Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 23rd October 2018 Commons Chamber

[Stephen Barclay]

I pay tribute to my hon. Friend for the longevity and sincerity of his campaigning on these issues. He draws attention to the wider point of how patients presenting with multiple and complex conditions need to be treated in multiple ways, and what he refers to is a part of that wider discussion.

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

NHS England is being ripped off to the tune of £230 million a year as the price of some off-patent drugs and non-standard preparations, or specials, have been hiked up hundreds of times, for example to over £1,000 for a bottle of pain-relieving mouthwash. In Scotland, specials remain in-house to keep the price down, but a year and a half on from the Health Service Medical Supplies (Costs) Act 2017, why have the Government not used its powers to stop this drug racketeering?

[Stephen Barclay]

The hon. Lady, very astutely and correctly, identifies the issue, which is how we ensure value for money from specials. Indeed, I commend The Times for highlighting a number of these issues. We are looking at this area. As we commit an extra £20 billion in funding to the NHS, our commitment is to ensure that we derive value for money from that investment. That applies to specials, too.

[Dr Whitford]

The healthcare market in NHS England is estimated to cost £5 billion to £10 billion a year and involves 2.5 million nursing hours a week being wasted on non-clinical paperwork. Does the Minister not recognise that this is the biggest inefficiency? Will he commit to reversing the disastrous marketisation of NHS England?

[Stephen Barclay]

Again, the hon. Lady draws attention to my work on driving productivity improvements within the system, which looks at a range of efficiencies such as sending texts and emails, dealing with missed appointments and the use of green energy. We can implement a whole range of initiatives as a part of that agenda.

Autism and Learning Disability Training: Healthcare Professionals

Philippa Whitford Excerpts

Monday 22nd October 2018 Westminster Hall

[Daniel Zeichner]

I am not coming quite to the end, but I have almost reached the close of Paula’s statement. I think my hon. Friend will understand from the suggestions later in my speech that I absolutely agree with her conclusion.

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

Does the hon. Gentleman not find it shocking and surprising that younger people with autism or learning difficulties have a higher incidence of dying in hospital than older people living with those conditions? It is hard to know exactly why that is, but he is discussing the case of a very young man that resulted in a completely unnecessary death.

[Daniel Zeichner]

The hon. Lady is very expert on such issues. I, too, am struck by that statistic. I do not know the answer, but it is the kind of thing we need to find out about.

To conclude Paula’s statement:

“Mencap’s Death by Indifference report, published ten years ago, set out many areas of concern behind avoidable deaths, and these findings have been built on by the detailed information now coming out of the national mortality review (LeDeR) process. Mencap’s Treat me well campaign report states that 1 in 4 doctors and nurses has never had any training on learning disability. This was our experience and is unacceptable, that’s why I launched this Government petition for all doctors and nurses to receive appropriate higher level mandatory training which could have saved Oliver’s life.

There needs to be a culture change in the way people with autism and a learning disability are treated by NHS doctors and nurses. This needs to be led from the top down by doctors and the GMC. It is not acceptable that people who have autism and learning disabilities die for no other reason than health professionals have not been properly trained on how to support them and work outside the limits of the medical model. We must do everything in our power to prevent future deaths like Oliver’s from happening again.”

That is Paula McGowan’s account. She started this petition to Parliament calling for mandatory autism and learning disability training for healthcare workers. The petition now has more than 50,000 signatures, and Paula is present in the Public Gallery to watch our proceedings.

An inquest has found that the medication was not wrongly prescribed, but Oliver’s family and Mencap were very unhappy with the inquest’s conduct and conclusions. The family firmly believe that better understanding of Oliver’s autism could have prevented his death. Paula believes passionately that Oliver’s experiences should lead to change, so that a lack of understanding does not result in future deaths.

There have been other cases such as Oliver’s, and every premature death of young person who is autistic or has a learning disability is a tragedy that we should be able to avoid. When Connor Sparrowhawk—or LB, as he is known—passed away in Slade House in Oxford, his mother called for:

“An effective demonstration by the NHS to making provision for learning disabled people a complete and integral part of the health and care services provided rather than add on, ad hoc and (easily ignored) specialist provision.”

There are, sadly, many other cases. Only last week, for example, a high-profile case was in the media about Bethany, aged 17, who has autism and extreme anxiety. She, it seems, has been locked in a seclusion room for almost two years.

