Oral Answers to Questions

Marie Rimmer Excerpts

Tuesday 7th February 2017 Commons Chamber

[Mr Dunne]

The hon. Gentleman is right to point out that the STPs are looking at providing more integrated care across localities. A number of indicative proposals have to be worked through. At the moment, NHS England is reviewing each of the STPs, and the results will be presented to the Department for its consideration in the coming weeks and months. On bed closures, I gently remind him that, in the past six years of the previous Labour Government, more than 25,000 beds were closed across the NHS. In the six years since 2010, fewer than 14,000 were closed by this Government and the coalition.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

7. What assessment he has made of the effect of changes to local authority social care budgets on demand for health services.

[Liz McInnes (Heywood and Middleton) (Lab)]

15. What assessment he has made of the effect of changes to local authority social care budgets on the provision of adequate health and social care services.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

The relationship between health and social care budgets is complex. A recent study by the University of Kent has shown that, for every pound spent on care, hospital expenditure falls by between 30p and 35p. The hon. Lady will also be aware that there has been an increase in delayed transfers of care over the past two years, which has resulted in an increase in the number of unavailable hospital beds. Our best estimate of that increase is around 0.7% of total NHS bed capacity due to the increase in social care delays.

[Marie Rimmer]

It is quite amazing that the Minister is prepared to stand up and accept that there is a crisis in the NHS caused by the lack of social care provision. The crisis in social care means that more and more local authorities are reduced to just washing, feeding and toileting our elderly people. The crisis in residential care means that people from homes are going into the hospitals and choosing to leave the patients with the most complex needs, because they cannot afford the staff to look after them—

[Mr Speaker]

Order. I apologise for interrupting the hon. Lady, but we must have a question: one sentence and a question mark, thank you.

[Marie Rimmer]

There is no comfort for our elderly people. It is not too late for the Government to act. I ask the Minister to look at protecting social care funding. Will he bring forward the £6 billion and the £700 million—

[Mr Speaker]

Order. I am sorry, but there is a lot to get through. It is not fair on other colleagues.

[Marie Rimmer]

It is not fair on the elderly.

[Mr Speaker]

Order. I am sorry. I say to the hon. Lady without fear of contradiction that we must spread things out evenly.

Alcohol Harm

Marie Rimmer Excerpts

Thursday 2nd February 2017 Westminster Hall

[Marie Rimmer (St Helens South and Whiston) (Lab)]

I applaud the right hon. and hon. Members who secured this debate with the hope of influencing the Government to update the alcohol strategy, which is absolutely necessary. In particular, the all-party parliamentary group for foetal alcohol spectrum disorder would like an update on action on point 5.15 of the strategy. It reads:

“Fetal alcohol spectrum disorders…result from mothers drinking alcohol during pregnancy. They are lifelong conditions that can have a severe impact on individuals and their families—leading to a wide range of difficulties including low IQ, memory disorders”—

such as forgetting how to swim, “attention disorders”, such as when people detach themselves from family members and adoptive parents—

“speech and language disorders, visual and hearing defects, epilepsy and heart defects. They are caused entirely by drinking during pregnancy, and so are completely preventable. We do not have good information about the incidence of FASD…FASD can be caused by mothers drinking even before they know they are pregnant; so preventing them is strongly linked to reducing the levels of heavy drinking in the population as a whole, and especially among women.”

The rate of alcohol consumption is much higher among women in my constituency than in many others. The alcohol strategy says that we need to reduce consumption in the population as a whole, especially among young women,

“including by increasing the awareness of health professionals.”

There is a lack of understanding and awareness about this problem.

Let me give a general overview. Some 10.8 million people in England drink at levels that pose a risk to their health. Most of us have a drink, which is why we do not recognise the problem—we say, “They are just having an extra one. They might have had a bit more than me, but they have not really got a problem.” Overall, alcohol costs the UK £21 billion every year. It affects millions of lives and places a huge burden on public services. The Government cannot afford not to do something about alcohol, because of the drain on the national health service, social services and children’s social care, and because of the number of children who have been placed in care or are up for adoption because of alcohol.

I have seen younger relatives die from alcohol. A great friend of mine died from alcohol—he was head hunted to work in this place some years ago. That professional, skilled person was lost to alcohol, and nobody recognised or faced the problem.

