Health Service Medical Supplies (Costs) Bill

Philippa Whitford Excerpts

2nd reading: House of Commons & Programme motion: House of Commons
Monday 24th October 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Like the right hon. Member for Chelmsford (Sir Simon Burns), I pay tribute to some of the research and development that has been done by the pharmaceutical industry. Europe has become the biggest research network in the world, and the biggest beneficiary of that has been the United Kingdom, through Horizon 2020 funding, in collaboration with others, and the European Medicines Agency. As others have said, however, both of those are going to change, so the pharmaceutical industry in this country will be rather nervous and anxious about its future.

Obviously, every new drug that the industry discovers creates an additional cost pressure for the NHS, hence the reason for the pharmaceutical price regulation scheme, which has existed since the 1950s. The current scheme has been in existence since 2014 and has brought significant benefits, as the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), has said. In Scotland it directly funds our new medicines and rare diseases fund. Ours is not a cancer drugs fund, so it gives us greater flexibility to treat very rare diseases. The patient’s condition does not need to be cancer, so we are giving Sofosbuvir for hepatitis C and Everolimus for tuberous sclerosis.

It is necessary, however, to have some form of management over the cost pressure, so the Scottish Government and my colleagues welcome the way in which the Bill tidies up the situation by closing some of the loopholes faced by the NHS. We have heard in particular about those who have a monopoly over generic medicines, whereby companies that are part of the PPRS can charge what they like for them. There needs to be much greater alignment and it needs to apply to all drugs, not just all companies.

The Secretary of State also mentioned the collection of data. As someone who has worked in the NHS, I have to say that it has struggled with that, and I have concerns about how it will work across the entire NHS, the entire pharmaceutical industry and medical technology and other supplies. We need to make sure that data collection is relatively simple and straightforward, and I also hope that we will bring together and use data that have already been collected.

I speak as a representative of one of the devolved nations and it is important that our Government are able to access those data easily. The Bill states clearly that the data gathered will be shared with Scottish Ministers, but on what basis? Will it be down to Scottish and Welsh Ministers to request data when they want them, or will they have to wait for an annual return, which might not happen when they want it to happen?

The Secretary of State said that there had been consultation, but I hope that that will continue, because the devil will be in the detail when it comes to the extension to all medical supplies. Scotland already uses a lot of central procurement to keep costs down, so it is important that the Bill enables, rather than interferes with, that.

[Rob Marris]

The hon. Lady is making a powerful speech, as ever. May I pick her medical brains, as it were, on the question of medical supplies? They are defined by the National Health Service Act 2006 as

“surgical, dental and optical materials and equipment”.

Would she, as a clinician and a surgeon, include a CAT or an MRI scanner, as a piece of surgical equipment? It is certainly not dental or optical. It seems to me, as a layperson, albeit a lawyer, that it is not surgical equipment, but investigative equipment, and MRI scanners, as she and many other Members will know, start at about 2 million quid.

[Dr Whitford]

That is an area that needs to be looked at. A narrow definition that covers only blades and swabs and that does not take into account our hugely expensive infrastructure would not make sense. When we buy those kinds of machines in Scotland, we tend to consider central procurement and assessment, which opens up the potential for massive savings. A lot more work will have to be done in Committee and then in regulation to make the process function in the way that everyone wants it to function.

We need something much more radical. That aspiration may not happen with this Bill, so it will have to come later. Patients in the UK face a delay of about five years to access new medicines. If we compare cancer survival rates, we will see that we are often ahead when it comes to patients with early disease. We are one of the earliest nations doing population screening for breast cancer. However, we start to fall behind when it comes to people with more aggressive or advanced disease. I think that that is where our poorer outcomes and survival rates by comparison with European countries come from, because it is palpable on the ground. Part of that is sometimes the eye-watering initial prices of new drugs. Yes, we can set methods to try to control that, but a lot of those drugs do not get through the system introduced by the National Institute for Health and Care Excellence because they are expensive. In my interactions with some of the major pharmaceutical players since I have been in the House, I have discovered an appetite for a different way of doing it. Prices could be much lower but there could be a guaranteed number of patients before a drug became generic. We might need to look at risk sharing, because at the beginning we often do not know whether a drug will really be as good as it is cracked up to be. If the price starts, like some cancer drugs, at £100,000, we will struggle to get it through any of our pricing systems.

Something else we have to deal with is the question of how we expect pharmaceutical companies to make a profit on drugs that we never intend to use. We need new antibiotics, but any brand-new class of antibiotics—we have not had such a class for 30 years—will have to be left on the shelf. The existing system will simply not fund research for such a drug. While the Bill tidies up some of the issues that we face now, we need to do much more blue-skies thinking on equipment, drugs and the way in which we develop different things. Otherwise we will have interminable debates, such as those in which I have participated in Westminster Hall: in one debate, we say that we want more research on, for example, brain tumours, but the next week we have a debate on the fact that we cannot access a brand new drug that has been developed by the pharmaceutical industry in the UK.

[Jo Churchill (Bury St Edmunds) (Con)]

The hon. Lady is making an informed and impassioned speech. Does she agree that we are entering a new landscape, and some drugs that have been discovered can be used for multiple treatments for different cancers, or even for other diseases? We therefore need an even more flexible approach so that we can benefit from those drugs and optimise patient outcomes.

[Dr Whitford]

Absolutely. We have entered the realms of using immunotherapies such as Herceptin for cancer. Equally, in the mid-2000s, people went to court to try to access that drug, which halves the risk of metastatic disease—and we end up spending much more on patients with that stage of the disease. We give Sofosbuvir in Scotland for hepatitis C because it is almost curative, so we have fewer new hepatitis C patients. We need a much more rounded way of looking at the costs and benefits of new drugs. The genetic drugs that we are likely to use in future will be even more eye-wateringly expensive, but then again, they may have a bigger impact.

The Bill tidies up loopholes, but I have concerns about the involvement of the devolved Administrations in the design of the schemes, access to data and ensuring that the funding for PPRS, which we use for our new drugs fund, is maintained. There is a call for us to do something much bigger and much more blue skies in future.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

This is an uncontroversial set of measures and I confirm my support for the Bill as it stands. The great strides in medical science over the past decade and beyond are obviously to be celebrated, with cutting-edge new treatments for life-threatening and life-shortening conditions, including a number of rare diseases and cancers, offering many people the hope of improved health, longer life and a quality of life that in the past would not have been possible. As well as the enormous benefits it brings to patients, the life sciences industry makes an incredibly valuable contribution to the UK, and it is only right that we acknowledge that today. However, there is an inevitable cost attached to the triumph of modern medicine, and the challenge is to ensure patient access to new treatments as quickly as possible, while ensuring value for money for the NHS.

The Bill seeks to address some of the shortcomings. It addresses clear abuses of the current system and I think that it will bring greater consistency to the existing arrangements for controlling the cost of medicines new and old. As I have said, I find myself in agreement with the proposals.

It is good that so many companies recognise their responsibility for keeping the branded medicines bill in check by signing up to the pharmaceutical price regulation scheme. Under the scheme, manufacturers pay a rebate to the Department of Health to cover expenditure on branded medicines above agreed limits. It is a responsible approach, helping to ensure that patients can benefit from access to novel drugs in a way that is sustainable for the taxpayer. However, I agree with the Secretary of State on the need to address the current disparity whereby the statutory medicines pricing scheme delivers lower savings than the voluntary scheme. Those differences are expected to widen, which is clearly not in keeping with the spirit of either arrangement, so it makes sense that they should be more closely aligned. As he said, we have to remove the incentive to shift from one scheme to another.

I particularly welcome the proposals to strengthen the authority of the Secretary of State to intervene where unbranded medicines are priced excessively. The NHS and patients benefit immensely from medicines, which were once available only at great public expense, becoming available far more cheaply after the patent expires and generic products come on to the market. We should recognise the great value that the competitive market brings, saving the NHS more than £13 billion every year, according to the British Generic Manufacturers Association, but we also know that the overall cost of generic items is increasing at a faster rate than branded items, and that there have been some outrageous increases, to which other hon. Members have referred, in the price of some individual generic drugs in recent years when there is only a single company producing that drug. It looks like a clear case of profiteering, where the NHS is being ripped off.

Let us be clear what the implications are when a particular company makes an excessive profit from increasing the price of a drug in that way. It means that other NHS patients, particularly those in more marginal areas that do not get the attention that they deserve, lose out. There is less money to spend on, for example, teenagers with mental health problems or learning disabilities. There is a price to be paid for that excessive profiteering. It is utterly unethical behaviour. I hope that the Competition and Markets Authority can find a way to take action against these companies, which appear to have constructed a business model to exploit the loophole.

As hon. Members have said, a number of generic medicines increased in price by more than 2,000% in the last decade. The most horrific example I have come across is a medicine that increased in price from £13.98 in 2005 to £632.96 in 2015, a rise of more than £600 per item dispensed. It is utterly despicable for any private company to think that it can do that. The Government are right to take action to end that outrageous practice.

Generics account for three quarters of prescription items dispensed in the community. In those cases where competition fails to deliver value for money, it is important that there are measures at our disposal to control prices and to tackle abuses that could place intolerable pressure on NHS budgets. It makes little sense that generic medicines can be controlled through the statutory scheme, but that the Government are currently prevented from stepping in when a company’s branded products are regulated through the PPRS. It seems clear that we should remove that anomaly. I should add that, in using these powers to introduce price controls, the Government should of course exercise caution and guard against any unintended consequences that may impact on the viability of smaller companies. I am sure that the Government will be alert to that.

The aims and provisions of the Bill are admirable, but it is only part of a much wider debate about how we can sustain access to groundbreaking new treatments when the NHS is in the middle of the longest financial squeeze in its history. One intervention from a Government Member on the Secretary of State drew attention to the fact that the total bill for drugs is rising at an unsustainable rate. The right hon. Member for Chelmsford (Sir Simon Burns) also raised this question, and we have to address that because the NHS will not be sustainable at the current rate of increase in cost.

