Junior Doctors’ Contracts

Philippa Whitford Excerpts

Wednesday 28th October 2015 Commons Chamber

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

The hon. Member for Lewisham East (Heidi Alexander) described what a junior doctor is, and that is really important. Many people think that being a junior doctor is just for the first couple of years, and isn’t it character-forming to work a bit hard and not have a lot of money? However, in the NHS, which is quite a hierarchical beast, a junior doctor is a junior doctor all the way until they are not a junior doctor and they become a senior doctor: either a consultant, as I was for the past 19 years, or a GP. That means we are talking about people who might be in their 30s, with children, families and mortgages. They are not youngsters who are able to move around flexibly and have very few financial commitments. It is important that we remember that.

It is obviously quite some time since I started as a junior doctor. More than 30 years ago, in 1982, we had absolutely no limits on hours. My light week was 57 hours; my heavy week was 132 hours. You just had no idea what your name was by the end of a weekend. It took more than 10 years of my career before the first new deal started to come in, in the early 1990s, and trusts or hospitals had to pay an additional premium to junior staff if they worked excessive hours. The definition of excessive hours at that time was still pretty lax, but it was the first step. It was tightened up in 2003, when the European working time directive came in. The Secretary of State talks about taking away those safeguards, but that he will replace them with something else. But with what? They have served us well. When trusts are in financial difficulties, the pressure on them to save money is likely to outweigh completely any little safeguard. The 48-hour working time directive does not come with punitive safeguards, and the financial one was important.

It is important to remember that the basic pay is already for 7 o’clock in the morning to 7 o’clock at night, Monday to Friday. That is a pretty long day for most people. It is proposed that the time covered by basic pay should be extended to 7 o’clock in the morning to 10 o’clock at night and include Saturday. What many people do not know is that a junior doctor starts at under £23,000 a year—below the benefit cap we have been arguing about. The salary is made up largely of out-of-hours.

[Mr Jim Cunningham (Coventry South) (Lab)]

Does the hon. Lady not agree that in any other walk of life that would be intolerable, yet we put up with this situation in the national health service? Secondly, does she agree we still have not seen the £8 billion the Government promised, during the general election, to put into the NHS?

[Dr Whitford]

I totally agree with that.

As mentioned on both sides of the House, people do not work in an NHS hospital to make a lot of money. It is not high up the list of ways for the smartest people in our country to make money; it is a vocation, which means we have a responsibility not to exploit them. The Secretary of State says that no one will lose money, but what will happen to the people who start next August? After the first hours change, when I started my surgical career in Belfast, the “two in three” rota—every third evening off and no weekends off for a year—was no longer legal, and the hospital henceforth considered extra hours to be voluntary service. The NHS is a hierarchical organisation, bullying exists within it, and the junior doctor is in a weak position. These safeguards have worked well for a long time, and I would be reluctant to see them go.

[Catherine West (Hornsey and Wood Green) (Lab)]

Does the hon. Lady agree that across the piece—nurses, doctors, everybody—there is a huge loss of morale in the NHS? It is down to us to stand up for the workforce and put them at the heart of our thoughts, rather than concerns about how it might look politically.

[Dr Whitford]

I totally agree. I also agree with the Secretary of State about patient safety. There is no one in the profession who does not want a seven-day emergency service that is strong and responsive to the needs of unwell patients, but we keep moving from people who are ill to routine services. He has said we must not call them avoidable, yet he just referred to 200 avoidable deaths a week, which is exactly what Bruce Keogh described as “rash and misleading”, and people object to that. There are no excess deaths at the weekend; the issue is with people admitted at the weekend, usually for radiology or investigation. Scotland has been moving on this for the last decade, by working with the profession, not pulling out the pin and throwing a grenade.

[Mr Jeremy Hunt]

For the sake of clarity, the 200 avoidable deaths are not about the weekend effect specifically, but come from the Hogan and Black analysis, which found that 3.6% of hospital deaths in England had at least a 50% greater chance of having been avoidable, which is separate from the weekend effect—the higher mortality rate among people admitted at weekends. None the less, where there are avoidable deaths—where death rates look higher than they should be—we have an obligation to do something.

[Dr Whitford]

I agree that it is important to investigate, but it is also important to understand the cause of the problem. A lot of the problem at Mid Staffs was the ratio of registered nurses to patients. That was echoed by Bray in his review of 103 stroke units, which showed that additional consultant ward rounds at weekends had no impact on death rates, while a better ratio of registered nurses reduced them by a third. We need to know the problem before spending billions trying to solve the wrong thing.

[Andy Slaughter]

I am grateful to the hon. Lady for busting this myth about weekend death rates—these might be sick people admitted at weekends who die within the 30 days. In fact, fewer people die in hospitals on Saturdays and Sundays than on other days. The Secretary of State is not giving the right impression of the figures.

[Dr Whitford]

I agree.

Since coming here, I have heard stories of people unable to access diagnostic imaging or to work up patients, but there is no argument about that from the profession. That is what we need to focus on, yet a lot of this seems to be about routine. There are fewer doctors at weekends because we do not do routine work. We have teams of people doing toenail and blood pressure clinics in the week. Professor Jane Dacre estimates that doing those at weekends would require 40% more doctors. We cannot do that. We need to make sure that hospitals at weekends have enough people and the right people to be secure, but junior doctors are already there—it is not they who are missing—and emergency services already have a consultant on call. We might need more discussion about their being physically in, but that is a discussion to have with the profession, whereas what we heard on 16 July, which gave the public the impression that senior doctors only worked 9 to 5, Monday to Friday, was very hurtful to the entire profession.

[Grahame M. Morris (Easington) (Lab)]

The hon. Lady is making some extremely powerful and relevant arguments. I wish to make a point about the importance of junior doctors in my region, having spoken to some of them at the demonstration on Saturday. They are essential to the functioning of the service. They have the option of going not only to the Antipodes but to Scotland, where these contracts do not apply. If we lose these valued staff, it could hurt my region more.

[Dr Whitford]

We will roll out a red carpet somewhere on the M74 and welcome them with open arms. The progression and migration in Scotland towards robust seven-day emergency care has been happening through a dialogue, not through a threat to impose a contract.