Last week, I met a local volunteer-led group, Caring for Cambridgeshire’s Homeless, who help homeless people in Cambridge. I was introduced to a 21-year-old man with autism and learning disabilities who is living on the streets. His safe place: behind a wheelie bin, at the back of a shop. His case is complex, but while volunteer interventions are a lifeline for that young man, he should be getting professional medical support from those trained to understand his needs.

[Daniel Zeichner]

I am not sure that I am sufficiently expert to answer that question straight off, because it is a complicated one, but it is certainly worth looking into further.

I shall explain some wider issues too. This weekend, I attended the excellent Volunteer for Cambridge event organised by Cambridge City Council and volunteer services, where I met Heather Lord from Cambridgeshire Healthwatch and Tara Forkin from Cambridgeshire Deaf Association. Tara told me, through the signer, about the experiences of deaf people in the health system. They, too, find that treatment is sometimes administered to them in ways they find baffling and frightening, too often with no one finding a way to listen to them. As Heather rightly asked, almost 25 years after the controversies around the Disability Discrimination Act 1995, which some of us still remember, why are people continuing to have to fight the battle? Why is it not yet won?

This subject is clearly highly sensitive. The examples I have given highlight heartbreaking incidents. Clearly, we must work harder and put measures in place to ensure that other people are kept safe after we as a society have failed Oliver, LB and 1,200 other avoidable deaths each year, according to research by Mencap. Even more remains to be done, however.

We must go back to the very beginning, as access to healthcare from the start can be extremely difficult for those with autism or learning disabilities. Seemingly simple tasks—to most of us—such as making an appointment over the phone, are a barrier to many of them. If we cannot make an appointment, or if we feel anxious about doing so, we are less likely to seek healthcare, even if we are experiencing symptoms that others would immediately refer to a doctor.

Some autistic people and people with learning disabilities find expressing themselves difficult, especially if that includes discussing intimate personal health issues, whether physical or mental. Some learning disabilities or types of autism make it harder for people to work out the sensations that their bodies are feeling, which can make it more difficult for them to realise that they are ill or need support. In terms of mental health, the group therapy sessions, for example, which work so well for some people, are often inaccessible to those with autism, who can feel very socially anxious.

Last week, the all-party parliamentary group on mental health, of which I am a vice chair, published its review, “Progress of the Five Year Forward View for Mental Health: On the road to parity”, which underlined the mental health inequalities that I have been discussing. That report recommends:

“Health Education England should improve development and training of frontline care staff with a specific focus on mental health, learning disability and autism so the existing workforce is supported and equipped to deliver direct care and support to those groups.”

The report explains:

“We heard that people with learning disability or autism (or both) routinely have their referrals to mental health services turned down because some services ‘do not accept referrals from that group’. Mental illness presents very differently in people with a learning disability or autism. As a result, symptoms of mental illness can be wrongly attributed to a person’s learning disability or autism meaning that this group does not receive the treatment they need for their mental health problems.”

Also, according to the report, the esteemed Baroness Hollins, a leading member of the APPG inquiry, emphasised throughout that

“services are legally obliged to implement reasonable adjustments so people with learning disability or autism or both can engage with mental health services. This doesn’t appear to be happening.”

Many doctors and nurses of course strive to understand autism and learning disabilities, and to adapt their practice to better cater for those needs, but with increased pressures on staffing and endless demands on the time of medical professionals, alongside increased demand, that will inevitably not be the case for every single individual in the NHS. We must better equip and empower our healthcare workers.

With the right training, doctors and nurses can help autistic people and those with learning disabilities feel more comfortable and, ultimately, receive better, more focused healthcare. Everyone working in the NHS will see autistic and learning-disabled people, even if unaware of it. Some of those workers could have an inaccurate or narrow view of what someone with a learning disability looks like, or of the traits of an autistic person, due to inaccurate stereotypes or unhelpful media representation of such conditions. All frontline staff, therefore, from GP receptionists to consultants in accident and emergency, should receive some evidence-led training about autism. The development of that training should be informed by autistic people and their families.

Paula McGowan has called for doctors and nurses to receive advanced training—tier 2—in autism and learning disability as soon as is reasonably practicable. She expressed to me that it must cover legislation such as the Equality Act 2010, the Mental Capacity Act 2005 and the Mental Health Act 1983, focusing on key areas such as reasonable adjustments to care, consent and best-interests decision making. She would like it to be

“mandatory that Oliver’s story should be used as a case study in all training”,

and for the training to be named after him: the Oliver McGowan mandatory training. As Members present will agree, Oliver’s story carries huge weight, and attaching his name will exemplify the training’s deserved importance.