It is no secret that the NHS has struggled to adapt to modern medicines, particularly those that carry a large budgetary impact. Both NICE and NHS England have had great difficulty in figuring out which medicines to approve and how those medicines are to be afforded and brought to patients. Recently, NHS England has delayed funding for the new hepatitis C treatment, so I was interested in the points made by the SNP representative, the hon. Member for Central Ayrshire (Dr Whitford).

We also have the ongoing and deeply unsavoury case of the PrEP, or pre-exposure prophylaxis treatment. Not only is NHS England taking its legal challenge to the bitter end to avoid having to pay for the drug, but there have been reports of it pitting patient groups against each other by saying that patients could miss out on vital treatments for cancer or rare diseases for children should PrEP be funded. We do not want to get into comparing the rights and interests of one group of patients against those of another in that way.

Earlier this month, NHS England and NICE launched a consultation on proposals to change the way some drugs are funded when there is a high cost involved. NHS England and clinical commissioning groups are legally required to fund drugs recommended by NICE as being clinically and cost-effective, normally within three months of the guidance being issued, barring unique circumstances. Under the new proposals, if NICE recommends a drug that will bring an estimated cost to the NHS above a certain amount—£20 million is the suggested figure—NHS England can go back to NICE and ask it for longer to roll out the medicine if it is unable to agree a lower price with the manufacturer. Surely that is precisely the opposite of what we ought to be trying to achieve as regards speedier access to new drugs that are coming on stream. Ignoring questions about how that somewhat arbitrary cost threshold was arrived at, there is a concern that this is a creeping step towards the rationing of approved treatments in the NHS. It seems to me to be an admission that the NHS cannot afford to pay even for the drugs that are found to be cost-effective by NICE; similar concerns have been raised by Nicholas Timmins, that highly respected observer who is a senior fellow at the King’s Fund.

The great worry is that opening up the debate on how quickly or slowly approved treatments can be adopted will put us on a slippery slope to a new discussion about whether approved treatments should be adopted at all, and at the very least UK patients will be further disadvantaged—the SNP spokesperson has already made the point that we compare very badly with other countries —and there will be more delays in getting access to new cost-effective treatments.

[Dr Philippa Whitford]

Does the right hon. Gentleman recognise that we are one of a tiny handful of OECD countries that allow that opening price to be set completely by the pharmaceutical industry and to be set as high as it likes?

[Norman Lamb]

I note that point. I suppose my overall point is that given the unsustainable increase in the total drugs bill and given the actions that NHS England and NICE appear now to be taking, it seems that we will be in a more difficult position in getting speedy access to new drugs that can be life-saving. The Government need to reflect on that. The hon. Member for Central Ayrshire made the point in her speech that this Bill tidies up things that have to be tidied up, but there is a much bigger debate about how on earth the NHS can afford vital treatments that in other countries patients are getting access to much sooner.

If we are approaching a situation in which we are unable to cope with new treatments that have been judged by an arm’s length expert body, NICE, to be clinically effective for patients and cost-effective for the NHS, it is yet more evidence that the NHS needs more resources, and I repeat again to the Minister—he will be sick of hearing me say it—that at some point the Government must recognise that they are simply drifting towards a crash with the NHS. We face an existential challenge that this evening’s debate has highlighted and that has to be confronted at some point. I urge the Government again to consider a cross-party approach so that we can ultimately achieve, in discussion with the public, a long-term and sustainable settlement for the NHS and care that recognises both this dramatic increase in the cost of drugs and that all our loved ones want to have access to those drugs in their hour of need.

We should also be mindful of the potential impact of Brexit on the life sciences industry and the additional challenges we face in keeping the NHS medicines bill under control. If trade between the UK and other EU countries becomes subject to customs duties, import VAT and border controls, thereby increasing costs to the life sciences industry, that might in turn drive up the costs of new medicines to the NHS, and impact on access for UK patients to the most innovative new treatments.

Finally, we also need to make sure that evaluation processes and methodologies are fit for purpose. Traditional appraisal methods and notions of cost-effectiveness are unsuitable for many modern medicines, especially for drugs of immense scientific innovation that target just a small number of patients, but the NHS has been slow to respond to that. The Cancer Drugs Fund is a case in point—established as a sticking plaster after a cluster of promising drugs were judged not to be cost-effective. While it is almost certainly the case that many of those treatments came with too high a price to be routinely funded, few would deny that they were being evaluated under outdated processes that could not fully capture their value. Many rare disease treatments suffer from the same problem.

Companies have a duty to ensure that their medicines are fairly priced, but NHS England and NICE also have a duty to make sure that their evaluation processes and decision-making criteria are fit for purpose, so that new medicines are given a fair hearing without some of the excessive delays we have seen in the recent past. We owe it to patients to make sure that happens.

I support this tidying-up measure and, in particular, the ending of the outrageous practice of a number of companies profiteering at the expense of NHS patients, but this debate has also raised a much bigger issue about how we in this country afford groundbreaking treatments that keep our loved ones alive.

--- Later in debate ---

[Jo Churchill (Bury St Edmunds) (Con)]

It is a pleasure to follow my hon. Friend the Member for Erewash (Maggie Throup).

We all know the background and I will not waste everybody’s time by going over it again. We know about the ageing population and about bearing down on the costs, to which my hon. Friend the Member for Salisbury (John Glen) and the right hon. Member for North Norfolk (Norman Lamb) alluded earlier. We know that advances in science are going faster than we can legislate. One of my local clinical commissioning groups, Ipswich and East Suffolk, suffered an exorbitant increase in Epanutin capsules two years ago and had to find another £600,000 in six months. Looking at drugs more widely, as my hon. Friend the Member for South Suffolk (James Cartlidge) mentioned earlier, not prescribing paracetamol in that particular CCG would save £1 million a year.

The measures in the Bill aim to manage the cost of drugs. The measure on efficient data collection, so that we start to have good decision making based on evidence, is also most welcome. Last autumn, the Secretary of State consulted publicly on how to address the problem of excessively priced unbranded generic medicines, and the industry and others fed back. They were glad of the dialogue. As I said, drug costs are unsustainable. A saving of some £90 million per health area was identified. My own CCG area could save £1 million per annum from unused repeat prescriptions. Nationally, it would mean that more than 12,000 more community nurses could be employed. We need to start making these decisions about where we want to be spending our money. With the pressure on social care, something alluded to by the right hon. Member for North Norfolk, these are decisions we are going to have to make as a Government and as patients.

The current system allows for some to be inside and others to be outside the system. That limits its robustness. It is for this reason that I support the Bill wholeheartedly. The system does not target those who do not play fair and we need to stamp down on them. It is better patient outcomes that I am passionate about. We all play a part, including the pharma industry, due in no small part to the unique infrastructure in this country. This industry is important to us. As my right hon. Friend the Member for Chelmsford (Sir Simon Burns), my hon. Friend the Member for South West Bedfordshire (Andrew Selous) and my right hon. Friend the Member for Cities of London and Westminster (Mark Field) have all alluded to, we need to be supportive of those companies that work positively for patients and engage in trying to find solutions. Indeed, the Association of the British Pharmaceutical Industry supports the Government increasing their powers where market failure has occurred. There is a balance to be had to ensure that new drugs are developed.

That brings me to the matter of repurposed and off-label drugs, those that have another use than that for which they were originally formulated, for example Everolimus, Rituximab, Cycloserine, Viagra and Thalidomide. As the hon. Member for Wolverhampton South West (Rob Marris) said, Thalidomide was originally developed for morning sickness. Lately, it has been found to be very beneficial for the treatment of some cancers and skin conditions. We need to understand new uses for approved drugs for the speediest of transitions from bench to bedside. As they have not gone through new trials, we need to be mindful that they are not new drugs; and just because the target is, for example, prostate cancer and not breast cancer, these drugs should still be costed accordingly.

[Dr Philippa Whitford]

I wonder whether the hon. Lady remembers the time we spent in the House last November debating the Off-patent Drugs Bill. I flagged up the concern that a doctor prescribing a drug with a licence for a use takes precedence over an off-patent drug that may actually be the same. With the sort of gaming we have seen, there is a real concern that drug companies will tweak a drug in the slightest manner and then start selling it to the NHS at hundreds and thousands of pounds, when in actual fact an off-patent drug would do the same job. That has still not been dealt with.

[Jo Churchill]

I thank the hon. Lady for making the point so succinctly. I am also grateful to the Secretary of State for his clarification and the comments that have been made about the medical technologies industry, which I believe needs looking at. I would be grateful if we could know whether the savings made are likely to be reinvested in patients, particularly given my position as chair of the all-party group on personalised medicine, and in the latest medicines and treatments.

The Bill is designed to stop individuals making vast sums of money and taking advantage of a loophole. I back the Government’s aim of value for money and fair prices for optimum patient outcomes. I am heartened by the cross-party support for the Bill and look forward to it making positive progress.

NHS Provision (Brighton and Hove)

Philippa Whitford Excerpts

Monday 24th October 2016 Commons Chamber

[Caroline Lucas]

I am grateful to the hon. Gentleman for his contribution and I entirely agree. When I have talked to staff of the CCG, they have acknowledged that they are using an off-the-peg contract that is not suitable for such a service, and that there have therefore been problems in the system as well as with the company, which is not providing the service that people in our city deserve.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I can see that in this case due diligence was not done in the contract, but is there not an underlying principle that when a piece of NHS service is outsourced the NHS version ceases to exist? Therefore, at some future date, if the service is not good enough or other circumstances change, it is not possible simply to take it back in-house.