Alcohol is 54% more affordable now than in 1980, which has helped to drive the historically high levels of alcohol consumption. I could not believe, and could not convince my colleagues on the council, how much cheaper alcohol is than bottles of water. I took them round two local supermarkets where alcohol was cheaper than water—cheaper than milk, even. Supermarkets frequently use heavy discounts to sell alcohol more cheaply. The evidence is still around us today.

The figures suggest a modest drop in overall consumption in recent years, but we are still drinking at historically high levels. It is the culture where I come from. St Helens was born of Irish immigrants; it was as far as people could walk from the docks of Liverpool when they landed there after escaping the potato famine. They worked very hard in the pits and in glass and chemicals manufacturing, so it was normal to have a drink at night. But what has gone wrong is that many of the pubs and clubs where the working men could enjoy good company with their pals on a night out have closed down, largely because supermarkets are selling drinks so cheaply. People buy alcohol and drink it at home, where they do not get the company and other people do not see how much they are drinking—it is just their families, who are least able to cope with the problem.

Some 2.1 million children in England are negatively affected by other people’s drinking every year, and the Government have to do more for them. Children do not ask to be born. Young people in the UK tend to drink more and start drinking earlier than young people in other European countries because they see drinking in the house more. Children exposed to a lot of alcohol advertising are more likely to drink heavily and start drinking at an earlier age—10 to 15-year-olds in the UK view more alcohol ads on TV than adults over the age of 25. By the age of 15, 44% of girls and 39% of boys in the UK have been drunk at least twice.

In England, 100 children end up in hospital each week due to alcohol. I could go on and on with the facts, but I would like to give a general overview. More than anything, I want to focus on children. As a member of the all-party group for FASD, I was driven to this issue. I was alarmed by the number of cases coming up at my surgery, many raised by parents seeking to adopt children. It was heartbreaking. I want to talk about one family in my constituency that came to see me. They were a couple with two children in their late teens and they were on the road to adopting a young child aged eight. They had fostered her and had been given no information at all on health issues, but it soon became obvious that the child was a victim of FASD. She had detachment disorder and had forgotten how to swim, even though she had been taught. She displayed inappropriate behaviour towards visitors and their families, and visitors stopped coming to the home.

A dreadful battle ensued to get a diagnosis and a care package from the local authority. It was difficult because the child was not from the local authority area that the family were living in. They were advised that if the adoption was not completed in a certain timescale, the child would be removed from them. The adoptive parents had taken time off work, but had to return to their jobs. They were prepared to reduce their working hours to care for the child, but they needed a diagnosis and a care package. They were at risk of losing their home—that is how much they loved that child.

[Bill Esterson]

My hon. Friend is speaking incredibly well. I pay tribute to her for the work she has done as a constituency MP and for the support she has given the all-party group as well. The point she is making demonstrates the need for support for adoptive parents. All too often there is no post-adoption support, particularly with this condition of FASD. It is even more important than perhaps we knew in the past, so perhaps I can make that point via my hon. Friend to the Minister to pass on to colleagues in the Department for Education.

[Marie Rimmer]

I totally agree with my hon. Friend.

My constituents needed diagnosis and a care package. They were at risk of losing their home. They were heartbroken at the thought of the child being taken away from the family and put into another foster home, and then going through, again and again, more placements because families cannot cope with such children. It is so difficult to care for them and yet they are so lovable. The parents were absolutely heartbroken. Silent tears rolled down the cheeks of this professional couple. The tears rolled down quietly as they sat facing me. It was heartbreaking to watch them. The child was part of the family. The two teenage children were beside themselves at the thought of losing their little sister who had become a part of the family. It was only through my direct contact with the local authority chief executive that the child was allowed to stay with the family. In the end, the chief executive apologised and gave a commitment to the family that the necessary diagnosis, care and support would be provided.

More than 7,000 children affected by FASD are born in the UK each year. As a member of the FASD all-party group, I have raised the issue with officers at St Helens Council, where statistics show that alcohol-specific hospital admissions of females were the fourth worst in the country. It is a cultural thing. We see drinking in the family: it goes on, becomes the norm and then leads to an extra drink. Where I come from, we never used to see alcohol in supermarket baskets. There was certainly never any alcohol in our homes. Unfortunately, alcohol is in most homes now. That is where families and children see it being drunk and then becoming part of the culture. It becomes the norm and it is much harder to tackle.