We need to focus on supporting the health professionals who see autistic people and people with learning disabilities most often to understand the nuances of their health. The community is diverse, and some of the physical and mental health problems those people experience require responses different from those required by non-autistic or non-disabled people.

[Dr Whitford]

As the hon. Gentleman knows, I speak as a breast cancer surgeon of more than 30 years. The issue lies not so much with medical and nursing staff, who deal often with autistic people or people with learning disabilities, but with the people who do not deal with them often. It is those people—people in A&E and other hospital departments—who do not have the skills who really need training.

[Daniel Zeichner]

The hon. Lady makes a fair point. Training needs to be provided to all staff, but absolutely, those who are not exposed to such people are a particular issue.

My comments so far have been decidedly non-partisan, and I hope Members from across the House are able to support most of what I have suggested. However, before concluding, I must make some observations about the staffing pressures that affect our public services—particularly changes to student nursing bursaries.

We have heard in the House many times that the current financial settlement for student nurses is insufficient given the intensity of their courses. I and many others believe that nursing students need bespoke financial support if the Government are to meet their commitment to growing the nursing workforce. Those students need support for living costs to incentivise a wider range of applications. There are many ways that can be done—through universal grants for students in recognition of their placements, means-tested grants to maintain diversity or targeted support for parents and carers, as many nursing students come to university later in life.

Since the coalition Government came to power in 2010, specialist areas such as learning disability and mental health nursing have been the worst hit by the wider staffing crisis. Those specialties struggle to recruit, since mature students are particularly likely to choose them. The Royal College of Nursing reports that there are 40.5% fewer learning disability nurses—2,176 fewer full-time equivalent nurses—today than in 2010. Despite Government claims, the removal of the NHS bursary in England failed to increase the number of nursing students. Recent data shows that the number of students accepted on to nursing courses in England has fallen by a further 4% in the past year, and by 8% since student funding was removed in 2016.

Intelligence from RCN regional networks indicates that directors of nursing across England are escalating concerns about course provision. They are concerned about the stark regional variation in course provision for learning disability nursing—particularly the risk of course closures in the south of England—which may exacerbate existing regional workforce supply disparities. The huge workforce pressure risks poorer care for learning disabled people. A commitment from the Government to encourage students into learning disability nursing may improve standards of care and patient safety.

--- Later in debate ---

[Mike Wood (Dudley South) (Con)]

It is a particular pleasure to serve under your chairmanship this evening, Dame Cheryl; we are debating an issue on which you have done much, not only to raise awareness, but to transform the legislative framework in which we operate. I thank the Petitions Committee for ensuring that time was made available for the debate, and congratulate the hon. Member for Cambridge (Daniel Zeichner) on his opening speech. I pay tribute to Oliver’s family in particular, and to the many other families who have done so much and worked so hard, exhausting reserves of energy and emotion that I am not sure many of us could have found, to ensure that some public benefit can come from their individual personal tragedies.

I have rather less direct personal experience of autism than many of the Members who will contribute today, but as a former governor at a special needs school that had a particular focus on autism I am familiar with many of the issues that Members have raised. As of last week I am a proud officer of the all-party parliamentary group on autism. I am fortunate to benefit from the fact that many constituents contact me to give me advice and tell me of their and their families’ experience in the healthcare system. I also benefit from the advice and experience of my former colleagues, the staff and governors at the school, and the National Autistic Society, which does much important work to push forward the agenda.

As has already been said, there are clear healthcare inequalities between people who have autism and the general population. That is clearly recognised by the Government. It was recognised in their mandate to NHS England and, of course, as one of four clinical priorities in the 10-year plan published last month. Those inequalities clearly have many causes. There are many co-factors more likely to affect people who have autism, such as issues to do with unemployment, mental health and poverty; but one of the most obvious ones, which is referred to in the petition, is the interaction between the national health service and healthcare professionals, and people with autism.

For many of us it can be hard to decipher what medical professionals tell us, particularly when we are very ill and perhaps not thinking as straight as we might. For people with learning disabilities and communication difficulties, the difficulty is on an entirely different scale. For many people with autism it is a question of heightened difficulty not only in understanding what they are being told, but also, of course, in communicating how they feel physically, emotionally and mentally. It is therefore essential that understanding of autism becomes part of the mandatory training for healthcare professionals, just as it is finally becoming a core part of initial teacher training.