There are other things in this, such as the plan to change pay progression, which is currently on an annual basis, to recognise experience. That will be replaced with just six pay grades. Such a move will affect women in particular, because they tend to take a career break and they tend to work part-time, so they will get stuck at a frozen level for much longer. It may also be a disincentive to people to go into research, because they will be stuck on the same rung of the ladder for longer. We do not want that disincentive. We need to make sure that we are valuing how people develop and the experience they accrue along the way.

[Mark Spencer]

The hon. Lady is making a powerful case for dialogue. Will she join the Secretary of State in calling for the BMA to come back to the negotiating table or join the shadow Secretary of State in refusing to call for it to do so? Which will she do?

--- Later in debate ---

[Dr Whitford]

There is no doubt that we require dialogue, but it must involve sitting down at a table without preconditions. What we had in July and through the summer was a threat of imposing a contract, instead of proper negotiation. That is where we should be trying to get to: both sides negotiating in good faith across a blank sheet of paper. The threat of imposition is what has hurt the junior doctors.

There has also been talk of taking away the guaranteed income protection of GP trainees, there to try to keep them at the same level as they were, and replacing it with a discretionary payment. Such a payment can be taken away at any time—it can be cut and it can be changed. The Secretary of State aspires to have 5,000 extra GPs by 2020. We know from the BMA that one third of GPs—10,000 out of just over 30,000—are planning to leave, which means we need to find 15,000 extra GPs. Anything that is a disincentive for people to go into that profession is not serving the NHS.

[Dawn Butler (Brent Central) (Lab)]

Does the hon. Lady think the Secretary of State is an incentive or a disincentive to junior doctors?

[Dr Whitford]

Sorry, I did not hear that. [Interruption.]

[Dawn Butler]

Conservative Members do not want me to repeat the question. Does the hon. Lady think the Secretary of State is an incentive or a disincentive to doctors?

[Dr Whitford]

I think that how this has been handled is a total disincentive, but that could change. We could simply take the decision to move to negotiations without preconditions—without the threat of imposition. We are talking about a threat to impose changes to the terms and conditions of people who, in the past, routinely worked more than 100 hours a week, as I did. That is a ghost that haunts the NHS and it really frightens junior doctors.

[Rehman Chishti]

rose—

[Dr Whitford]

I will give way one last time, but I need to make progress; otherwise nobody else will get to speak.

[Rehman Chishti]

I have a huge amount of respect for the hon. Lady. She talks about her experience of working long hours. Does she think that what the Secretary of State has just said about introducing new limits on junior doctors’ working hours is the right way forward?

[Dr Whitford]

What the Secretary of State has not explained is how, within the same pay envelope, there will be more people at weekends, but not working extra hours—and not having fewer during the week. At the moment, we have a circle that cannot be squared. We need to see the detail of how that can be done. If the vision is to have more routine work at the weekend, that would result in a massive uplift in the number of doctors, which we simply cannot afford. We are already haemorrhaging doctors. Acute physicians describe 48% of junior places as unfilled, with the figure for obstetrics being 25%. They can go anywhere. We heard that over 1,500 of them registered for certification for overseas work just last week. We need to be careful that we are attracting them to stay. They are the brightest and best in our society; they have chosen a vocation. We need to bring them to the table, but by offering to start with a blank sheet of paper—not threatening them. As has been said, they are not radicals, but people who want to do the best for their patients.

I suggest that the Secretary of State and those working with him look at how they have spoken to both senior and junior doctors over this summer. Frankly, being new to this House, I found that to be quite shocking and quite disgraceful. We should draw a line under that and try to change the tone. We need to go forward and find a solution that is fair to junior doctors, fair to patients and safe—one that is not exploiting people and not threatening people.

Secondary Breast Cancer

Philippa Whitford Excerpts

Wednesday 21st October 2015 Westminster Hall

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

I commend the hon. Member for North Warwickshire (Craig Tracey) for securing this debate, which marks breast cancer awareness month. Most Members know my interest. I was a breast cancer surgeon for 33 years. The hon. Gentleman said that secondary breast cancer does not gain from the focus that we put on primary breast cancer. I have to disagree with that. In Scotland, we collect the stage at diagnosis and one in five patients still have metastases at the time of diagnosis. That means that we still have a huge job to do to get earlier diagnosis through screening and raising awareness, which is what October is all about. We are limited for time and I will do my best to respond to as many points as possible.

Regarding audit, I chaired the discussions on quality improvement standards for breast cancer in 2001, at which time we discovered that about a quarter of units did not gather any data at all. By 2003, we had managed to change that and we were getting data on the primary treatment of patients. That was against the breast cancer standards that we had set for the entire journey that a patient would go through. In 2007, I was chair for the update of those standards and, at that point, it became a standard that all patients with recurrence or metastases must come back to the multidisciplinary team for discussion. At that point, those data are also gathered. As yet, we do not have a Scottish-wide, absolutely rock-solid way of providing the data. They are being collected through our cancer registry, from SMR01 data and from what we do in-house.

In my unit in Ayrshire, we had a follow-up page for the patient at the end of the data system. Every year when the patient came for the follow-up, a chitty was ticked, sent up to the office and on it went, showing that the patient was alive and well on whatever date they had come. For patients moving to mammographic follow-up, if the mammogram is clear and there are no issues, the procedure is the same. The data on patients with recurrence or metastases must be collected at the multidisciplinary team. That is something that we were doing. We have to look at the systems to make it easy and not burdensome, but that requires that hospitals and trusts have an audit team. Our auditor sits in the multidisciplinary team, where she captures all the treatment of the primary and secondary patients. That is really important.

The hon. Member for North Warwickshire mentioned CNSs. There are different approaches. In our unit, we treat approximately 400 new breast cancers every year, which means that a significant number of patients have recurrent and secondary breast cancer. We talked about whether we should split our teams and have one for secondary breast cancer. We decided against that because we have a breast cancer team, which the patient will have met at the beginning. I felt that meeting the same team—a friendly face or someone the patient knew from three or four years ago—is a benefit.

Many units have surgical cancer nurse specialists, who do not move into chemotherapy or oncology. Obviously, that would not work that way. Our cancer nurse specialists travel the whole journey with the patient, looking after the patient in the surgical part of the journey and in the oncology clinic during chemotherapy. They are also there if the patient is unlucky enough to face recurrence or metastases. I believe that this linear approach—as long as enough nurses are provided for that support—gives the advantage of continuity.