In Peterborough, 75% of children referred for adoption have a medical history of pre-natal alcohol exposure. Most of the looked-after children in St Helens come from alcohol-related problem families. I have met officers at St Helens Council who have given me a principled commitment to progress matters. I am delighted that a training programme with all appropriate staff took place last year. It is estimated that 1% of babies born each year in Knowsley have FASD—that could mean 19 babies in the two wards in my constituency that are in that authority.

I am delighted that action is being taken locally by St Helens Council, but without a national response from the Government, FASD as an issue will continue to be overlooked by the population as a whole. As a local MP, I have done my best, but it is certainly not enough. I have supported the awareness strategy and campaign at Whiston Hospital maternity unit. A recent survey found that 72% of people in Merseyside believe the Government have a responsibility to reduce alcohol-related harm, which is a drain on services.

My understanding of where I live in the north-west—not just in the Merseyside authorities but outside—is that well over 50% of the children on looked-after registers and going forward for adoption are damaged by alcohol and are being raised in families with alcohol-related problems. How can the Government not look at that drain on services, but—more importantly—the damage to those children’s lives? What will they grow up to be? What quality of life will they have? They do not ask to be born. The Government must do more than they are doing now.

I commend the hon. and right hon. Members who secured this debate. So many people and families are distraught at the damage caused by alcohol. More must be done and I plead with the Minister to act accordingly.

Southern Health NHS Foundation Trust

Marie Rimmer Excerpts

Tuesday 3rd May 2016 Commons Chamber

[Alistair Burt]

The best way that I can convey it is to say that constant monitoring is being done. First, the improvement director, who was appointed not by the trust, but by NHS Improvement, is there. In due course he will have a constant presence, but the monitoring needs to be done on a very regular basis. Also, the CQC has made it clear that should there be any need for further unannounced inspections, it will carry them out, so the trust is on constant notice that there can be a further inspection at any time. Further powers of the CQC include issuing another warning notice, varying and removing conditions of registration, monetary penalty notice for prescribed offences, suspending registration, cancelling registration, and prosecution. I understand from speaking to Mr Paul Lelliott that none of these measures has been ruled out.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

It is that very point I wish to talk about. The duty of candour was going to give us so much more strength, but it is not being applied as yet. It is a statutory duty, placed on people carrying out regulated activities. It can lead to prosecution by the CQC, including without a warning notice. Will the Minister assure me that he will watch carefully to make sure that the CQC uses those powers appropriately? If it does not, we are once again failing these very vulnerable people.

[Alistair Burt]

Absolutely. If we now have a system where there is, quite rightly, a degree of autonomy, and Ministers’ responsibility is to make sure that the process and the system work well, Ministers cannot make all the decisions personally, but we do have to make sure that decisions that need to be taken are taken and, if not, that there is a good explanation of why not.

The CQC’s powers have been strengthened. Just a few months ago, we had the first case of a care home owner being jailed because of the care given to people in their home. While I recognise that the work done in caring for vulnerable people is complex and difficult, and that prosecution will not be the right answer in every case, knowing that powers are there is really important. The hon. Lady’s anger is appropriate, and I know the CQC takes these powers very seriously.

NHS Trusts: Finances

Marie Rimmer Excerpts

Monday 1st February 2016 Commons Chamber

[Ben Gummer]

I can give the hon. Lady that reassurance. When I was in Hull a few months ago, I had a fantastic series of conversations with clinicians—not just those who are leading the hospital, but those on the frontline in the wards—about how to address the staffing challenges in Hull and east Yorkshire. It is tailored responses to the problems in individual localities that will provide the quality of service in Hull that she wants for her constituents. I am committed, as are the staff in Hull, to ensuring that she sees it.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

Will the Minister join me in visiting my local clinical commissioning group, trust and social services? The reason I ask is that St Helens and Knowsley Teaching Hospitals NHS Trust has just been rated “good” in four of the five areas and “outstanding” in care. The chief executive is managing Southport hospital to help there in the interim. She previously helped Warrington out of its problems. We have no problem with our chief executive and our staff are outstanding and work hard. However, we are having to recruit nurses from Spain. There is a wonderful working relationship between the CCG, the hospitals and adult social care, with lots of pooling going on. Nevertheless, Whiston faces a £7 million deficit and that is not down to the PFI tariff. [Interruption.] Sorry, Mr Speaker, I will come to the question. Will the Minister please join me for a constructive discussion with those people to see what is happening on the frontline?