Like other hon. Members, I am pleased to see that the new core skills education and training framework finally sets out proposals for a tiered approach and levels of training depending on levels of contact that can be expected for people with autism. There are half a million people in England—more than 1% of the population—who we already know have autism, so there can be barely any part of the healthcare system in which any worker is unlikely to have regular contact with patients with autism and their families. So it is a core part of their job and responsibilities to be able to respond, and to make necessary adaptations in the way they behave. That is a core part of being a healthcare professional.

[Dr Whitford]

There are throughout society people with varying skills, disabilities or learning difficulties, so do not we need to bring that right into medical and nursing school, and try to have a philosophy that counters what we see in society? That, frankly, is attacking the “other”. We have had so much of the politics of “other”, and attacking the “other” socially, and we need to try to get rid of that when people are at school and in medical and nursing school—not just when they have qualified.

[Mike Wood]

There are two important and slightly distinct points there. For mainstream education it is vital that an understanding of autism and other learning disabilities is part of personal, social, health and economic education—I do not know whether we still call it that—for precisely the reasons that the hon. Lady describes. Of course, in medical or nursing school it is vital that there is a core level of understanding of the issues for autism and other learning disabilities and of the impact they have on how people need to do their job once they have qualified and are practising and in work. That needs to be embedded from day one, but just as importantly, it must be reinforced and built on with continuing professional development.

Although there is clear evidence of inequality in many health outcomes, there is little concrete evidence yet known about how the wellness of people with autism compares with that of the general population. I hope the new framework will explicitly cover primary and community health as well as acute healthcare. Primary and community health is where much of the early interaction with patients and the wider population takes place. It could not be more important that our GPs and community healthcare staff understand the particular issues faced by patients with autism and their families, and how they should respond to them.

However, I hope the framework will go slightly further than that. I am sure that you, Dame Cheryl, might have wished to raise this issue were you not chairing the debate: the need for a GP autism register, as recommended by the National Institute for Health and Care Excellence, with a relatively easy and simple code so that people’s progression through primary healthcare pathways and on to an acute healthcare or a mental health setting can be tracked and we can have a better understanding of the impact of autism and learning disability on wellness and the particular challenges and experiences of people with autism.

[Dr Whitford]

The hon. Gentleman touched on poverty earlier. The learning disability employment gap is over 90%; if we actually want to look at the wellness of people with learning or communication difficulties, we as a society must include them, rather than parking them on the side and wasting their talents.

[Mike Wood]

The hon. Lady is right, and if I may give a quick plug, the all-party parliamentary group has done some important work with the National Autistic Society on precisely the issue of autism, employment and education. I understand it will be published shortly and I hope it provides a focus for a future debate.

Breast Cancer

Philippa Whitford Excerpts

Thursday 18th October 2018 Westminster Hall

[Jim Shannon (Strangford) (DUP)]

It is always a pleasure to speak in any health debates—as my party’s health spokesperson, I am interested in them—but it is particularly pleasing to speak in this debate. I thank the hon. Member for Crewe and Nantwich (Laura Smith) for presenting the case so well and, through having secured the debate, giving us other MPs the opportunity to make a contribution. It is also always a pleasure to follow the hon. Member for Lincoln (Karen Lee). All of us in the Chamber today, or who were in the main Chamber when she spoke on this topic some time ago, will remember her contributions. I thank her for them.

I am pleased that we again have an opportunity to highlight breast cancer issues while we have the Minister’s attention. We all know he is deeply interested in this subject, and we look forward to his response. I also look forward to the contribution by the shadow Minister, the hon. Member for Washington and Sunderland West (Mrs Hodgson), because I know she has an interest in the subject, too. There may be few of us here, but I know everyone’s contribution will be significant.

Some 55,000 people in the UK are diagnosed with breast cancer every year. Breast Cancer Now’s new 55000Reasons campaign calls for investment in breast cancer to feature in the NHS’s long-term plan. That beseechment is worthy of the Minister’s attention. Some 11,500 women and 80 men in the UK still lose their lives to breast cancer every year. I know men are a smaller proportion of sufferers, but we sometimes forget that they can be susceptible to breast cancer; I was given a salient reminder of that while researching for the debate. We sometimes do not think about that, but we should be aware of it.

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

Does the hon. Gentleman recognise that although far fewer men suffer from breast cancer, because services—particularly support services—are designed for women, men often delay coming forward with concerns and find it difficult to access support? Because they still see breast cancer as a women’s issue, they are almost afraid to be open about it.