My hon. Friend the Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) mentioned looking at the wellbeing of patients. In Scotland, we use something called the distress thermometer, which is used for patients undergoing treatment for primary and secondary breast cancers. It is quite a quick, easy tool that, at least, allows us to pick out a patient who is not doing so well and therefore identify them for additional support. Our cancer nurse specialists have all had additional training. We have a specialist oncology psychologist on our health board, who provides additional training to the nurses. Therefore, for someone who needs it, that extra help and counselling is available. For someone with more complex needs, or where the diagnosis of breast cancer or metastatic breast cancer comes on top of mental health issues, the oncology psychologist would give us that back-up by taking on the patient.

The hon. Member for North Warwickshire mentioned palliative care. In Ayrshire, we are lucky enough to have a hospice. It is routine for us to refer patients at the point at which they are metastatic and symptomatic. We do not refer them as soon as they are metastatic because if a patient is hormone-sensitive, they have a 50% five-year survival with metastatic disease. That is because we have so many treatment options and breast cancer appears to behave quite differently from other cancers in that we can get it into a balance. The patient can be very well and active, yet the disease is sitting there. As soon as the patient starts to have symptoms, we have liaison nurses in our hospitals and we make a referral. Part of our GPs’ quality outcome framework is that patients who are defined as palliative must be discussed regularly in primary care and be on a palliative care register.

We had the debate on assisted dying just last month. The clear decision of the House was that we would not go down that route. That throws back on to the Government, and us all, the responsibility to ensure that high-quality palliative care services are there. We cannot vote that way as convincingly as we did and then not step up to the mark. That is really important.

I do not have a lot of time to speak, but I should say that we are doing good things in Scotland. Because we are smaller, we have been able to create a single day when all the teams in Scotland come together—actually, they come together for two days: a trial and research day and an audit day. Our whole audit—all the dirty washing—is put up in a PowerPoint presentation and we have a completely open learning discussion about it. A one-year project is starting now, so hopefully the data, including detail on secondary, recurrence and survival, will be available in autumn next year.

--- Later in debate ---

[Jane Ellison]

I am sure we would all agree with that important point.

I will finish by discussing the new guideline that the clinical reference group is developing. The guideline will state that all patients with primary breast cancer should have a consultation with a clinician at the end of treatment that will include advice on spotting signs and symptoms that might indicate secondary breast cancer. That information will be delivered together with an assessment of the patient’s physical, psychological and social needs—I am interested in the distress thermometer that the hon. Member for Central Ayrshire mentioned, as well as in the contribution of the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron). The overall recovery package is being developed in partnership with Macmillan Cancer Support. The evidence is that that work is very effective where it has been done well. The advice that has been given will be recorded in the records of every breast cancer patient so that we know it has happened and so that we can track it.

NHS England hopes to publish the new guidance as a cancer resource on its website in the next few weeks. We will promote that guidance through the usual channels, but we would appreciate it if hon. Members with a particular interest, and particularly my hon. Friend the Member for North Warwickshire—I congratulate him on his appointment as co-chair of the all-party group—could draw this important document to people’s attention.

The clinical reference group will also consider how the care and support of patients diagnosed with secondary breast cancer can be improved, including through the provision of clinical nurse specialists. Of course, we agree that clinical nurse specialists play an important role. The number of patients reporting that they have been given the name of a CNS rose from 84% in 2010 to 89% in 2014, including 93% of breast cancer patients. We are doing a lot better, but hon. Members are right to highlight that, in the case of secondary breast cancer, we have some distance to go.

Members have said that we need to step up on palliative care, particularly in the light of last month’s debate—the hon. Member for Central Ayrshire made an important speech in that debate. We are committed to ensuring that everyone has access to high-quality, personalised palliative care. Breast Cancer Care’s new report, “Too little, too late”, is an important contribution to the debate about what we need to do. The Government have introduced five new priorities for end-of-life care—those are five important new principles—and my ministerial colleagues will be taking that forward. Nevertheless, I welcome Parliament’s new focus on palliative care and quality end-of-life care, which is important.

In the few seconds that I have remaining, I want to give people confidence that a lot of research is going on in this area. There is more research into cancer than any other disease in terms of National Institute for Health Research funding. In particular, the NIHR’s clinical research network is currently recruiting patients for nearly 100 trials and studies in breast cancer. One is a global trial that aims better to control secondary breast cancer using a drug called a dual mTOR inhibitor. I am delighted to say that the network recruited the first patient in the world to this trial, which I hope is an indication of the importance of our research infrastructure.

[Dr Whitford]

Will the Minister give way?

[Jane Ellison]

I am afraid that I do not have time to give way. We can speak after the debate; I apologise.

A lot of other things are going on in that area, but I will leave just a few seconds to my hon. Friend the Member for North Warwickshire. However, I reassure Members that this subject is of huge importance to the Government.

Mental Health (Armed Forces Veterans)

Philippa Whitford Excerpts

Wednesday 14th October 2015 Commons Chamber

[Johnny Mercer]

Thank you, Madam Deputy Speaker. I apologise—I spoke to Mr Speaker before you took the Chair.

I thank the hon. Member for East Kilbride, Strathaven and Lesmahagow for giving me a few minutes of her allocated time, and offer my sincere thanks to her for bringing what the Prime Minister rightly described today as “this very important issue” before the House. He correctly identified the strategic defence and security review as an opportunity to get our approach right in the future, and I fully support him in that intention.

The subject before us this evening refers to that great stain on this nation of ours, which I mentioned when I first spoke in this House. I regret to say that, aside from some excellent individual practice and charitable work, the way we look after our veterans’ mental health in this country remains poor. Many of our young men and women, who by good training and fortune walked away from battle without any physical scars, have been stricken in later years by an underlying sickness that can tear at the very core of the strongest and most enduring individual. I speak as a Conservative Member of Parliament. I work hard to support all the efforts of Government to produce and implement the exciting and progressive agenda so clearly laid out by the Prime Minister a week ago, but on this issue, while it remains in its current state, I am afraid I will not be silenced.