[Caroline Lucas]

I thank the hon. Lady for her intervention—someone who knows a great deal about these issues. I absolutely agree. Once the service has been outsourced, the ability to do a convenient U-turn is taken away. That is failing patients in Brighton and Hove.

The Department has said that allegations of ambulances operating illegally warrant investigation by the CQC. I have written to the Department of Health to demand that that happens and I have written to the CQC as well. Will the Minister go further tonight than admitting the severity of the problem, and let us know what he thinks he can do about it? Specifically, will he provide assurances that the Department of Health is no longer content to leave patient safety in the hands of private companies such as Coperforma, and that it intends to step in, bring the service back in-house and at the very least check that the sub-contractors’ contracts meet the requirements?

--- Later in debate ---

[Caroline Lucas]

I am going to make some progress, because I want to finish making my case about funding.

Last week the Prime Minister claimed that NHS funding was being increased by £10 billion. In doing so, she ignored a plea from the respected Chair of the Health Committee, the hon. Member for Totnes (Dr Wollaston), for Ministers to stop using such a misleading figure, when the correct figure is less than half the amount claimed.

The chief economist of the Nuffield Trust argues that even that is overstating the case, highlighting King’s Fund research that found that NHS-specific inflation means that the real increase is about £1 billion—about a 10th of the figure that the Secretary of State and others repeatedly use. It is certainly not £350 million a week. I would be very surprised if any Ministers repeated that blatant lie again, but anyone who claims that the investment is £10 billion is playing hard and fast with the truth. Indeed, the NHS chief executive admitted to the Health Committee that the spending review settlement would actually deliver

“negative per person NHS funding growth”

in 2018-19, with “very modest” increases in the other years.

On top of that, Ministers expect the NHS to find £22 billion in efficiency savings by 2020-21. No one with expertise thinks that that is possible. In a scathing report in March, the Public Accounts Committee found that a significant number of acute hospital trusts are in

“serious and persistent financial distress”.

It said that there is a “spiralling” trend of increased deficits and that the current payment system is “not fit for purpose”. That is perhaps most starkly demonstrated by our beleaguered social care provision, the funding of which all three Care Quality Commission inspectorates agree is seriously affecting the NHS. The Committee goes on to warn that it must be funded sustainably as a priority.

Yes, we have the better care fund, intended to advance the integration of health and social care services, but the majority of that comes directly from the NHS budget, resulting in what the King’s Fund describes as

“a sharp and sudden reduction in hospital revenues.”

In other words, the Government are robbing Peter to pay Paul, while local authority social care budgets are slashed and people are having to sell their homes to pay for care or are not getting it.

Nor is the Government’s secretive sustainability and transformation programme the solution. Many constituents are worried that plans are being conducted behind closed doors and that vital NHS services could be cut as a result. We urgently need clarity on what STPs will mean in practice for both patients and staff. The Sussex and East Surrey STP area, which includes Brighton and Hove, faces a financial funding gap of literally hundreds of millions of pounds by 2021, and it is not at all clear how our STP will bridge that financial gap or whether acute services will be cut.

[Dr Philippa Whitford]

Does the hon. Lady agree that the principle of STPs going back to place-based planning could actually help reintegrate the NHS, but that, if it is done on the basis of budget-centred care instead of quality and patient-centred care, we will get the wrong answer?

[Caroline Lucas]

I am grateful to the hon. Lady for her intervention. I agree that place-based planning is potentially a very useful tool, but I fear that it is being used as a back-door way of making yet more cuts. I am also worried that that is happening in an untransparent way, which is giving rise to concerns among my constituents about exactly what is being set out. Winter is coming and the crisis already playing out in Brighton and Hove is likely only to get worse if the NHS continues down the path on which the Government have put it.

Specifically, we spend 2.5% less of our GDP on health than countries such as France and Germany. I am prepared to say what few others will say, which is that, if we want an NHS that meets our complex health and social care needs, we do not need privatisation and competition; we need those who can afford it to pay more in tax. This is something we can put a price on, whereas the cost of the worry, misery, pain and sheer uncertainty for many of my constituents is incalculable. Whole families have to live with the agonising wait for a loved one’s treatment. It often falls to them to act as carers during that time. The knock-on effect of NHS delays cannot and should not be dismissed. Concerns about delays and cancellations at our digestive diseases unit, for example, come up repeatedly. Operations are repeatedly cancelled, with patients in distress. There is the amazing mum fighting tooth and nail for adequate care and support for her severely disabled son. For her, the system is a battleground. She has to co-ordinate equipment in four different places and put up with repeated delays. She told me:

“It’s this that pushes people beyond despair and to breaking point.”

Breaking point is exactly where we are. A perfect storm caused by decades of chronic underfunding and privatisation has met the consequences of fragmentation and ramped-up marketisation. Terms and policies manifest themselves in grave and very real problems of the kind that I described when I opened this debate. Those problems are not unique to my constituency or city, but Brighton and Hove has an unusual demographic profile, with many younger people, as I have said, with complex needs, mental health problems, drugs and alcohol addiction, homelessness and long-term conditions. It also has some very elderly people.

That means that the array of services to support people using the NHS may need to become more complex, more tailored and more multi-agency, including police, voluntary agencies and so on. We need an ecosystem of healthcare, in which each part complements other parts as well as the whole, and which is achievable locally and nationally if we strip back the unnecessary, ineffective and damaging complexity that currently infects the NHS; if we reinstate the basic principle of a publicly funded and provided national health service that is free at the point of access; and if we give patients, staff and the public a voice from the outset and not just as part of a box-ticking exercise. I believe that is the way to bring us back from the brink.

I have raised a number of questions, and I will repeat them for the Minister before I give the floor to him for his response. Will the Department of Health step in to bring back accountability and stability to the non-emergency transport system in Brighton and Hove? Will it bring that service back into the public sector as a matter of urgency and pick up the Coperforma bill? Can the Minister promise that the STP plans will not mean cuts to services and closures? Will our hospital trust and mental health trust get the money that they need to address the staffing and other crises that they face without having to impose cuts dressed up as efficiency savings?

Will the Minister and other Ministers stop using inaccurate figures when they talk about investment in the NHS and use the autumn statement to announce a genuine step change when it comes to funding social care via local authorities and NHS services in the round, taking full account of NHS-specific inflation? Will he petition the Home Secretary to immediately guarantee EU workers the right to remain and protect the NHS from yet further instability and uncertainty? Finally, will he take a really honest look at the knock-on effects and inefficiencies of a healthcare model that is jeopardising accountability, transparency, standards and patient care?

Community Pharmacy in 2016-17 and Beyond

Philippa Whitford Excerpts

1st reading: House of Commons
Thursday 20th October 2016 Commons Chamber

[Mr Speaker]

My apologies to the hon. Lady; I call Dr Philippa Whitford.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Thank you, Mr Speaker.

We discussed this on Monday and, as I pointed out, Scotland has had a national minor ailments service, a chronic medicine service and public health prevention for many years within community pharmacies, and we have found them to be very effective. Research showed they could cut 10% of the pressure on GPs and 5% on accident and emergency.

The problem with the Government’s proposal is that it is going to be a bit random; pharmacies are just going to be shutting on the basis that they cannot survive. Should there not be a planned system, to look at and discuss where they should be? It is not just a question of rural or deprived. It is also about transport; a mile away may be a real problem for those who are elderly and frail and for whom there is not a bus going in that direction. I welcome England taking forward these services, but my concern is the way in which it is going to be done; if it is just done due to cuts, it might not give England the answer it really wants.

[David Mowat]

I thank the hon. Lady for her point. She mentioned Scotland’s minor ailments programme. The announcement I made on that about a week ago was in many ways modelled on the Scottish model, because we know that pharmacies can do much more on minor ailments than at present. That will be commissioned separately from the other things we are talking about today, and paid for separately from the integration fund. We are a little behind Scotland in that regard, and we are going to catch up.

Community Pharmacies

Philippa Whitford Excerpts

Monday 17th October 2016 Commons Chamber

[David Mowat]

It will not surprise the House to learn that I agree. Last Thursday night, I announced to over 1,000 pharmacists at their annual dinner that we are moving ahead with an urgent access scheme. From the beginning of December, all 111 calls for repeat prescriptions will go directly to pharmacists, not to the out-of-hours GP service. That is a tangible difference. We will do just the same with a minor ailments scheme, which will be commissioned right across the country so that, by April 2018, pharmacists will be paid—over and above any money that comes out of this settlement—for minor ailments work on things such as earache and so on. Those are exactly the sort of sensible steps that need to be taken to integrate pharmacy more closely into GP practice, and that is what we are doing.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

In Scotland, we already have a national minor ailments scheme within our community pharmacies, and it has had a huge impact. The Scottish Pharmacy Board estimated at the beginning of the project that 10% of those making GP visits and 5% of those making A&E visits could be seen in community pharmacies, so our investment has been in completely the opposite direction—in that of developing and strengthening such pharmacies. On top of minor ailments, one of the big areas that has made a difference is in chronic disease management. For people on repeat prescriptions, the pharmacist requests their next prescription and has it ready, while for housebound people, they deliver it, as they do with blister packs.

The concern about these changes is that pharmacists are afraid it will be a case of cutting and then seeing who survives. If it is felt that there are too many pharmacies in one place, reducing their number needs to be done in a planned way, otherwise rural and deprived areas will end up without one. The Government should be making sure that community pharmacy is a real part of the NHS, not slashing it.

[David Mowat]

The hon. Lady made several points. On her last point, the access scheme on which we are currently consulting will protect pharmacies in rural and deprived areas. That is precisely the point of the scheme.

The hon. Lady’s first point was that Scotland has moved ahead on minor ailments, and we agree. I am on the record as saying that the pharmacy first scheme in Scotland is a good model. We want the profession to move away from just dispensing towards more value-added activities, such as services. That is precisely why we are putting into effect the minor ailments scheme that has been piloted. It will be implemented right across the UK—right across England, I should say—from April 2018.