[Ben Gummer]

I know that the Under-Secretary of State for Public Health was in Whiston last year. I was in Manchester a few weeks ago, and I plan to go back there and to the north-west in the next few weeks. I will be doing a regional tour, and I would very much like to meet the hon. Lady and talk to her trust’s chief executive. She raises an interesting point, which is that chief executives in many trusts across the NHS are of exceptional quality. It is often easy to knock managers in the NHS, but there are some fantastic managers, and I am sure that her constituency has one.

Mental Health

Marie Rimmer Excerpts

Wednesday 9th December 2015 Commons Chamber

[Mr Hunt]

My right hon. Friend is, of course, absolutely right, and I think we do a great disservice to the many people suffering from mental health conditions if we allow this to become a partisan issue. Of course Oppositions must hold Governments to account for their promises, but we should never try to suggest that one side of the House cares more about this issue than the other or that the efforts on one side have somehow been compromised by a lack of interest in or commitment to the issue. It is clear from the number of Members of all parties speaking in today’s debate that the determination to improve mental health provision is shared right across the House.

We urgently need to address other issues, including the increase in eating disorders such as anorexia, which can be a killer. Between 5% and 20% of anorexia sufferers tragically die, and we have to do something urgently about that. We need to deal, too, with the pressures on child and adolescent mental health services, with which all Members will be familiar through their constituency surgeries. Referrals were up 11% last year, and we need to make sure that CAMHS is able to deal with that extra demand, as well as looking at what can be done to improve early intervention so that we reduce the increase in those referrals.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

rose—

[Mr Hunt]

Let me make some progress, and I shall give way later.

We need to look at the use of police cells, which has often been spoken of here. We have seen a 55% reduction in the use of police cells over the last three years, but they were still used 4,000 times last year. Particularly for children, that is totally inappropriate, and it is often inappropriate for adults, too. Out-of-area placements for non-specialist care are another issue, and the Minister for Community and Social Care is working extremely hard and is committed to implementing a plan to turn this around by March next year.

--- Later in debate ---

[Mr Hunt]

We are working very closely with the Department for Work and Pensions to improve mental health provision for people who are looking for work—not just those who are experiencing difficulty in finding work because of stigma and bias among employers, but those who are in work but may fall out of the workforce because of a mental health condition.

We cannot do everything, in this area of health provision as in others, but that does not mean that we should not make tangible and measurable progress towards the ambitions that are shared by Members in all parts of the House. The first important step involves funding. The Chancellor delivered a record settlement for the NHS in the recent spending review, confirming a £10 billion real-terms increase in its funding over the course of this Parliament. That is very significant for mental health, because not only will there be a rise in the baseline funding of the clinical commissioning groups that hold local health budgets, but those CCGs are committed to increasing the proportion of their funding that goes into mental health.

[Marie Rimmer]

rose—

[Mr Hunt]

I will proceed with my speech for a little longer, if I may.

We are seeing the prospect of very real progress, and we as a Government need to give careful thought to which areas to prioritise. We do not have a monopoly of wisdom in this area, which is why we set up the independent mental health taskforce that is led by Paul Farmer, the chief executive of Mind. We will receive its report early in the new year. It will follow a successful independent report produced by the cancer taskforce, chaired by Harpal Kumar. I think that it is a good way of uniting the Government, Members in all parts of the House, and the mental health campaigning charities, so that we can decide together on the key areas that we want to transform in the coming years.

We are still working on the detailed planning, but we have already announced the provision of £2 billion of additional mental health funding over the course of this Parliament, which will benefit CAMHS, perinatal mental health treatment, the treatment of eating disorders, and talking therapy. Some of that funding is a result of promises made by the coalition Government which we have said we will honour, and some is a result of promises that we ourselves have made.