[Jim Shannon]

As always, the hon. Lady makes an intelligent contribution; I do not mean to say that nobody else does, but she always brings her knowledge of her subject to our debates. I told her beforehand that I looked forward to her contribution, because, as always, it will be full of information we can learn from.

The hon. Lady is right: as the men present will know, we hide our health problems. We do not go to the doctor as often as we should. We just grin and bear it—except in the case of man flu, when we are probably dying almost before it starts. I should not be facetious—that is not right. I am just saying we do not react in the way we should. As the hon. Lady said, when we do go to the health service, the services are not there. We need to address that.

Between 2012 and 2016, an average of 66 women a year were diagnosed with breast cancer in the Strangford constituency. On average, 20 of those women—almost 30%—lost their battle with breast cancer in each of those years. As the MP for Strangford, that puts the issue into perspective for me, but it also tells me that the survival rate is not as good as we would like. The hon. Member for Bexhill and Battle (Huw Merriman) referred to early diagnosis, which I will come to. That statistic represents 20 homes deprived of a mother, a daughter, a sister, an aunt or a friend.

Outcomes vary tremendously among clinical commissioning groups. We continue to lag behind other European countries, such as Sweden, Portugal, Malta, Germany and France, on breast cancer survival. Projections indicate that if current trends continue and we do not address the increase in the number of people diagnosed with the disease, the number of breast cancer deaths will begin to increase within four years. I know the Minister has a cancer strategy in place and is addressing these issues, but perhaps he will indicate what is happening.

Those projections are shocking when we consider how far cancer diagnostics and treatment have progressed. My colleague the hon. Member for North Down (Lady Hermon) told me this week that a good friend of hers—a 42-year-old—has just died from cancer. Again, the reality is pertinent for us all.

I said to the hon. Member for Crewe and Nantwich that these debates always seem to come at the time when we can relate to them best. A very good friend of our family was diagnosed with breast cancer and is going through all the radiotherapy treatment. She has lost all her hair, as so often happens, and wears a scarf. The treatment is quite harsh. She is a friend of my son and the wife, and she works just down the road from us. Her employers have been good with her—they have ensured that she can at least do some part-time work. It is important for people to have something to focus their mind on when things are difficult.

Breast cancer is no respecter of the person. The large number of people affected by it means that even seemingly incremental changes have a huge potential to save more lives. Before I highlight some of the Breast Cancer Now recommendations, let me thank the Library for its work on the excellent briefing for the debate, which outlines the things we need, including public awareness and screening. It states:

“On 2 May 2018 the Secretary of State for Health and Social Care reported to Parliament a serious failure in the national breast screening programme in England and announced an independent review to investigate.”

Again, perhaps the Minister will indicate where we are with that review.

I underline the need for access to breast cancer drugs for people who are going through the most difficult times. We all know it is not just the patient who suffers—their family suffer, too. The hon. Member for Lincoln referred to that in a very personal way, which we all understand. The cancer care strategy refers to earlier diagnosis. One of its priorities is:

“A shift towards faster testing and responding more quickly to patients who present with symptoms. A target that by 2020, 95% of patients referred by a GP will be definitively diagnosed and receive test results within four weeks.”

If we reach that wonderful target, we will certainly be going the right way.

I often say to the hon. Member for Central Ayrshire, (Dr Whitford) who speaks for the Scottish National party, that she genuinely—she knows I mean this—brings a wealth of knowledge to our debates. I also tell her that, in many cases, Scotland leads the way with some of its health strategies and plans. We should look at its cancer strategy, which was published in 2016 and deals with prevention, detection, diagnosis and treatment—and aftercare, too, which is so important.

People who suffer from breast cancer often worry about financial issues, because they have a mortgage to pay and a family to look after, and sometimes the lady is the breadwinner. We must have all those things in place, so I encourage the Minister to look at Scotland’s cancer strategy, which I know the hon. Lady will refer to, probably in some detail. We look forward to that.

The excellent Breast Cancer Now recommendations include: specific lifestyle interventions; optimising the screening programme through increased uptake; strengthening the workforce; introducing new technologies; developing a screening programme tailored to an individual’s risk so cancers may be detected earlier; and reducing variation by reinforcing the position and ambition of cancer alliances. We will do this better if we do it together—I often say we are better together in everything. We can certainly learn from one another.