European Medicines Agency

Philippa Whitford Excerpts

Wednesday 12th October 2016 Westminster Hall

[Jim Shannon]

I thank my hon. Friend for his comment. I was not aware until seeing the briefing pack that there had been a decrease in the pharmaceutical business over the past few years; I actually thought we were holding our own and moving forward. Brexit will give us the opportunity to move forward, so we should look positively upon where we are.

This debate is not simply an opportunity for remainers to highlight something that may be difficult to negotiate, with no desire other than to prove their opinion on Europe. There is nothing wrong with that—people have different opinions—but let us work together to ensure that we deliver.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Is it not possible that part of the reason why the pharmaceutical industry has gone down is that the clinical trials directive of 2001 was very bureaucratic? Following that, we had a fall of one quarter in trial research in the UK, particularly in oncology. That directive is due to be replaced in 2018 with the EMA’s new regulation, which will streamline it.

[Jim Shannon]

I thank the hon. Lady for her intervention and the knowledge she brings to this Chamber and the House. I hope that we can improve on what she refers to when we get into the Brexit negotiations, and through our negotiations outside Europe when article 50 is triggered next year.

Let us work together to allow the EMA and the MHRA to come to an arrangement to continue what has been a great partnership to date and has achieved many results. According to the Financial Times, the EMA outsources up to a third of its work to the MHRA, and that work is responsible for a third of the MHRA’s income. A report in The BMJ states that that work makes the UK an attractive location to carry out clinical trials. The hon. Lady outlined that in her intervention, and I know that the Minister will respond and the shadow Front-Bench spokesman will add his comments.

That relationship, which has been proven to work, does not have to die because the EMA may—I emphasise “may”—move its headquarters. Work must be undertaken to underline the fact that although we will not be in the EU, we will remain the best in Europe at this type of clinical work. We have many things to be thankful for in our experience of it. We all understand the red tape in Europe, and I find it very hard to believe that the only reason why the work was outsourced to the MHRA was the location of the EMA.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under you, Mr McCabe. I, too, pay tribute to the hon. Member for Cambridge (Daniel Zeichner) for obtaining the debate and for such an excellent opening speech, which laid out many of the key issues that we face.

In my constituency there is GlaxoSmithKline, which produces the largest amount of one of the key antibiotics used across the world. It is natural that there are concerns in my constituency and in that business. It is slightly tragic that we are having both of the debates on this issue today, instead of prior to the June referendum. Perhaps a little more airing of what we gain from the EU might have been helpful. Forty years of describing the EU in terms of straight bananas and bureaucracy has not been helpful.

In health, we have had nothing but gains. The two canards that were raised during the debate—people ahead of you in the queue to see the GP and £350 million a week on the side of a bus—have evaporated. Someone is much more likely to be treated by an EU national than to be squeezed out of an appointment in a hospital.

We have had nothing but health gains. The EMA is typical of everything the EU has done in many areas. Before 1995—prior to expansion, so we would be talking about 12 countries—we faced regulation in multiple languages across multiple countries. What we have seen in the EU is the development of harmonisation of regulation to the point where we have a single agency. Having one agency means, as the hon. Member for Cambridge said, that drugs get from research bench to patients much more quickly. The EMA monitors safety throughout Europe so that we can more easily pick it up when, in real-life use, there turns out to be a problem with a drug. It also helps to direct research into the big challenges that the population of the EU faces.

There has been a lot of discussion about the MHRA. It is clear that there would need to be significant investment in it. Even if we are still in the EEA or in a position to be part of the EMA, we will not have any influence. The MHRA does not just provide briefs and reviews. It was massive in influencing the structure and principles of the EMA, and such influence will be lost. The loss of influence over pharmaceutical firms that are here has been talked about. The chief executive of the Association of the British Pharmaceutical Industry has said that he foresees a major loss of inward investment in this country because of the loss of the EMA headquarters in London and because of our possible exit from the EMA.

Many such examples will come up in different sectors with regard to Brexit, but the EMA encapsulates all of it. It is not a separate bureaucracy telling us what to do. Twenty-eight countries were working together to find the slickest way to encourage quicker research and to bring it to some benefit. Research is a big part of this. It has been possible for the EMA to direct research on the challenges that the whole of Europe faces, such as antimicrobial resistance or modern plagues such as Ebola. As was mentioned, it supports research into rare diseases. One pharmaceutical firm or one academic unit would not access enough patients to ever get an answer. Across a population of 500 million, we have the real potential—we are already seeing that potential come through—to find answers to some of the horrific illnesses suffered by small groups in a population. “Suffering” is the right word, and we will lose the potential to find solutions.

Lots of drug companies do not bother trialling drugs in children because it is just too much hassle. The EMA has been able to push and say, “We need to have paediatric trials. We need to have trials in children.” That dovetails with the business of research across the EU, which has the biggest research network in the world. It is much bigger than in China and the US. The UK has led in benefiting from that. We put in £5.5 billion and get £8.8 billion out. The biggest share of research of all types through Horizon 2020 and framework 7 has been done in this country, and we are in danger of losing that.

The reason we lead in pharmaceuticals is not just because the headquarters is here; it is because of the dovetailing between academia, pharmaceuticals and universities, and the ability of researchers to move around. We have gained because English has become the language of research and science, because of America. So that has been a benefit that we have had. Of course that is a benefit that we will keep, but we are in danger of sitting out on a little rock all by ourselves.

There may be a delay if pharmaceutical firms have to go through a separate process with the MHRA, but what about British firms? What about the innovative medicines initiative, which encourages small and medium-sized enterprises and often works on the biological aspects of new medicines? They will face an absolute nightmare trying to sell their drugs in Europe. That is something that we are not giving remotely enough attention to.

I was a remainer. I am still a remainer and my population were remainers. Obviously, we are not happy with the idea of being taken out of Europe and of being taken towards such a hard Brexit, as the rhetoric has suggested in the past month. We need to realise what we may lose. We still have everything to fight for. What “Brexit means Brexit” actually means can still make a huge difference to what we manage to hang on to from the EU and what we lose completely. We need to ensure that the people who are at the table take account of this.

I worry because we are describing the EU as a shop. We are talking only about the single market and whether we will get access. Sometimes people mean that as a shorthand for everything else we have gained, but that allows us to be mentally sloppy and therefore allows someone to say, “Oh, good. We are like Canada. We have got access to the single market. Job done.” But it is not job done. The EMA was an example of Europe coming together, streamlining itself and finding a better way forward.

It has been recognised that the clinical trials directive of 2001 made it very difficult for the UK because the system became quite bureaucratic. The EMA has responded to that. The vastly streamlined clinical trials regulation starts in 2018. In fact, the EMA and the EU in this sector are getting rid of bureaucracy and making it easier for our companies and our academics to do research throughout Europe. Some 80% of all the top flight research of all kinds is international and multinational. If we do not allow the researchers to easily work with each other, we are cutting our noses off to spite our faces. We need to recognise that Europe has not just been about burning orchards or straight bananas. It has brought us huge gains in health and safety, in research and in getting drugs to patients. I call on the Minister to ensure that that message is brought home to the core Brexit team as strongly as he can manage.

--- Later in debate ---

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

It is a pleasure to serve under your chairmanship today, Mr McCabe. I congratulate the hon. Member for Cambridge (Daniel Zeichner) and all the other hon. Members who have brought their experience to bear in the debate. I am sorry to disappoint everyone by not being from the Brexit Department. I will pass that on to those who are in it, but as has been noted, they are otherwise engaged in the main Chamber.

One reason why I am particularly pleased that we have had this debate today—I regret that all the answers may not be clear in 11 minutes’ time—is that often when there is talk in the media about the Brexit negotiations we are about to have, we hear a great deal about the importance of financial services, the City and passporting, and of the need to get those things right and the terrible effect it will have on our economy if we do not. The fact that we have had this debate, and that the hon. Gentleman and others have talked about how important the medicines industry is to our economy—not just in Cambridge, Cheshire or Scotland, but right across the country—is a reminder of the importance of this issue and has rightly put it on the agenda. I am sure the hon. Gentleman will keep it on the agenda, as will Ministers from the Department of Health.

At the start of the debate, the hon. Gentleman quoted the Prime Minister, who said:

“It is hard to think of an industry of greater strategic importance to Britain than its pharmaceutical industry”.

That is on the cover of a report, which I recommend everyone reads, on the structure and future of the life sciences industry post-Brexit. In a moment, I will talk a bit more about the work that the Office for Life Sciences is doing in that area. The pharmaceuticals industry is right at the centre point of where we need to be as a country in development work. It is an area that we are world-class in—an area of advanced manufacturing, which we need to be doing more of. We are leveraging the expertise and brilliant work in universities to actually make money, in a way that we do not do in all industries at all times. It is vital that we do not lose that.

I will repeat fairly quickly some of the statistics that we have heard on the structure of the industry. There are nearly 6,000 companies in the industry in the UK, and two of the major companies are GSK—located in many parts of the country, including Ayrshire—and AstraZeneca, which is located in Cambridge in particular. I have made the point earlier that a larger part of it was located in Cheshire a couple of years ago. Those are major, world-beating organisations, and for us to have an industrial future and a future as a country, we have to nurture them. In fairness, the thought that we would not do that is a nonsense. A fair challenge is to make sure that we do it right and keep it on the agenda, and I will try to address that today.

However, this is not a European industry, it is a global industry. AstraZeneca and GSK also have massive facilities in places such as Sweden and Philadelphia—all over the world. Of course it is absolutely essential that we get our relationship with the EU right. I think the point was made earlier that we have 3% of the EU market in terms of sales, although we are a lot bigger than that in terms of drug production and the importance of the pharmaceutical industry—it is probably more like 10%. GSK’s recent announcement of an £800 million investment in biologic and bioelectronic activity is to be welcomed.