I have no personal agenda to drive here. I have never had the misfortune to need to use one of our tremendous military charities. I will forever be the soldiers’ voice in this debate, crafted from much time spent on operations with our young men and women, and now in my privileged position as a Member of this House and attracting a great deal of correspondence on this issue it is incumbent upon me to speak out and I will do so. I feel embarrassed at my fellow man sometimes as we stand here again tonight in 2015 in the seat of the world’s most advanced democracy and talk yet again about the stigma of mental health.

The stigma results from a basic lack of education and understanding about a human condition that affects one in four of us—a condition as medically valid as a broken leg or a fractured arm, but because it occurs in our heads, its treatment has historically been subjected to unacceptable social, political and financial disadvantage. That stigma ends in this Parliament, and I will not rest until it has.

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

I had the honour of chairing a disability employment session at the TUC today and a young man with autism came out with what I thought was a fantastic phrase about mental health issues in the workplace: “There is no normal.” We all have mental health; sometimes it is good and sometimes it is not. Maybe instead of us thinking about a certain percentage having a problem, we should acknowledge that we all have different problems at different times. That might make it easier for people to come forward.

[Johnny Mercer]

Absolutely, and when we have more time, we might discuss specific projects looking at what normal is and that process. That is an important part of this.

I could inevitably speak all night on this issue, but I will not. In preparation for tonight, I stayed up most of last night and read as much as I could of a couple of books I have on my desk in my office here in Westminster. One is called “Aftershock” by Matthew Green and another is called “The Battle against Stigma” by Mark Neville. We have got better in this area as a nation over the last few years. I would ask however that before any of us enter into an exercise of back-slapping on how far we have come on mental health, we all read those two books and reflect on both what we ask of our servicemen and women and how we look after them when they come back.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 13th October 2015 Commons Chamber

[Mr Hunt]

Once again, I thank my hon. Friend for his persistent campaigning on behalf of Kettering general hospital. It is a very busy hospital under a great deal of pressure, and I know that people work very hard there. The Under-Secretary of State for Health, my hon. Friend the Member for Ipswich (Ben Gummer), who has responsibility for hospitals, met campaigners from Kettering recently to discuss this issue, and I will bring the matter up with Monitor as well.

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

The Department of Health’s own figures show a dramatic change, from a £500 million surplus to a £100 million deficit in 2013, following the introduction of the Health and Social Care Act 2012. That deficit moved to £800 million last year and we have heard in the past week that it stood at more than £900 million from the first quarter of this year. Does the Secretary of State recognise that this situation has been exacerbated by the outsourcing and fragmentation of the NHS, which involves spending money on shareholder profits and tendering bureaucracy, rather than on patients?

[Mr Hunt]

I do not. That Act meant that we reduced the number of managers and administrators in the NHS in England by 19,000, saving the NHS £1.5 billion a year. The reason for the deficits that the hon. Lady talks about is that, around the same time, we had the Francis report on Mid Staffs, and hospitals in England were absolutely determined to end the scandal of short-staffing. However, agency staffing is not a sustainable way of doing that, which is why we are taking measures today to change that.

[Dr Whitford]

The Francis report recognised the problems of nursing levels. As hospitals will not be able to use agency staff or immigrant staff, how does the Secretary of State suggest they tackle the nursing ratios in hospitals?

[Mr Hunt]

If the hon. Lady looks at what has happened with permanent full-time nursing staff, she will see that the numbers have gone up in our hospitals by 8,000 over the past two years, so there are alternatives. We need to do more to help the NHS in this respect, and I will be announcing something about that shortly.

NHS: Financial Performance

Philippa Whitford Excerpts

Monday 12th October 2015 Commons Chamber

[Ben Gummer]

When my right hon. Friend the Chancellor made his commitment in the autumn statement on this year’s spending, he said it was a down payment on the five-year forward view and expressed his determination to ensure that the NHS is protected and promoted in all areas of Government.

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

The Minister mentioned successful trusts, but fewer than one in five predict reaching the end of this financial year in balance. That does not leave an awful lot of successful trusts. I echo the call for the funding to be front-loaded. Where are trusts meant to find staff if they are not allowed to use agency staff or nurses from overseas? Given that the deficit started to appear only in 2013—after the Health and Social Care Act 2012—does the Minister not feel that the Conservative party should review the direction of travel? The NHS was in balance from 2009 to 2013 and it has been on a downward slope ever since.

[Ben Gummer]

I will address the hon. Lady’s final point first, if I may. The previous coalition Government’s 2012 Act has saved considerable numbers—billions of pounds—which we would now have to make up if we had not made difficult decisions.

That allows me to address the hon. Lady’s first point. We have a choice: we can take the traditional view of politicians, which is to try to paper over the cracks and pour money into an unreformed system, or we can take the difficult decisions that will mean that we deliver patient care in the long term. That is what the Conservative party is willing to do: we are not only providing the commitment to funding, but taking the necessary, difficult decisions.

On the specific issue of agency nurses—one such example of difficult decisions—it is not so much the number of nurses available as the scandalous rates at which they were hired out to NHS trusts. We have taken action on that to ensure that NHS providers can procure agency staff when and how they need them at a reasonable rate.

NHS (Contracts and Conditions)

Philippa Whitford Excerpts

Monday 14th September 2015 Westminster Hall

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

I declare an interest: I am a doctor and member of the British Medical Association, and I still work in the hospital.

We are talking about data showing that people admitted at the weekend are more likely to die within 30 days than those admitted on weekdays. It is important to listen to what Bruce Keogh said, which is that it would be misleading to assume that all of those deaths could be prevented. We use terms as if the deaths were avoidable or talk about people “dying unnecessarily”, but we do not know. We must understand what the data show. There is nothing wrong with the data and nothing that can ever be bigger, because the NHS is the biggest single health service in the world. Professor Freemantle has done the work twice and the pattern is there, but it is not people dying at the weekend; it is important to realise that his data show the reverse. They show fewer people dying on a Saturday or Sunday then dying on a Wednesday. What is higher is the number of people who are admitted, and we need to understand that. As the hon. Member for Totnes (Dr Wollaston) said, they are sicker people. On a Saturday, there are 25% more people in the most ill category and on a Sunday there are 35% more people in that category.

