stephen Barclay)]

It is a pleasure to serve under your chairmanship, as always, Mr Hollobone. It is also good to see a number of Members from across the House in the Chamber to debate this important issue. I congratulate the hon. Member for Blaydon (Liz Twist) on securing this debate. I am pleased to be able to join her in discussing an issue that is of concern and interest to many in the House.

I understand that Gateshead Health NHS Foundation Trust established its wholly owned subsidiary company, QE Facilities, in 2014 to provide estates, building and engineering services to the trust and cleaning services to the new emergency care centre building. QE Facilities is a separate legal entity, which operates along commercial lines. It has separate governance arrangements and the ability to employ its own staff and deliver services to other organisations on a commercial basis. As the hon. Lady said, a number of staff from the Queen Elizabeth Hospital in Gateshead transferred under TUPE rules to the new organisation in December 2014. I will respond to her points.

A number of hon. Members raised the concern that what happened amounts to privatisation, but I must point out that the legislation enabling NHS organisations to create subsidiaries of this sort was put in place by the Labour Government in 2006. If it is privatisation, it is privatisation enabled by Labour legislation, and I do not think that is the way Ministers described it to the House at the time. The subsidiaries are also 100% owned by the trust, so they are within the NHS family.

It is right that the board of the Queen Elizabeth Hospital was able to use the powers enacted by the previous Labour Government. It did so because creating a subsidiary is, in its view, the most effective and efficient way of maintaining the trust’s hospital estate, which includes several new buildings. Again, that is consistent with the previous Labour Government’s approach, which was to allow local trusts to determine the best manner of managing their own estates.

[Alex Cunningham]

I do not care which Government provided the enabling legislation. Surely the Minister agrees that the intention was never to undermine the working terms and conditions of people within the NHS just to enable trusts to cut the amount of money they need to spend?

[Stephen Barclay]

I will happily address that. The hon. Member for Bradford South (Judith Cummins) also made that point and said that this is about exploitation. The hon. Member for Stockton North (Alex Cunningham) may not care whether the legislation was introduced by a Labour Government; I was merely drawing hon. Members’ attention to the fact that when the legislation was passed it was not described as privatisation. It is obviously a leap to describe the legislation as enabling privatisation when the subsidiaries are wholly owned by the NHS.

[Alex Cunningham]

I am grateful to the Minister for giving way again. The North Tees and Hartlepool NHS Foundation Trust said in its question and answer document that such an organisation could be taken over by another organisation—in other words, it could be privatised. This is one step along the way to the potential privatisation of all those services.

[Stephen Barclay]

The trust has stressed that the organisation remains in public ownership. Let me deal with the hon. Gentleman’s substantive point—it was also raised by the hon. Member for Bradford South— that this is about exploitation. I discussed that point with the trust ahead of the debate.

Previously, the trust had difficulty in attracting and retaining quality maintenance staff because the salaries paid in the local market were about £19,000 per annum. Under the subsidiary company, multi-skilled craftspeople are employed at about £25,000 per annum, plus a performance bonus, attracting better-qualified staff and ending retention issues, in exchange for the fact that they do not have access to the NHS pension.

--- Later in debate ---

[Stephen Barclay]

I do not know whether we are moving away from the subject to a wider debate about finance, but the Chancellor’s Budget settlement makes the Government’s finance commitment clear. The fact is that the issue of subsidiary companies is about using the resources of the NHS in the most efficient manner. That is the view not just of the Government and of the previous Labour Government, but of the trust itself. It is delivering a better outcome for patients and delivering savings—I repeat, the savings accrued go to the benefit of the trust that owns 100% of the subsidiary. It is a shame that those on the Labour Benches seem to want to deprive staff of choice and opportunity. Staff are benefiting, and that is reflected in the staff survey.

I hope that in responding to the debate I have allayed a number of the concerns of the hon. Member for Blaydon about the setting up of subsidiary companies by trusts. I am sorry that there is such concern about the legislation put on the statute book by the previous Labour Government and that it is being deemed to be a form of privatisation.