The EMA was formed, as was generously mentioned, in 1995. There are 890 staff, the majority of whom are not from the UK; I think that only something like 60 are UK-based. The hon. Member for Heywood and Middleton (Liz McInnes) made the fair point that those people have families and futures, and asked how they are to be protected. The Prime Minister has said that we hope and expect that all EU nationals who work in the UK will stay here into the future. I have not heard any leader of any other country in Europe make the reciprocal point. I do not know if that is on the Labour party’s list of 171 questions, but it would be reasonable if it were. Having the EMA in the UK is of benefit to us not just because of those jobs but because, as Members have said, it is natural that people like to be close to their regulators. It would be reasonable to suppose that, although that might not be a decisive factor in many investment decisions, it would be a factor.

We also have the UK agencies: the MHRA, which covers medicines, and the Veterinary Medicines Directorate, which covers veterinary medical activities. They have 1,200 staff and 160 staff respectively. The point was made today that their activities are commingled with those of the EMA. Many of the EMA’s major committees are chaired by people from the UK, including from the MHRA and VMD. Equally importantly, the hon. Member for Central Ayrshire (Dr Whitford) made the point that 30% of its activities are done by the MHRA. The figure I have is 20%, but nevertheless, a significant amount of work done for the EMA is done in the UK. That is not just because of location—it is not just because the people who do that work are down the road. It is because they have the expertise, the science base and the people that are needed. Of course, with Brexit, all of that is up for discussion.

We have touched on the university sector, and I will not say a great deal about that. I have already made the point that the industry is an example of us successfully taking a sector with world-class, world-beating innovation and turning that into world-class, world-beating companies, in a way that we do not everywhere. It is of paramount importance that the sort of research that goes on in our universities continues. The Government intend to make sure that happens and, indeed, to increase it.

I have set out the regulatory and industry structure, but we are just about to impose Brexit on all of that. That is where we get into the territory of speculation and conjecture, and I apologise that I cannot be more definitive. Many of the questions that have legitimately been raised, in particular by the Labour spokesman, the hon. Member for Ellesmere Port and Neston (Justin Madders), will be central to any negotiation that the Government take part in. It is not possible for a Minister to address the House of Commons and say, “This is our position, these are our red lines, these are the things we are going to give a bit on and these are the things that really matter to us.” That would be nonsense. That is not how any of the commercial companies located in Cambridge or other places would deal with things. What we have to do—this is the role of Members here today—is make sure that the issues are raised with and understood by the negotiating team, because there will be trade-offs in any negotiation.

With respect to some of the Members who have spoken, I have to say that we do pay £20 billion a year to the EU. We may all vary in our view of how much value for money that provides, but the fact is the £350 million on the side of the bus was not an entirely made-up number. That did not influence how I voted in the referendum, but it was not an entirely made-up number. We pay £20 billion a year for the things that we get from the EU, one of which is the EMA and the activity around it. There is a dialogue to be had both on that amount of money and on issues such as the location of the EMA and all that goes with it. Of course, its location is one point to be discussed, and I have no idea how that will end up. The point has been made that it regulates not just for the EU but for Liechtenstein and Norway—I think there was another country as well, but I have not written it down. The UK could be another such country. For me to say it is an absolute line in the sand that the EMA must stay in the UK would be a nonsense.

A number of Members have asked what we are doing to prepare for the negotiations that will happen. That question can be divided into two parts: what are the agencies—the VMD and the MHRA—doing, and what are the Government doing? The agencies have set up groups looking at the opportunities and at how regulation might carry on into the future. A number of Members have made the point that there might be a time lag in medicines coming to the UK if they have to be regulated by more than one body, or if in the future the EMA does it separately from how we do it in the UK. That is really a decision for the UK. It is about how we choose to regulate, and that decision has not yet been made. It would be disappointing if that happened, and many of us will be working hard to ensure that it does not.

The Government have set out fairly clearly that we intend to underwrite EU payments to academic projects even after we have left the EU, to protect the important activity of research programmes. Through the Office for Life Sciences, we have set up a steering group charged with informing how we make the transition. The group is chaired by the Secretary of State, Sir Andrew Witty and Pascal Soriot from AstraZeneca, and over the next few months it will be responsible for informing our negotiating position.

I do not know how many colleagues know about the report, “Maintaining and growing the UK’s world leading Life Sciences sector in the context of leaving the EU”. I think it was put together by PricewaterhouseCoopers. It is a good start in setting out a number of issues we have heard about today and the importance of getting the process right. I very much recommend it. It does not answer all the questions, but it sets out the issues in areas such as trade, people, research, funding and regulation.

A whole string of points were made in Members’ contributions this afternoon. I do not want to spend too long on them, but the hon. Member for Cambridge mentioned that not being part of the EMA’s marketing authorisation might cause delays. That depends on how we set up regulation in this country, and there are a lot of choices. A lot of other countries, including Switzerland and Japan, regulate in different ways, and it would be premature for me to say too much about it. The hon. Gentleman also made the valid point that the EMA and the MHRA are completely intermingled, and that both benefit from the current arrangements. It is not just about the EMA contracting and hiring the MHRA. We do a lot of the work that leads to that top-level and highly professional European legislation.

The hon. Member for Strangford (Jim Shannon) reminded us that whatever we think, the country has voted and we are going to leave the EU. There is no ambiguity about that, and we have to make the most of it. That is a mature reflection, because it forces us to address the negotiations, and not to continue to go over what was on the side of the bus and all the rest of it. We are where we are, and we need to make the situation the best that it can be.

The hon. Member for Heywood and Middleton used her experience and knowledge as a research scientist to make a good speech. She made a point about people, which I tried to answer by reflecting on other EU states. She mentioned the Nobel prize winners’ remarks. I heard those remarks as well and thought that there was a slight irony in that they were asking us to remain in the EU and so on from the University of Chicago. That shows that we live in the world, not just in Europe, and we must reflect on that.

[Dr Philippa Whitford]

Those Nobel prize winners represent the last time we had a major brain drain, when, in the ’80s, we lost some of the best minds from the UK. That is one of the dangers: the people who want to be at the cutting edge will not see this as the place to be.

[David Mowat]

That is a fair point. It could be a danger. The point I was making was that they made the plea to remain in the EU from the United States, which is the leader in many aspects of science. I think we can agree that science is international—it operates in Japan, the US, the UK, Germany, France and elsewhere—and that, however we achieve Brexit, we should do what we can to avoid creating barriers to internationalisation.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 11th October 2016 Commons Chamber

[Mr Dunne]

I can reassure my hon. Friend that there is considerable excess demand from UK-based students to train to become a clinician in this country—only half of those who apply to train in medical school are accepted at present—so we are confident that there will be plenty of take-up for those extra places. With regard to clinical placements, we are in discussions with universities, colleges and teaching hospitals to ensure that there are adequate numbers of places.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I welcome the 25% expansion in medical student places, but I reject tying that to the elimination of 25% of overseas doctors who currently work in our NHS. With 10% of posts unfilled and ever-rising patient demand, the Secretary of State must know that we will always need international graduates in the future. Does he not recognise that he is creating unrealistic expectations and conflict with this idea of a British-only medical service?

[Mr Dunne]

I am grateful to the hon. Lady for giving me the opportunity to set the record straight and stop this scaremongering, which is undoubtedly unsettling many of the very valuable doctors, nurses and other foreign nationals who are currently providing vital services to the NHS. Last week’s announcement was about adding more doctors to be trained who are UK-based. We are not changing any of the present arrangements for international students being trained here, or doctors and nurses working here.

[Dr Whitford]

The Government might not be changing their position right now, but with one in 10 posts currently unfilled, and given the rhetoric used last week, how does the Minister expect us even to retain foreign doctors, let alone attract them to fill those posts?

[Mr Dunne]

There was no rhetoric used. In making that announcement, my right hon. Friend the Prime Minister used no rhetoric whatsoever regarding the very valuable contribution of foreign clinicians to our health service, and that remains the case.

NHS Sustainability and Transformation Plans

Philippa Whitford Excerpts

Wednesday 14th September 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I am sorry that this is such an acrimonious debate. I welcome the principle of the sustainability and transformation plans, as they are a key opportunity to reverse fragmentation and to reintegrate the NHS, but we have to get it right. To turn this whole matter into just a game of moving the deckchairs on the Titanic is something that we would all regret in a few years’ time. We are talking about a place-based approach, which is very similar to what we have in Scotland. I absolutely welcome it, but the places must be right—they need to cover the whole population and the geography must make sense. That is in the relationships of the organisations that are there, but we have to think of things such as public transport. There is no point plonking a community in an STP if there are no connections to it. How these places are designed is really important, as are the partners that are in them. All of this should be about integration and re-integration from acute care through to primary care and local authority care. We need single pathways and wrap-around patient-centred care.

[Andrew Gwynne]

I have some sympathy with what the hon. Lady is saying. Does she agree that that integration will not happen if any one part of those partnerships is severely underfunded? For example, she mentions local authorities. Many of the pressures in the NHS today are solely as a result of the severe underfunding of adult social care. Do we not need to ensure that the finances are in place for these STPs to work?

[Dr Whitford]

I totally agree with the hon. Gentleman. I was about to come on to that. However, it is not just the funding, but the entire model. The tariff model that we have at the moment rewards hospitals for doing more minor things, and punishes them for doing more acute things. Taking on more A&E cases and more complex cases, working harder and doing more make their deficits grow. Our problem is that we have all sorts of perverse incentives in the system that mean that organisations will still be looking out for their budgets and their survival instead of working together.

In Scotland, we got rid of hospital trusts and primary care trusts, and, since 2014, we have had integrated joint boards. Those boards were handed joint funding that came from health and the local authority, which meant that the whole business of “your purse or my purse” disappeared. They were then able to start to look at the patient’s journey and the best way to make the pathway smooth. That is what we want to see.