[Mrs Cheryl Gillan in the Chair]

It was said that there was an increased number of deaths among elective patients admitted on a Sunday, and people wondered why that was. As a surgeon with a Monday list, I can say that the norm now is that patients come in on the morning of surgery. So, for me to get permission for someone to come in on a Sunday, let alone a Saturday, means that that person has complex co-morbidity. If we are simply looking at additional populations, we cannot simply use a broad sweep and assume that all of this can be changed, because it cannot be; these people are inherently more ill, whether they are elective patients or emergency patients. Those data are absolutely there and they remain when we re-analyse them or try to balance them, so this issue needs to be tackled.

There are a few myths going around, including the idea that the opt-out clause is a major barrier. The opt-out clause that was cited was for routine work. Consultants do not get to opt out of emergency work at night or at weekends if they work in an acute service. If a consultant works in a service where acute provision is at all relevant, that acute provision is part of what they do and they do not get to opt out of it. Nine out of 10 consultants work out of hours and the other 10% are engaged in specialties for which there is not an acute service.

There has been talk about getting people to work for only 40 hours. My colleagues who are still up the road holding it together work for 48 hours and they simply cannot work more than that because it is illegal under the European working time directive to do so. Most consultants within the acute system work 48 hours a week, and I am sure that those of us who are married to them or simply aware of them will be well aware of that fact; indeed, we will have been told that in no uncertain terms in the last few months.

It is important that we focus what we do on trying to save the lives of those among those 11,000 people who can be saved. When I was a junior doctor, I was aware that getting scans out of hours or at weekends was very difficult, and so patients hit “pause” for a few days. I do not think there is that much difference in services; I find it hard to believe that there is. In Scotland, the situation has been changing for five or 10 years, not by threatening or cajoling people but simply by evolving. Our consultant radiologists cover the entire weekend; our stroke patients get CTs; and our heart attack patients go straight to get angiography, will get an angioplasty there and then, and will go home after breakfast the next morning. So this idea that we have big tracts of those in medicine sitting home watching “Coronation Street” is not true.

The NHS will be cash-strapped; it has to save £22 billion per year in the next five years, which is a big challenge. So now is not the time to say, “We can provide GP services eight to eight, seven days a week.” The pilots have not been successful. The uptake was 50% for Saturday and 12% for Sunday, and some of those pilots reported that there was great difficulty in covering the out-of-hours GP service, which people who feel unwell should be going to, because what was being talked about was totally routine.

Both in hospital and in primary care, we need to focus our attention on improving the access for people who feel unwell, which includes people being able to access a GP and not having to go to A&E with something that means they do not need to be there. That is recognised within the profession, but it is important for people to work together towards that aim rather than pulling out the pin and throwing a grenade at somebody, which is obviously how the profession regards what has happened during the summer. Like many people in Westminster Hall today, I was inundated by messages from colleagues, including from doctors south of the border who I do not know at all. They were very angry at the statement on 16 July that senior doctors do not work outside 9 to 5, which is patently not true.

We need to look at what we should do about these figures. One of the groups that shows the effect of this situation very strikingly is stroke patients. However, research by Bray looked at 103 stroke units, including units where there was seven-day consultant review through the day, and compared them. There was absolutely no difference between that seven-day service and units where there was a routine ward round and no ward rounds at the weekend. What made a significant difference was the ratio of fully trained registered nurses to patients. When that ratio was halved, so that there were twice as many nurses, the mortality was reduced by a third. So, before we go rushing into policy, even if we are working cross-party it is important to understand the data sufficiently to answer the question, “Do we need more doctors or do we actually need more nurses?” That is a pretty important question to answer before any moves are made.

It is also important to focus on the emergency side. People say, “Well, Tesco is open 24/7”. Actually, it is not open 24/7 totally. People will not find the fishmonger 24/7; the baker will not be making fresh bread; and there will not a butcher producing fresh cuts of meat. It will be the basic system that is open 24/7, so let us not confuse matters. And frankly, we can generate a person to work in Tesco, stacking shelves or operating the till, an awful lot quicker than we can create a GP, which will take 10 years because there are five years of medical school and then five years of training, or a consultant, which requires five years of medical school and—in my time—about 15 or 16 years of training.

There is no quick fix for this situation and we cannot afford to take on extra staff, but actually the money would be the easiest bit because we do not have the extra staff. The Government talk about 5,000 extra GPs and yet the British Medical Association shows that we will lose 10,000 GPs in the next five years. That means that we would need 15,000 GPs, and we simply cannot produce that number. So we need to ensure that we hang on to all the doctors we have, including the junior doctors, because that partly comes down to what those junior doctors see, including how they see their seniors working and what they think of that as a career. I say that because junior doctors have always gone to places such as Australia but they used to come back; now they are not coming back.

This whole matter could have been handled better, but the issue is working with people. The Scottish Government are also working towards seven-day cover, but they have been very clear that what they are talking about—the priority within that system—is seven-day cover for people who are ill. That means expanding the out-of-hours service for GPs and expanding what is available to us as senior doctors inside hospitals. That is the route that must be followed, and not the use of a grenade.

After the Francis report and the increase in the number of nurses being taken on to try to get the figures that are sought, what we had at the beginning of the summer was trusts that are struggling being told, “Cut back. Don’t use agencies. Don’t replace people unless they’re absolutely crucial.” We need to give serious thought about whether it is actually more nurses that we need before we rush in to bring in a whole lot—

[Maria Caulfield]

I welcome the hon. Lady’s thoughts and agree with a lot of what she has said. On the issue of nurses, does she agree that it is not just the number of nurses that matters but the skills mix? Because of budget constraints, what has happened over the past two decades is that the skill of senior nurses has been cut back, and those senior nurses are now often not on duty at nights and weekends, which has made a crucial difference.

[Dr Whitford]

I made the point that Bray’s paper talked about registered nurses—so, degree nurses—and that reflects the skill mix.

We need to know what the actual problem is rather than just running in and throwing ideas and policies around. Attacking staff who work very hard and for really long hours is not very fruitful. We need NHS staff to believe in the political decisions, the guidance and the direction being taken in the future, so I simply suggest that everyone in this House look at the way forward.