I agree with the hon. Member for Liverpool, Wavertree that as we increase investment in mental health, we need greater transparency in respect of the way in which that money is spent. I am pleased to say that next June, following consultation with the King’s Fund, there will for the first time be independently assured Ofsted-style ratings that will tell us very simply, CCG area by CCG area, whether mental health provision in the health economy as a whole is outstanding, is good, requires improvement, or is inadequate. As far as I know, ours is the first country in the world to do that. The hospital sector underwent the same process in the wake of Mid Staffs, and, on the basis of that experience, I believe that it will lead to a dramatic reduction in variation and an improvement in care as people are given independent information about how their services compare with those of their peers. That increased transparency will also mean the development of a new mental health data set, which will enable us to collect more and better data and then share them with the House, debate them, and learn what needs to be learnt.

--- Later in debate ---

[Mr Bradshaw]

My hon. Friend is absolutely right. As she clearly articulates, the picture on the ground is very different from the one that is so often painted by the Government.

The House may remember a case that caused headlines a couple of years ago when I raised it in another debate. A 16-year-old girl in Devon was kept in a police cell for two nights because no bed could be found for her anywhere in the country. Her case is not unusual. As we have heard in this debate, more than 6,000 people with mental illnesses were held in police cells last year.

[Marie Rimmer]

Does my right hon. Friend agree that the provision of tier 4 CAMHS beds is a national commissioning issue? Those beds are commissioned by NHS England, not by the CCGs. I think that that is a problem. The Government need to focus on the nationally commissioned beds. Many young people who have eating disorders get to the stage where they need such beds.

[Mr Bradshaw]

My hon. Friend is absolutely right. I hope that the Minister heard her intervention, because I will leave that bit out of my speech. I was going to raise the ongoing problem of the interface between mental health services for young people and adolescents and those for adults. A lot of people are falling through the gap.

There has been a lot of talk, including from the Government, about parity of esteem, but there is scant evidence of it on the ground at a local level. I ask the Minister to explain when he responds to the debate why, if the Government are serious about parity of esteem, NHS England has removed it from this year’s NHS mandate. That is the important document that the NHS publishes every year to tell local health services what they have to deliver. Why has parity of esteem been removed?

Why are the Government cutting so drastically the funding for public health, which delivers many preventive services, such as alcohol and drug treatments and psychological support for young people in schools, that stop people getting ill in the first place, saving money and lives?

As we have heard, after years of falling, the rate of male suicide is on the increase again. Suicide is the main cause of avoidable death among young males.

Junior Doctors Contract

Marie Rimmer Excerpts

Monday 30th November 2015 Commons Chamber

[Mr Hunt]

I cannot provide my hon. Friend with that information this afternoon, because we do not yet know whether the strike will go ahead tomorrow, and how many operations will end up being cancelled in advance of it because of the late notice, but I am happy to get that information for him when we have an estimate.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

This junior doctors dispute is not just about pay. We are very fortunate to have such marvellous junior doctors. My concern, and I know that it is their concern, is about the change to the training of junior doctors in the proposed imposed contract, which will have such a negative impact on the research and development that makes our national health service the greatest in the world. Will you comment on the impact that the change in the contract will have on training and research? Will that be altered, and if not, will you please look at it again, because that is absolutely essential?

[Mr Speaker]

I will do neither of those things, but we will soon discover whether the Secretary of State wishes to do either.

Junior Doctors’ Contracts

Marie Rimmer Excerpts

Wednesday 28th October 2015 Commons Chamber

[Marie Rimmer (St Helens South and Whiston) (Lab)]

We have a very real problem in recruitment and retention in our national health service. Hospitals and general practices are forced to recruit doctors from overseas and highly expensive locum and agency staff. The British Medical Association has described the plans as unsafe and unfair. My postbag is full of letters from junior doctors in the past weeks. Many of them feel that they are already overworked and undervalued. The threat of the imposition of the new contract does nothing to make that feeling better and only compounds it.

One of my constituents, Elizabeth, was born in Whiston hospital, which is ranked the best hospital in the country—I am so proud of it. She has lived in St Helens her entire life and is now a junior doctor in the hospital where she was born, training to be a GP. Admirably, she wants to put something back in to her community, but she tells me her plans are at risk because the new proposals financially penalise those on maternity leave. She tells me that she will have an enforced pay cut of approximately 30%—I listened to what the Secretary of State said about that—which would leave her unable to pay her mortgage, which she carefully budgets for.