Having a shared vision of where we are trying to go to is crucial. That means that stakeholders—both the people who work in the NHS and the people who use it—need to believe in where we are trying to get to. Public conversations and public involvement are the way forward. We should not be consulting on something that has already been signed off, but involving people in what they would like the plans to be, as that would make those plans much stronger.

We need to make deep-seated changes to the system, as opposed to only talking about the money for the deficits. This is something that the Health Committee has been talking about for ages. The phrase “sustainability” has become shorthand for paying off the deficit. Of the £2.1 billion earmarked for sustainability and transformation, £1.8 billion is for deficits, which leaves only £300 million to change an entire system. I know that we talk about money a lot in here, and of course it is important, but we have far bigger sustainability issues than the £2.5 billion deficit in the NHS. We have an ageing population, and those people are carrying more and more chronic illnesses, which means that we have more demand, more complexity and more complications. That is one of the things that is pushing the NHS to fall over. On the other side of that, we have a shortage in our workforce; we do not have enough nurses or doctors, and that includes specialists, consultants, A&E and particularly general practitioners. Although the advice has been very much that finances were third, and prevention and quality of care were meant to come first and second in delivering the five year forward view, finances seem to be trumping everything else.

It is absolutely correct that health is no longer buildings; there are lots of methods of health that are bringing care closer to patients, and also some things that are taking patients further away from their homes. We have hyper-acute stroke units, and we have urgent cardiac units, where they will get an angiogram and an angioplasty that will prevent heart failure in the future. However, we cannot start this process there; we cannot shut hospitals and units to free up money to do better things. We have to actually go for the transformation and do the better things first. We have to design the service around the pathways we need—that wrap-around care for patients—and then work backwards. If more health and treatment is coming closer to the patient, at some point they will say, “Actually, I don’t go to the hospital very often. I want the hospital to have everything it needs when I need it.” Then we can look at the estate to see whether we have the right size of units and the right type of units in the right place. What concerns me is that the process we have seems to be the other way around—we are starting with hospitals, which is often a very expensive thing to do, and hoping it will deliver everything else.

[Norman Lamb]

rose—

[Dr Whitford]

I give way to Norman.

[Norman Lamb]

I am grateful to the hon. Lady for giving way, even if she used my first name. Does she share my concern that, out of the original sum allocated for this sustainability and transformation process, the vast bulk appears to be going, in effect, to propping up acute trusts that face substantial deficits, and that little is available for transformation?

[Dr Whitford]

As I said, the proposals leave only £300 million. We cannot transform a system on the scale that is being considered with £300 million.

As I said, the guidance talks about prevention. We need to be tackling health inequalities. We need to be focusing on health and wellbeing—and by that I do mean physical and mental wellbeing. We need to be strengthening public health—something else that has been cut. We need to be looking at the quality of health and care, and that means right across into social care. We must fund social care, because it can make a difference to things like delayed discharges. We are not even three years into the integration in Scotland—we are only two and a half years into it—but delayed discharges have dropped 9%. Yet, the last time the Secretary of State was in the Health Committee, they had gone up 32% in NHS England. So literally just moving things around and allowing one part of the system to fail will mean that the entire system fails.

[Dr Murrison]

I always listen with great care to what the hon. Lady has to say, and I agree with a great deal of it. Does she agree that part of the problem in England in relation to delayed discharges has been that we have seen a retrenchment of community hospitals and their beds, which have provided step-up, step-down care—intermediate care beds. Unfortunately, they are no longer available, which means inevitably that hospital discharges are delayed, with all the distress that causes.

[Dr Whitford]

I totally agree with the hon. Gentleman. I think it is about care in the home for those who are able to have that and convalescence for those who require it; that, basically, is the step up, step down. In my health board in Ayrshire and Arran, we have rebuilt the three cottage hospitals. They are now modern, state-of-the-art, small units. That means that our population has less far to travel and that older people will not, in the end, need to come to hospital. Now, we are still in that transition; those units are not doing everything they have the potential for—indeed, we are a rural population. However, certainly in Scotland, there is much more recognition that we need intermediate care between people being at home and being looked after by their GP, and people ending up in a very expensive acute unit. It is not just about finance; any Member who has been in hospital knows they do not want to be there, and nor do our elderly population. These levels of care are therefore crucial, and it is important that that grows out of the STPs. I see that as a crucial opportunity for the NHS, which cannot be missed.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

Does the hon. Lady agree that there is a startling fact about the underfunding of social care that Ministers cannot get away from, whatever they do or say? We have heard today of the case of care workers who are suing the contractor that they work for because they were paid only £3.27 an hour. How can somebody be discharged from hospital in an adequate way when that is the domiciliary care that will be waiting for them? It was interesting to hear the former care Minister, the right hon. Member for North East Bedfordshire (Alistair Burt), say this morning that

“we have not got the cost of…adult social care really sorted out.”

[Dr Whitford]

I totally agree with the hon. Lady. I am not sure whether she took part in the carers debate that we had not that long ago, where I pointed out that unless we develop social care as a profession, then we all face a fairly miserable time in our old age. Nursing is a profession that is recognised and valued, and caring for our older ill population should also be recognised. We need to recognise them, to give them time to do their jobs, to pay them adequately, and to give them a career development structure that means that we bring the best people up and get them running teams.

As I said, I am disappointed by the aggression on both sides of the House. I know that such a debate is always a good tennis match for point-scoring, but the development of the STPs is an opportunity to do things that everyone in this House would agree with. However, if it is not done properly—if it is just a fig leaf whereby we pretend that something is being done—the NHS will suffer and we will be the generation of politicians who moved the deckchairs on the Titanic.

--- Later in debate ---

[Dr Wollaston]

I thank the hon. Gentleman for his intervention. As I said, the plans that are produced at the end of the day will be better if we involve those who are using the services and those providing them, as well as those commissioning them, as we go along, rather than present a plan, even if it is a draft, as a fait accompli, because then it becomes a binary choice rather than one where people can make suggestions to improve the plans as they develop.

[Dr Philippa Whitford]

I know that Scotland is a lot easier to get around in population terms, although size and transport are not always that easy, but one of the mechanisms that the Scottish Government use when developing strategies is what they call the national conversation, whereby the ministerial team literally go walkabout and have meetings to hear from people directly before anything goes on paper.

[Dr Wollaston]

If we get too caught up in the process of consultation, we will not address the other serious hurdles in the way of STPs achieving their aims, chief among which is the issue of finance. The NHS is now in its seventh year of a historic level of austerity, and the average of a 1.1% annual uplift in funding for the NHS over the past six years represents an extraordinary challenge in the context of increasing demand. It is good that we are living longer, but we are doing so with much more complex conditions, and the treatments available to tackle them are more expensive. We need to be clear that, because of that, and even though the settlement for health has undoubtedly been generous in relation to other Departments, a significant gap is opening up in health, and the situation is even worse in social care.

Figures from the Association of Directors of Adult Social Services show that 400,000 fewer people are in receipt of social care packages in 2015-16 than there were in 2009-10, and not only are fewer people receiving social care packages, but those packages are smaller. Many STPs are about transferring care into the community. We need to make sure not only that the funding is available to provide those social care packages, but that we have the workforce to deliver them. The proposal in the area that I represent is to close two community hospitals that are used by my constituents. As a former rural general practitioner, I know just how important those facilities are to local people. They are special to them not only because of the step-up, step-down care that they provide and to which the hon. Lady has referred, but because these are the places that more people like to be at the end of their lives. They provide personal care and allow people, particularly those in rural areas who are doubly disadvantaged by not being able to travel to larger local centres, the opportunity to be treated closer to home.

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[Richard Fuller (Bedford) (Con)]

Change in life is frequently a source of anxiety or downright scary. When people are young and change schools, when they get married or when they start a job, that change is scary. There is nothing scarier for a community than change in how its health services are provided, so perhaps it is not surprising that the NHS has found managing change to be one of the most profoundly difficult things to accomplish.

As the hon. Member for Central Ayrshire (Dr Whitford) mentioned, we frequently face substantial or overwhelming challenges in society, with people growing older and having more complex needs, and the requirement for more expensive equipment and supplies to meet ever increasing standards for and expectations of healthcare in our country. The NHS was presented with two options for change. One is radical and will meet those challenges in a fine future that offers great health outcomes for all, but sounds a little too scary. The other option is the incremental approach, which will move things along a little bit. It will not deal with the fundamentals but it will enable us to feel that we retain the institutions and structures with which we are familiar.

As someone who was born in Bedford hospital, grew up in Bedford and now represents Bedford, I am very familiar with each of the buildings and institutions in my community. To see them change is a very scary thing. When we consider processes of change, we have to recognise that the population start from that position of anxiety. It is therefore important that Members do not play on those anxieties. It is not effective opposition to create scare stories ahead of an outcome. That is not in the public interest. We can raise concerns, yes, but in a way that looks to the sensitivities of local situations. That is what I would like to focus on in my remarks: the specific circumstances of my part of the country.

I welcome the STP approach because of the integration of care with health and because it provides local authorities with a voice, for the first time, in decision making about local care choices. For the first time, the NHS will not be getting its own way, if this process lives up to the promise of local decision making. That will be helpful in getting local support and control. In my own locality, we have a cross-party community approach. We have a Liberal Democrat mayor, a Liberal-Labour group on the council and Conservative Members of Parliament. We are all united in an approach of wanting our voice heard on local care in the NHS. An STP is a way of us having that.

[Dr Philippa Whitford]

Would it not therefore have been more effective, particularly if there is cross-party working in the local authority, to have local consultation early on about what could be gained in exchange for what might be felt to be lost?