[Mrs Cheryl Gillan (in the Chair)]

When time permits, it is our practice in Westminster Hall that when a Member has been here for the opening speeches and then had to step out temporarily, we give them the opportunity to speak. So I call Andrea Jenkyns to speak.

--- Later in debate ---

[Ben Gummer]

Those are very reasonable questions. If the hon. Lady will allow me to continue with what I was setting out, I will certainly answer them.

That assortment of academic research, together with the wide anecdotal evidence from people who have experienced poor care in good hospitals, either for themselves or for their relatives, led NHS England to conduct the Seven Days a Week forum in 2013, which gathered together clinicians to look at the challenge. It produced a clear strategy for dealing with differences in care quality at weekends, compared with the week, and set out 10 clinical standards that it believes hospitals must meet to eradicate the difference between weekday and weekend working. Many hospitals are implementing the 10 clinical standards on a variable basis during weekdays, so the work done for weekends was helpful in determining a standard clinical approach for maximising the ability to reduce avoidable deaths for weekend and weekday admittances. The product of that forum was taken forward by NHS England and incorporated into its five-year forward view, in which the NHS, separately from the Government, made a commitment to seven-day services. It did so not because of the benefits to patients—as my hon. Friend the Member for Sutton and Cheam (Paul Scully) said, that is a secondary reason for pursuing the agenda—but purely because of the need to reduce excess mortality where possible.

This is a challenge on the scale of infections in hospitals. It is our duty not only to find out precisely why excess deaths are happening—as the hon. Member for Central Ayrshire correctly said, further work is needed and the data must be understood—but to do what we can as quickly as possible to reduce them where we think they are preventable. That is why NHS England incorporated the seven-day service into its five-year forward view. NHS England asked for an additional £30 billion of spending between 2015 and 2020, of which it said £22 billion can be achieved through efficiencies within the service. It is important to point out to the hon. Member for Warrington North, who made that point, that they are not cuts but genuine efficiencies within the organisation. On top of the £22 billion of internal efficiencies though a better use of IT, to which she alluded, and better job rostering—I will turn to that in a minute—there will need to be an injection of £8 billion to make up the rest of the £30 billion. That package will implement the five-year forward view, which includes seven-day services and many other things of great importance and about which all parties agree, such as shifting resources from providers to primary care, social care and the community sector.

This programme was not invented by the Secretary of State in a speech given to annoy doctors and consultants, much as that might be the impression given by some people on Twitter. It is the policy response of a Government taking seriously the clinical evidence and advice of NHS England, led by Professor Sir Bruce Keogh. We are responding to give NHS England and the providers tools with which they can deliver a seven-day NHS service in hospitals and GP practices.

I turn to the changes in the contracts, which are at the heart of the petition and the speech of the hon. Member for Warrington North. The contract terms are based on a review by the doctors and dentists pay review body, which identified a number of areas where contract reform is needed, including the systems of opt-out and on call. It asked a completely reasonable question: why should it be that some members of the workforce, who are expected to work at weekends as part of their normal shift patterns, do not have the option of an opt-out from their contract, while others—who tend, as it happens, to be far more highly paid than those who do not have the option of an opt-out—do? It proposed a series of changes, which in our view make up a far better contract for both junior doctors and consultants. On balance, we feel that it presents a real opportunity for consultants and doctors to improve not only their working conditions but, in some cases, their pay.

To take some salient examples from the consultants’ contract, we want a far more equitable and reasonable distribution of clinical excellence awards—many consultants are privately critical of how they are awarded—within not a cut to the total consultant budget, but exactly the same existing pay framework.

[Dr Philippa Whitford]

To point out a slight difference, we do not have those awards in Scotland. We have local discretionary points, but the national clinical awards have been done away with for quite some time. Much as we also struggle with staff, we have not been haemorrhaging them south on that basis.

[Ben Gummer]

The hon. Lady points out that contractual differences already exist between NHS Scotland and NHS England. Officials have looked with interest at the experience of NHS Scotland—one of the pleasures of the devolved NHS system is that we can all learn things from one another. I hope that the new replacement of the clinical excellence award will be perceived as far fairer by clinicians and will reward those surgeons who are giving their utmost in academic research and the professional development of others. That is a tangible improvement to consultants’ terms.

It is important to point out, as several of my hon. Friends have done, that we are talking about ensuring that, at most, consultants work no more than one weekend in every four. That is the basis on which they will be contracted to work in a seven-day NHS. We are not talking about seven days at a time, but about shift rotas and patterns, as many people in professional life already recognise, not least some of those who have spoken in this Chamber. We need to get to a situation in which NHS professionals at the top, as well as those at the bottom, are trusted to organise their life and work patterns according to the professionalism they hold so dear. Many consultants in the NHS want to move to contract reform so that they may express their professionalism in that way, and we need to ensure that it happens so as to bring them with us, rather than its being forced on them.

For that reason, I am delighted that the consultants committee of the BMA has agreed to rejoin negotiations. It has seen that there is a basis for reaching an agreement, which suggests—contrary to some of what has been said by Opposition Members—that things are being done with a sense of collaboration. We have wanted to enter the negotiations for some time. The BMA, for reasons no doubt connected with the election—probably understandably—decided to withdraw from negotiations, but it has now come back. We and the consultants committee can reach a good position on the proposed contract.

The junior doctors’ contract is a proposal of great strength, not least because we include a significant increase in basic pay rates, which should be welcomed across the board. The contract addresses one of the points made by the hon. Member for Warrington North and does something important for the way in which junior doctors are perceived by their management. Instead of offering, in effect, danger money for excess hours, which is surely not the way to manage a workforce, it gives junior doctors a right to a review of their hours, so that they may properly manage their work rotas and patterns. For the first time, that will be enshrined in their contract. They will have far more predictable work patterns; providers—employers—will be forced to think seriously about work-life balance when constructing the roster; and, on pay and on the offer to juniors for their working life, the proposed contract will produce a far happier outcome.

I had hoped that the juniors committee would already have agreed to come back to the table, and I remain hopeful. The committee is meeting imminently—in six minutes’ time, in fact—and I hope that it is listening to the words in this Chamber, because hon. Members and others listening have heard nothing from both Government and Opposition Members but unalloyed praise for NHS staff and a real desire to work cross-party to secure the kinds of advances in quality that everyone wishes to see. With the juniors at the table, we could reach a constructive and reasonable resolution to the need to change their contract. That need was impressed on Ministers not only by the DDRB—the review body on doctors and dentists remuneration, but by the NHS’s own independent pay review body. Many in the service, perhaps more quietly than those who have been most exercised on Twitter, know that it is necessary.