She would also be unable to pay for the compulsory exams needed to complete her training. Sadly, that means she would be forced to take her skills elsewhere. She went on to tell me that other countries, such as Australia, can offer a better quality of life compared with what the new proposals mean for her. Given the very real prospect that she might default on her mortgage, she would have no choice but to move abroad with her family. Applications for certification to practise abroad are soaring. These proposals will also impact unfairly on female junior doctors, 80% of whom are part-time trainers, as pay progression will be slower for them; we will lose even more doctors as a result.

I do not want to go back to the old days, when a junior doctor told me he fell asleep while with a patient—the patient had to wake him up. Another junior doctor was killed in a car crash on the way home after working for nearly 30 hours without a break. It cannot be proved that his working pattern was responsible, but nothing would convince his colleagues and family that that was not the case.

We cannot afford to lose the doctors we are training. Not one hospital in the north-west would be able to balance the books in the next financial year. The clinical commissioning groups are facing enormous financial challenges. Hospitals can only get the money from the tariff from the Government and the CCGs, and it is not there. We cannot pay consultants seven days a week if there is not the money in the CCGs.

NHS: Financial Performance

Marie Rimmer Excerpts

Monday 12th October 2015 Commons Chamber

[Ben Gummer]

Conservative Members disagreed with my hon. Friend’s predecessor on many points, but he did great cross-party work with Members who were not of his political persuasion to find a good solution for urgent care in his area. I hope that we will follow that model on a larger scale across the country. If we can do that, there will be a much better resolution to the challenges facing the NHS. Patients and people want us to address those challenges without turning the whole thing into a political circus.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

I agree that the use of agency staff places a great cost on the national health service, and I am sure the Minister will accept that cutting the number of training places for nurses and doctors at the beginning of the previous Government will have had an impact on that. St Helens and Knowsley teaching hospital is currently recruiting in Spain because it cannot recruit here. Recruitment and retention are crucial, and more than 50% of doctors now apply to practise abroad. Does the Minister think it sensible to further punish trusts that are in financial deficit—there are many across the country—by reducing their quality pay if they do not balance the books this year?

[Ben Gummer]

The hon. Lady asks about nurse training places, and this year the number of places is consistent with the number in 2010. The key point is not just the number of nurses in training, which is determined by NHS providers, but the number of nurses in hospitals serving patients and the public. The number of nurses is currently at a record high thanks to this Government’s actions.

A&E Services

Marie Rimmer Excerpts

Wednesday 24th June 2015 Commons Chamber

[Dr Whitford]

Before the movement of out-of-hours GP services under the banner of NHS 24, most local areas had a doctors-on-call service. In my county, we had Ayrshire doctors on call, which was provided by local doctors at rooms in the A&E departments in our two hospitals. Patients quickly learned where they could go to be seen quickly. We also had a car service that allowed us to make home visits. That functioned very well until NHS 24 came and pulled it away.

We have to get back to local GPs working like that as part of a co-operative in a focal position. Each practice cannot generate enough GPs or work to have someone sitting there all day Saturday and all day Sunday. When the Secretary of State talks about 8 till 8, it is not clear whether he means that that will happen in each individual practice or on a regional basis. Most of the pilots that have started to publish their experiences have quickly made it into a doctors-on-call service. There is more common sense behind that approach and it is more sustainable.

We have to look at the flow within hospitals. We should not have trackers running around bean counting when patients had what done, but people going in front of patients, opening the gates, looking at bed management and ensuring that patients are in the right place.

All these matters cascade back on to staff. We are struggling to maintain and recruit staff. There was only a 50% take-up of trainees for accident and emergency, and we are haemorrhaging senior people, which exacerbates the problem. We need the co-location of GPs and we need to look at the exit block, not only out of A&E and into the hospital, but out of the hospital.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

A 25% reduction in the number of GPs and practice nurses has been forecast over the next five years. I have the statistics to prove that. People talk about the cost of agency staff and locums in hospitals, which is out of all proportion. There are also massive increases in costs—

[Madam Deputy Speaker (Natascha Engel)]

Order. It is essential that we keep interventions to the absolute minimum.