[Richard Fuller]

I very much appreciate the hon. Lady’s question, because it gets to my point. I am actually quite sceptical about what consultation means. She might not know that Bedford has been through a review process for our acute services. I was trying to measure the length of that process in terms of Members of Parliament for Corby: it preceded Louise Mensch becoming Member of Parliament, carried on through the whole period of Andy Sawford being Member of Parliament, and is now taking up the time of my hon. Friend the Member for Corby (Tom Pursglove). We do not involve Corby any more; it is now just Bedford and Milton Keynes. That process included consultation and participation, with the NHS saying that it wanted to listen to people. It consulted them, yes. Did it listen to them? No. It was the NHS’s own process. It ticked all the boxes, but it was a complete and utter disgrace to local accountability.

I do not have distrust of Pauline Philip, chief executive officer and leader of our STP, and I do not need to know everything. I want to know that our local authorities are having their voice heard in the process just as much as our local CCG, as they are our representatives. I feel relatively comfortable that the process will lead to options that are more acceptable to the population, because it involves local authorities as well as the NHS. We should, however, expect the outcomes of the process to be highly varied around the country. Some will be correct and acceptable, and will go forward. Others will be controversial, and others will be downright wrong. We should not curse this whole process across the country, because it achieves a difference in outcome in different parts of the country. We should be prepared to look at each on its own merits and judge them accordingly.

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[Kwasi Kwarteng (Spelthorne) (Con)]

It is a great honour to be able to speak in this important debate. We have heard some very interesting contributions, and some contributions which were, perhaps, less constructive. I will not state publicly which are which, but I would like to take up what was said by the right hon. Member for Newcastle upon Tyne East (Mr Brown), who spoke of Labour’s commitment to meeting the OECD’s health spending average in 2001.

I think it perfectly acceptable, in a discussion of this kind, to point out that in 2001 the Labour Government had succeeded in running a balanced budget for four years, more or less, and we thought at the time that we had the money to meet that commitment. Having been a member of the Labour Government, the right hon. Gentleman will recall that over the next nine or 10 years we ran consecutive deficits, and as a consequence of policy that I happen to believe was misguided in many instances we had a deficit of £160 billion when the coalition Government took office in 2010. Given the circumstances, it was inevitable that there would be a constraint on finance, and that is something that we have to speak about.

If I recall correctly, the hon. Member for Central Ayrshire (Dr Whitford), whose speech I enjoyed very much, said that we kept talking about finance, and that it should be the third consideration. I wish it were as easy as that—I wish we could relegate finance to a subordinate, back-burner role—but I do not think that that would be fair to the country, or to our constituents.

[Dr Philippa Whitford]

Will the hon. Gentleman give way?

[Kwasi Kwarteng]

Forgive me; I cannot. The debate is very constrained now, in terms of time.

The right hon. Gentleman talked, obviously, about the budget constraints, but he also talked about the fact that we were not spending enough money. I think that the STPs present the opportunity for a serious engagement with what all Members recognise is an ongoing problem. We have a growing population and an ageing population, and inevitably, whether we like it or not, issues of finance and resources will become increasingly important.

I am pleased to learn that local consultation will be at the centre of the draft proposal, because that is essential, and it is what our constituents want. There are two hospitals in my area; one is just outside my constituency but many of my constituents go to it, while Ashford hospital is in the centre of Spelthorne. A number of the facilities have been downgraded—it has been a difficult time—but the borough council and I, as the local Member of Parliament, always tried to explain to residents what was driving the decisions and the changes that we sought to make, and they were broadly very understanding. I think that people throughout the country are very sensible when we explain to them and carry them with us, and that they take a measured view of health services. They realise that the old NHS of Nye Bevan and 1948 has had to evolve. I believe that they are much more open to evolution and change than many Members of Parliament.

The last point that I want to make is slightly negative. I have attended many debates of this kind—not necessarily on the health service, but on the economy and welfare—and all that I hear from Labour Members is the same old mantra: “Stop the cuts, more money.” That seems to be their sole solution to every single problem that we face as a country. It is said that to a man with a hammer, every problem is a nail. Labour Members seem to think that “Stop the cuts, more money” is the answer to everything, and I consider that entirely unconstructive. I find it very disappointing to hear no constructive ideas and no proposals for reform, and to observe no appetite for fresh thinking and absolutely nothing in the way of intellectual engagement with the real problems that we face as a nation. I find it very disappointing to take part in yet another debate and hear the same old mantra: “Stop the cuts, more money.”

Junior Doctors: Industrial Action

Philippa Whitford Excerpts

Monday 5th September 2016 Commons Chamber

[Mr Hunt]

As ever, my right hon. and learned Friend speaks incredibly wisely. Actually, his last comment goes to the nub of why this is totally extraordinary, unprecedented and completely unacceptable. It is true that the junior doctors have rejected the agreement that was reached in May in a ballot, and we have to accept that. There are all sorts of reasons why that might have happened, but the choice to escalate the industrial action and to call the worst strike in NHS history was made not by those junior doctors but by the BMA leaders. They made that decision about a contract that they themselves had described as being good and safer for doctors and patients only in May. How can they justify that? Is there not perhaps a desire to pick a very big fight?

We were making good progress over the summer in a whole series of dialogues in different areas to try to resolve some of the non-contractual issues that the junior doctors are worried about, but this action makes it virtually impossible to continue that progress, although we will try very hard to do so. My right hon. and learned Friend is absolutely right to say that this is completely unacceptable and damaging for patients. I am afraid that I am having to go through some of the very same battles that he had to go through when he was Health Secretary.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I know how difficult it will be for junior doctors to take part in the strikes that have been described, and I personally am really sad that we have come to this point. Does the Secretary of State recognise the anger and desperation among the junior doctors that have led us to this point? In my mailbag from junior doctors, two things stand out. One is that the threat of imposition was there right from the word go last summer, and it therefore felt like a threat rather than a negotiation. The other involves the misuse of numerical statistical data by translating it into a claim that it refers to avoidable deaths at weekends, even though there has been no evidence of avoidable deaths. The Secretary of State has not commissioned a review of cases that might show how many of those deaths were avoidable and whether a lack of junior doctors contributed to them. The real danger in the NHS at the moment is rota gaps. Doctors are being asked to do double shifts or to carry two pagers, which means that where there should be two doctors covering an area or a service, there is only one. That is a real, palpable danger right now.

The Secretary of State has said that he would employ extra junior doctors rather than spreading the same number more thinly, but where does he plan to get them from when we cannot even fill the existing posts? I welcome the focus on the four clinical standards that boil down to greater senior doctor review and access to diagnostics, but does he not think that we might have got further if we had started at that point last summer? He calls for a turn away from strikes and for getting around the table to co-operate and discuss these matters, so when is he going to meet the junior doctors to try to avert these strikes?

[Mr Hunt]

The hon. Lady is a doctor, and I would simply say to her, as I said to the shadow Health Secretary, that she needs to justify the claims that she constantly makes in this Chamber about a misuse of statistics. I have been very clear about when we can actually statistically say that a death is avoidable. The studies demonstrate clearly that a higher number of people are dying from weekend admissions than we would expect. What this Government will not do is sit and ignore those numbers, which are backed up in study after study. I think that we are doing the right thing, and as a doctor she should recognise that.

The hon. Lady has said time after time over the past year that the Government should lift the plans to impose the contract and get around the table and negotiate. She could today have given the Government credit for doing exactly that in May when we thought there was an opportunity to do a deal. We lifted the imposition of the contract and got around the table to negotiate a deal that turned out to be good for both sides. Having done that, the problem is that the same people with whom we negotiated the deal have decided to call the most extreme strike in NHS history, which is unacceptable.

Rota gaps are a real problem that we are trying to address by, first, ensuring that systems are in place for junior doctors to blow the whistle if they think that such gaps are unsafe for patients. That is why we have introduced guardians of safe working, and we are committed to that. Secondly, we want to ensure that there are people to fill those rota gaps by training more doctors. We are training 11,420 more doctors in this Parliament than in the previous and already have around 9,000 more doctors than in 2010. As a doctor, those are things that the hon. Lady should recognise.

Capsticks Report and NHS Whistleblowing

Philippa Whitford Excerpts

Wednesday 13th July 2016 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Unfortunately, this has been a repeating story since Bristol Royal Infirmary in the mid-’90s when Stephen Bolsin, the anaesthetist who raised that issue of poor survival of children having cardiac surgery, ended up in Australia. That has been a repeating theme. Regardless of the GMC telling us that it is our duty to step forward, whoever steps forward is always the one who is suspended or loses their job or suffers detriment in some way.

There are a lot of common themes when we look at Morecambe Bay, Mid Staffs and this case. In some of them, there has been the issue of trying to obtain trust status and going for cost savings. As the hon. Member for West Lancashire (Rosie Cooper) said, we have management chasing one goal while staff should be chasing a different goal: clinical quality. We see the stories of bullying and gagging and we see a coalface under pressure, with things going wrong and, if someone whistleblows, inevitably we hear of detriment: destruction to their reputation and perhaps loss of their job.

In an ideal situation we would rarely ever need to have a whistleblower. We need clinical audit, which audits not just the money but the quality of performance to give quality assurance. At one time here in England we had the Commission for Health Improvement, but that was got rid of back in 2004. When NHS Improvement came out, I thought that was like what we have in Scotland, which is called Healthcare Improvement Scotland, which we have had under one name or another since 2000. However, NHS Improvement just looks at the money, so we still have this business that the money is trumping the quality assurance.

That audit needs to be seen and problems need to be put right as soon as they are reported. Complaints should be seen as something that are used and looked at in every directorate meeting, which is something we do locally in my trust. Datix, which is used north and south of the border, is a way of trying to lower that barrier and to get people used to reporting every routine misstep, whether minor or major, bringing down the barriers to doing that and getting rid of any sense of hierarchy.