Dementia Care Services

Philippa Whitford Excerpts

Wednesday 9th September 2015 Westminster Hall

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

I commend the hon. Member for Charnwood (Edward Argar) for securing this debate on what is probably one of the biggest challenges we will face over the coming decades. There is no easy answer, north or south of the border or on either side of the House. I think we all fear it. Previous generations have feared other illnesses and avoided them. They talked about consumption instead of TB, or about “the big C” instead of cancer. Most of our generation are less afraid of cancer than of Alzheimer’s. We are afraid of disappearing, or of being married to someone who simply is not who they used to be. That is a fear we all live with.

The Scottish National party welcomed the then Government’s introduction of a national dementia strategy in 2009. The Scottish strategy came in 2010. We set out clinical standards the following year and updated our strategy in 2013. We reached the 64% diagnosis target in 2013, when England was diagnosing 48% of those with dementia. I commend the fact that that has now risen to 59%, although there is obviously more work to do. Northern Ireland was diagnosing 63% of sufferers. What happens to someone when they are diagnosed? Think of the fear that we all have, and then imagine the bombshell that diagnosis is.

There is no easy answer, but we have done a few things in Scotland that we feel have worked. All our health boards now have a linked member of staff, like the cancer nurse specialists we have for breast cancer, which was my specialty. Since 2012, we have had the older persons’ acute care plan, which looks at secondary care and modern hospitals. I welcome the talk about dementia-friendly towns and villages—I will go home and throw down that challenge to my area, because that is not something I have come across.

In the past 18 months, our hospital has been completely redesigned, with colour zones and images of what everything is, instead of just words. Toilets, beds, kitchens—how to find one’s way around is all visual. We also have champions in every single ward. All that has really changed things. We have reduced length of stay from 22 days to eight days; we have reduced falls by half, and we have reduced returns to A&E from 26% to 8%. These relatively cheap, simple changes actually save a lot of money.

We obviously need more research and development, because at the end of the day families want a treatment to make early diagnosis worth while. Otherwise, what is the point? We have to be able to intervene. We can slow things down, but we want a drug that will stop dementia and reverse it. At some point further down the line, we will face the challenge of drug companies coming to us with an expensive drug that will do that. It will be important for the National Institute for Health and Care Excellence and other agencies to weigh up the sheer scale of dementia that we face and the money that could be saved by using even quite an expensive drug.

[Kit Malthouse]

One of the interesting developments over the past couple of years, which was looked at by Dennis Gillings, the international dementia envoy appointed by the G8, has been the question of whether the financial equation around the development of a drug could be changed by negotiating an international exception for its patent life, extending it by, for instance, five or 10 years. That might propel investment into research to find a cure and also make it cheaper when it does emerge, because the time for commercially exploiting it would be extended. Would the hon. Lady support such a proposal?

[Dr Whitford]

I absolutely would. In my previous life as a breast cancer surgeon, when I was also doing breast cancer immunology research, I watched what became Herceptin go from its development on the bench-top into common use. That took 21 years. This is something we often do not recognise when we moan about big pharmaceutical companies: they are investing in something that may turn out to be a mirage. The more that we can look at supported or shared R and D, the cheaper the drug will be when it finally comes to market. I would commend something like that.

The current problem is that most patients face living with dementia, and we must think about how we help them and their families to do that. We should be challenging ourselves to make dementia-friendly our surroundings and all the agencies that sufferers may interact with, whether through visual aids, through other people recognising them or, as the hon. Member for Stockport (Ann Coffey) said, through technology. The eHealth programme in Scotland is working on that, including devices in patients’ homes that it can interact with and establish whether the person is okay. Much of the care that people receive is the 15 minutes that the hon. Lady mentioned. How can we improve that? How can we ensure that the faces are not different every day? Some patients and families report 100 carers in a year. We should look at how we organise the care and remember who the real carers are: the family.

It is predicted that one in three of us will be carers for someone with dementia. We have a vested interest in ensuring that we look after them. The carer’s allowance is currently £60 a week, which does not even match jobseeker’s allowance, for a job that could be 164 hours a week, so we need to think of how we support carers and the work that they do. In Scotland, things are slightly different as we have free personal care, so the family does not pay for the carer who comes into the home. If that person has to go into a care home or nursing home, they do not pay for the personal care. The system has been expanded and deepened and actually allows us to keep more people at home for longer.

One problem is that care jobs attract lower earners. How can we motivate people and attract high-quality candidates if they are being paid the lowest possible amount?

[Ann Coffey]

On free personal care, the budget in Scotland is capped. Free personal care is probably welcome, but the problem is that sufferers do not necessarily get the required level of care because demand is managed by stopping the supply. That is the problem with a capped budget. Free personal care is not really a panacea for families seeking the care that their relatives need.

[Philip Davies (in the Chair)]

Order. Before I call Dr Whitford, may I ask that she bring her remarks to a close?

[Dr Whitford]

Okay. Free personal care is obviously not a panacea, but some families have someone coming in four times a day to offer support and people of different levels are coming in. The request for such care is made through the general practitioner, so a health assessment is made. As I said when I first stood up, Scotland does not have a magic answer, but we are coming at the issue from a different angle. Some of what is being done in Scotland can be shared and clearly the same goes for some of the things being done elsewhere.

Remembering who these people are and helping them to remember is important. The volunteer projects involving music and football to help people find themselves are really important. We must remember that they are still in there. They are still a person, and they require our sympathy and to be able to keep their dignity.

Contaminated Blood

Philippa Whitford Excerpts

Monday 20th July 2015 Commons Chamber

[Ben Gummer]

My hon. Friend is entirely right to say there are some exciting medicinal prospects on the horizon. The demands, especially on those for hepatitis C, have to be seen in the round of all sufferers of hepatitis C, but this is an additional factor to be played in. We hope the particular group affected by hepatitis C will be considered by NHS England as part of its discussions on how to take forward future cures.