[Alex Cunningham]

Does the Minister think it is fair for one of two different people in an organisation to receive a defined benefit pension scheme with a 50% contribution and the other to get 3% into a defined contribution scheme worth a fraction of the other in pension terms?

[Stephen Barclay]

Within the NHS as a whole—nothing to do with subsidiaries—there is a range of treatment of staff on pensions. First, there are the legacy pension arrangements for staff in previous schemes and, secondly, people opt out of existing pension arrangements in the NHS. Again, it is a complete mischaracterisation of this debate on subsidiaries to suggest that there are differences. The point, however, is that there are also differences in pay, as has come out of this debate: the maintenance staff for whom the trust is paying a premium can be paid so because of the subsidiary.

Medicines and Medical Devices Safety Review

Alex Cunningham Excerpts

Wednesday 21st February 2018 Commons Chamber

[Mr Hunt]

I wish I could say to my hon. Friend that those people’s terrible suffering has been taken as seriously as it should have been, but the truth is that we have a system that has not treated patients’ concerns with the seriousness that it should have done. That is why we want to make the important changes that we are announcing today.

[Alex Cunningham (Stockton North) (Lab)]

Forty-four years ago, my constituent Lesley Holmes took two Primodos tablets that had been handed to her by her trusted GP, to check whether she was pregnant. She was, but the consequences for her son have been devastating. With the expert working group’s report having been stripped of its credibility, Lesley is still seeking answers and recognition of her family’s plight. The Secretary of State appears to agree that we need to recognise that fact and provide the answers, but how long is this going to take? How is he going to ensure that the outcome is actually credible this time?

[Mr Hunt]

All I can say is that we completely understand those concerns and the despair that many people feel about this issue, but it is difficult to resolve it quickly when there is disagreement among the scientists. What we are trying to do today is to create a process to resolve that disagreement, and that is what I very much hope will happen.

NHS Winter Crisis

Alex Cunningham Excerpts

Monday 5th February 2018 Commons Chamber

[Stephen Barclay]

My hon. Friend is absolutely right. What he points to is the variance in performance between some of the best trusts, such as Luton and Dunstable, and other trusts. One of the key challenges is how we ensure that that best practice is better socialised across the NHS, because unlike Labour we recognise that it is not just about how much money we put into the NHS; it is what we get out for that money. Luton and Dunstable illustrates that point, and more trusts need to follow suit.

[Alex Cunningham (Stockton North) (Lab)]

North Tees Hospital staff are doing a great job of dealing with the winter crisis, but even they have been struggling this year. The trust says it is going to record its first ever deficit, because it cannot make the £18 million cuts demanded by the Government. Is the answer really to deprive it of more money or to have it set up a wholly owned subsidiary company to cut the terms and conditions of future staff?

[Stephen Barclay]

The hon. Gentleman’s trust has received an additional £1.6 million, so it is simply factually incorrect to say that its budget has been cut.

Hormone Pregnancy Tests

Alex Cunningham Excerpts

Thursday 16th November 2017 Commons Chamber

[Steve Brine]

The step that we will take is to implement the report’s recommendations. As I have already said, the way the families were handled when they came down to speak to the expert working group could have been a lot better, which is the understatement of the day, and I apologise for that on behalf of the MHRA.

[Alex Cunningham (Stockton North) (Lab)]

A constituent who took one of the Primodos tests and whose son was born deaf visited my surgery on Friday, and she is deeply disappointed with the latest outcome. The Minister said a few minutes ago that checks had to be made before the final report was published, so what hope can he offer her and other parents that the matter will not be swept aside, that work will continue to flush out the truth and that the affected families will be properly supported?

[Steve Brine]

All I said is that there were checks to be made to ensure that the report was as readable and as accessible as possible. We are confident in the report, and we are not going to sweep it away and forget about it and move on to the next story; we will implement the recommendations.