From our patient safety initiative in Scotland, we do things like using first names in theatre to try to get rid of that “fear of the prof” or fear of the consultant, so that an orderly who notices something going wrong feels able to speak up and say, “That is the wrong leg. I think we should check the paperwork again.” Once we get into a situation of having things going wrong, we need to enable any member of the team to easily draw attention to it. Traditional in surgery—this will be UK-wide—are morbidity and mortality meetings in which the whole unit will review any death or significant morbidity. That does not tend to exist in other specialties but it ought to—we ought to have it for every stillbirth and for deaths in other specialties. Maybe then we would know exactly how many deaths or major detriments were avoidable. That cannot be done with stats—we have to look at the cases. One of the things I set up in my unit was something we called, to make it easier for everyone, the difficult case review. Any team member—it did not matter who—could put a name in the book for the next difficult case meeting so that that case would be looked at.

Whistleblowers need internal support so they can go and not suffer detriment. We have had the Francis report and we have the freedom to speak up, and I commend the Government for setting up the national guardian system—we are doing something very similar—but what comes back from whistleblowers I meet is they are concerned that the person who has been appointed is an NHS manager. We have to have someone who is utterly outside the system. Most of all, we need to change the culture that is close to the frontline. Management must have clinical governance responsibility, not just financial governance responsibility, so that staff get used to raising issues that are then dealt with, learned from and changed, and that management see that as part of their role.

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[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

It is a great pleasure to respond to this debate that you are chairing, Mrs Main. I echo the compliments paid by the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), to the hon. Member for West Lancashire (Rosie Cooper). The hon. Lady has been very brave in pursuing this cause, which she has taken up on behalf of her constituents. I agree that it is striking that this matter would not have come to the fore had she not had very sad and unfortunate personal experience of the failure of care at Liverpool Community Health. I thank her for her persistence in the face of opposition, not just from the usual quarters but from places that might not have been considered to be inimical to a Labour party Member. That is why I particularly commend her for what she has done and for continuing to fight the cause for her constituents. It is absolutely true that as a result of what she has taken up on their behalf, the care being provided is now safer than it would otherwise have been. Sometimes we need to remind ourselves that doing this job is worth while, and she has done that in great measure for herself and other Members of Parliament.

I would like first to offer an apology. It is right that the Government recognise it when things go wrong even if they are not within the direct control of Ministers. Everything in the NHS is the responsibility ultimately of the Secretary of State and of the ministerial team, and I am sorry that the NHS in this instance let down the hon. Lady’s constituents. At the same time as saying that, I hope that she and other hon. Members recognise that it is partly through the measures put in place by the previous Government that we have been able to flush out some of the problems that she identified. It was a Care Quality Commission inspection, under the new regime, that really began to unearth the problems in LCH, and it has been the tougher management of failing trusts that has meant we have been able to bring reform to this trust quickly. Not all is perfect; not everything is right in terms of the CQC or of the Trust Development Authority or its new iteration, but we are a great deal further forward now than we would have been five years ago. To be completely fair, we would have been further forward five years ago than we would have been 10 years before that. We are on a journey, and I appreciate the collegiate atmosphere that has been created in this debate and elsewhere.

I will answer the specific points and questions, because I do not want to reiterate the excellent exposition given by the hon. Member for West Lancashire. She asks who polices HR departments. The simple answer is that the Care Quality Commission, in its well led domain, as it looks at organisations will continue to look at the quality of leadership within an organisation. I will talk in a second about the kinds of thing that I think it should be looking for in the new round of inspections that it will begin in due course.

The hon. Lady asks about the fit and proper persons test. As it is currently constructed, it is for boards to be judging people by the fit and proper persons test. That is the way I think it should be, and there is consensus on that, but clearly those boards need to be properly constituted and know what they are doing. I think that that gets to the crux of what she is saying.

To answer the point made by the hon. Member for Ellesmere Port and Neston about training for non-executive directors, that is, funnily enough, something we are actively looking at to try to improve the quality of boards precisely so that they can ask the questions that are needed, not just in terms of a fit and proper persons test but in order to hold their executive directors fully to account.

The hon. Member for West Lancashire asks about the need for a review, and I know that that is the main purpose of bringing this matter to the attention of the House. I have commissioned NHS Improvement to do a review or at least to ensure that a review happens. As she will be aware, there has been some discussion about the terms of reference for that. I know that Jim Mackey has talked to her about it; she is in communication with him. I, too, am in communication with Jim and I hope that in the course of the next few weeks I or my successor will ensure that that review is as robust as it needs to be. The hon. Lady knows my view on that, which is that I do not want something excessively expensive and excessively long, because that will serve no one’s interests. We need to get the balance right, so that it is timely and good value for money and we are not taking money out of the NHS that would be better spent on her constituents’ care. If we can get to the root cause of these problems in a timely and efficient manner, that will serve her and her constituents well. I commit myself to ensuring that that happens quickly.

The hon. Lady asks about conflicts of interest. As it happens, NHS England is looking at precisely that at the moment. It is an area that we need to be much better in. However, I hope that as we see an evolving NHS, which is far more about collaborative working than the purist approach to competition that was the drive under the original foundation trust mechanism set up in the early 2000s, it will be less of a problem than she correctly anticipates it might be in this instance.

The hon. Member for Central Ayrshire (Dr Whitford) makes a number of important observations about her experience in Scotland, but I am afraid she is wrong on two points. NHS Improvement is not just interested in money; it is very firmly an improvement agency that deals with quality as well as financial performance. She will know that the two do go hand in hand. The best run trusts tend to be those that look after their money as well as their patients. We can see that relationship in the CQC inspections and their relationship with deficits. I suggest that she speak to the director of quality in NHS Improvement, Dr Mike Durkin, who was moved across from NHS England precisely so that NHS Improvement could become a true quality organisation. I am sure she will know him from the past. He is a globally respected expert in the issues of quality and institutional learning.

The hon. Lady is also wrong to say that the national guardian was an NHS manager. She is one of the leading chief nurses in the NHS, and I am sad that she felt unable to continue with that role. The hon. Lady will be pleased to know that her replacement, Dr Henrietta Hughes, is also a clinician—a practising general practitioner. It is very important that we give the right message to whistleblowers, and that is as much the case in Westminster Hall as it is outside in the public space.

[Dr Philippa Whitford]

The feedback that I have had from whistleblowers is that they see the new replacement national guardian as someone who is in an NHS manager role, and they feel that that is not sufficiently independent for the national guardian for whistleblowers. They are talking about the new guardian.

[Ben Gummer]

The new guardian is a practising GP and her office is deliberately set aside from the Department of Health; it is not part of our structures. The purpose of that is to ensure that the person is independent. I hope that that will give confidence to whistleblowers. I have asked her to make a decision on the helpline, because it is important that she makes that decision, not I, in the future.

Finally, I come to the questions asked by the shadow Minister. He talks about FT status. Much was right about the drive for foundation trusts, but a lot of things went wrong. We saw that at Mid Staffs and we have certainly seen it in this instance. I think that he will have noticed a far more considered approach to the FT pipeline in the past few years than previously. I know from experience of my own hospital, which failed to get FT status but is now a very good hospital, that the two do not necessarily correspond.

In all of this, we have to strike an important balance whereby we ensure that hospitals are performing while spending public money properly. The best hospitals and community care organisations do that by energising their staff, eradicating bullying and harassment and ensuring that people are free to speak up and exercise the duty of candour. That is why the thrust from the Department in the past 18 months to two years has been about living the values of the Francis inquiry. We have been putting that into practice in terms of the duty of candour, the whistleblowing apparatus that we have set up, and freedom to speak up.

We are at the beginning of a long journey. There is much to do to make the NHS the world’s largest learning organisation, but we have begun that process. I hope that the report that comes out—the further clinical review for the hon. Member for West Lancashire and her constituents—will be a further step on that journey, not just to correct and expose the failings in her area, but to ensure that the system as a whole, including the Department of Health, learns from them so that they are not repeated elsewhere and we continue to make the NHS the best healthcare organisation in the world.

Junior Doctors Contract

Philippa Whitford Excerpts

Wednesday 6th July 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, am disappointed by the outcome of the ballot yesterday. It has to be recognised that it reflects a real desperation and unhappiness among junior doctors, who are dealing with increased demand and pressure. They have felt that, at times, the tone of the negotiations has left a lot to be desired. The threat of imposition was there from the start, and they felt that hanging over them.

I welcome several things in the statement, and I absolutely welcome its very measured tone. I welcome the attempt to tackle the gender pay gap, to deal with unhappy foundationers and to limit hours. I would say that junior doctors’ biggest concern is rota gaps. In some specialties, the rate is as high as one in four, so one doctor covers the role of two. That is a real patient safety issue, and patient safety is meant to be the whole point of the contract. I welcome the fact that the contract will be phased in, and I call on the Secretary of State to ensure absolutely that, as this goes forward, he will learn, because junior doctors’ concern is about how we spread a short-staffed workforce across more days. I called for the contract to be phased in through a trial, and it is being phased in, but in a different way. We need to recognise the pain that the vote represents.

[Mr Hunt]

I thank the hon. Lady for her constructive comments, which are born of her NHS experience. She is right: we are phasing in the contract carefully to make sure that we learn lessons. She is absolutely right to talk about rota gaps. Unfortunately, the problem of rota gaps cannot be solved at a stroke on signing a contract; it has to do with making sure that we have a big enough supply of doctors in the NHS to fill those rota gaps. We now have much greater transparency about the safety levels that are appropriate in different hospitals; that is one of the lessons that we learned post Mid Staffs. We are investing more in the NHS in this Parliament. We recruited an extra 9,300 doctors in the last Parliament and we are increasing our investment in the NHS in this Parliament, so that we can continue to boost the doctor workforce in the NHS. In the long run, that is how we will deal with the rota gap issue; but unfortunately, that cannot be done overnight.