Penrose reported just before the election. There is an enormous amount of work going on in the Department at the moment, and this is a priority for the Department. We know we need to move quickly. I want to reassure my hon. Friend ‘s constituents that we want to have this matter settled before the end of the year.

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

The problem of contaminated blood products was an international one, but Penrose was a Scotland-only inquiry. It could not compel witnesses from elsewhere in the UK and that needs to be borne in mind. The victims and their families are key. Many families were infected because patients were not warned, and families have been bereaved. What consultation has there been with the Scottish Government, who held the inquiry and apologised on the same day, about this apparent delay? How much of the £25 million will be spent? We must ensure access to treatment, whether that is the new antivirals or transplants. We hurt these people; we must not let them down.

[Ben Gummer]

I thank the hon. Lady. It is a good example of the new mode of working between our Governments that officials in the Department of Health have been working very closely with their counterparts in the Scottish Government. Of course, most of the events that the Penrose report refers to were pre-devolution. It is therefore entirely right that the recommendation is adopted across the United Kingdom, not just in Scotland. I expect that cross and close working will continue through the course of the settlement process.

NHS Reform

Philippa Whitford Excerpts

Thursday 16th July 2015 Commons Chamber

[Mr Hunt]

I thank my hon. Friend for her important comments, and for sitting through a very long speech I gave this morning. We are trying to achieve many things. At their heart, as she rightly says, is a recognition that culture change does not happen overnight. She is right that the profiling of the extra money that the Government are investing in the NHS is important, because we need to spend money soon on some things, such as additional capacity in primary care, as in two to three years’ time that will significantly reduce the need for expensive hospital care. We are going through those numbers carefully. She is also right that local leadership really matters. I know that she will agree, especially as she comes from Devon, that leadership needs to be good at a CCG level as well as a trust level, because CCGs have a really important role in commissioning healthcare in local communities. That is an area where we need to make a lot of improvements.

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

I have to declare an interest: like most doctors, I am a member of the British Medical Association.

I commend the Secretary of State for his announcement about a national officer for whistleblowers. Shona Robertson, Scotland’s Cabinet Secretary for Health, announced this in June, and we are taking action on the Francis report in the same direction. It is vital that members of staff feel they have someone to speak to if things are not going well, and that if they are not being responded to locally there is an independent voice that they can go to.

With regard to seven-day services, the excess deaths of people who are admitted at weekends is recognised and abhorred by the vast majority of doctors. I do not know anybody who gets up and works the hours we do and does not care that someone did not do well. However, I think we are blurring the lines between the elective and emergency systems. The sickest people the Secretary of State mentions—those who run the risk of dying if admitted on a Friday or a Sunday—are not part of the elective system but of the out-of-hours emergency system. It is suggested that hospitals are like the Mary Celeste and there are no doctors. In fact, any service with an emergency component runs 24/7, but there is a multi-disciplinary team. Sometimes patients will be stuck on a ward because they cannot get access to a scan or there is no physiotherapist to help them recover from their stroke.

We are already working towards solving this in Scotland. We are doing so in a more collaborative way, and that is important. There is no resistance to that, because it is recognised that we need all parts of the service. This is different from people coming in for a routine check-up on a Sunday when that does not result in a detriment to them if it is not available. The biggest shortage we have is in human resources—doctors, nurses, physios, occupational therapists and radiographers. I recommend that the Secretary of State separate these two aspects. The first is that hospital consultants did not get the option to opt out of 24/7 care for emergency patients in the contract, whereas GPs did. It is a matter of providing, funding and setting up a full service with all that is behind it to deal with ill patients seven days a week, no matter when they come in.

The other aspect is trying to get value for money. If we have invested in expensive machines and theatres, we want them to work as many days a week as possible so that we get value for money, but that must be secondary to the first priority, which is looking after sick people. I suggest that the Secretary of State starts talking about the two aspects on separate tracks and not crossing backwards and forwards, and that this should be collaborative. I echo the hon. Member for Totnes (Dr Wollaston) in saying that we require the money to be front-loaded so that we get it to start changing the service now.

[Mr Speaker]

Order. May I gently say that from now on we are going to have to enforce the time limits on Opposition responses to ministerial statements much more strictly? Otherwise they eat into the time available for other colleagues. The shadow Secretary of State has five minutes in response to a 10-minute statement and the third party spokesperson has two minutes. That really does have to be adhered to as a matter of course from now on.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 7th July 2015 Commons Chamber

[Mr Hunt]

I am very happy to do that. My hon. Friend is right to point out that the solution to the problem is not just about expanding the number of appointments offered by GPs, although we are doing that; it is also about looking at the very important role that pharmacists and other allied health professionals have to play in out-of-hospital care.

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

The Secretary of State mentions recruiting 5,000 extra GPs, but I note in a recent speech that that was downgraded from a guarantee to a maximum. With 10% of trainee posts unfilled and the BMA’s recent survey suggesting that a third of GPs will leave in the next five years, is that not going to be difficult? Has the Secretary of State had any consultation with the BMA and the royal college to ask why they are leaving?

[Mr Hunt]

It will be difficult. The commitment has never been downgraded: we always said that we needed about 10,000 more primary care staff, about half of whom we expected to be GPs. We have had extensive discussions about the issues surrounding general practice, such as burn-out, the contractual conditions and bureaucracy. We are looking at all of those things. The commitment is to increase the number of GPs by about 5,000 during the course of the Parliament, and that is a very important part of our plan to renew NHS care arrangements.

[Dr Whitford]

I assume the Secretary of State is aware that two of the pilot sites for the seven-day, 8 till 8 working—one in north Yorkshire and the other in County Durham—have abandoned the project owing to poor uptake by patients, with only 50% of appointments used on a Saturday and only 12% on a Sunday. Given that they found that it had a detrimental effect on recruiting cover for out-of-hours GP urgent services, does not he feel that this needs a rethink and that consultation with the profession and looking at cover would be of most benefit?

[Mr Hunt]

The hon. Lady is presenting only a partial picture. In Slough there are about 900 more appointments every week as a result of the initiative for evening and weekend appointments. Birmingham has dramatically reduced the number of no-shows and Watford has reduced A&E attendance measurably. Some really exciting things have happened, but of course we will continue to consult the profession to make sure that the programme works.