We should provide long-term funding and look at funding specific CNS posts to support secondary breast cancer patients in trusts where there is not a dedicated secondary CNS. We should ensure access to clinically effective drugs at a price that is affordable for the NHS. Let us have a price system. The Minister knows about the issues with the price structure for some drugs, and I know he is pursuing that matter so we get good drugs at a fair price.

I will take the time to list Breast Cancer Now’s recommendations. Its first priority is to fund

“specific interventions to prevent the 23% of breast cancer cases that are attributable to lifestyle factors in England every year.”

We should address the avoidable cancers.

The second priority is:

“Prevent over 1,200 breast cancer deaths by increasing breast screening uptake from the current decade low of 71.1% to the 80% standard set for breast screening units.”

It is so important to have that in place.

The third priority is:

“Urgently invest £39 million in recruitment to the breast imaging and diagnostic workforce to enable breast services to cope with increasing demand over the next ten years.”

I welcome, as we all should, the Government’s commitment to spend an extra £20 billion on health; it is a step in the right direction and it is quite a commitment.

The fourth priority is:

“Adopt new technologies, such as tomosynthesis and Artificial Intelligence, into the breast screening and symptomatic services as soon as proven effective.”

The fifth priority is:

“Transform breast screening to risk stratified screening to spearhead the prevention and earlier diagnosis of breast cancer over the next ten years based on evidence as it emerges.”

As evidence indicates the trends and how to respond to them, we should make the changes to make that happen.

The sixth priority is:

“Ensure that innovative, clinically effective cancer treatments are quickly available to NHS patients at a price that is fair and affordable, including by reviewing the NICE appraisal methodology.”

The seventh priority is:

“Introduce a Catalyst Fund worth £3 million to incentivise generic manufacturers to make it quicker and easier for patients to routinely access cheap, off-patent drugs found to be effective in new uses.”

The eighth priority is:

“Fund new Clinical Nurse Specialist posts to support secondary breast cancer patients in over 120 Hospital Trusts without a dedicated post.”

Those things can make a difference.

[Dr Whitford]

The hon. Gentleman talks about having a separate secondary breast cancer nurse as opposed to the breast cancer nurses who are involved in the initial treatment, but that is a discussion about local set-up. The hardest thing is to tell a patient, “It’s back.” To have a nurse to support her, who she knows from five or three years ago, is a big contribution. At our hospital, there was a conscious decision not to have a separate nurse—if a patient got sent to her, that would be a bad sign—but to have the nurse they already knew.

[Jim Shannon]

The hon. Lady is right and I accept that we should look at what is being done in Scotland. If there is a better of way of doing something, let us do it that way.

The ninth priority is:

“Improve the Cancer Dashboard by including more detailed data on performance across Cancer Alliance geographies to identify inequalities within and between Alliances.”

The tenth priority is:

“Provide multi-year funding for Cancer Alliances, to increase confidence and encourage long-term thinking to drive investment in innovation, including a dedicated fund to address pathway variation.”

It would be remiss of us all not to thank the charities, which work so hard. We all know them and I will mention just a few I am aware of: Cancer Focus Northern Ireland; CancerCare; and Marie Curie—I met a Marie Curie lady at the Northern Ireland Affairs Committee yesterday. I know Marie Curie’s work because some of my constituents have been referred there in the last month. Its end-of-life care is incredible, as is that of Macmillan Cancer Support.

We need a plan of action and we must have the funding for that plan of action to be put into place. I support so fervently the English reforms that the Minister will put forward, in the hope that the ethos and the funding for my constituents will follow. We are in a different place in Northern Ireland; health is a devolved matter and the responsibility falls under the Northern Ireland Assembly, but it is not functioning correctly at this moment. Men and women need to know that there is a way forward, to ensure that no one dies of breast cancer anywhere in the UK in the not-so-distant future.

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

I pay tribute to the hon. Member for Crewe and Nantwich (Laura Smith) for securing this debate. I am sorry that it is not more highly subscribed, but it is competing with other debates elsewhere. I also pay tribute to the hon. Member for Bexhill and Battle (Huw Merriman) and particularly to the hon. Member for Lincoln (Karen Lee), whose daughter did not survive. I am sure that that was very difficult for her to speak about; I know she has done so before, and it is very brave of her. I am sure her daughter would be proud.

I declare an interest, which most people know about—I was a breast cancer surgeon for 33 years before coming to this place. Naturally, I am one of the co-chairs of the all-party parliamentary group on breast cancer and I am a Breast Cancer Now ambassador. In my previous life, I was part of its clinical advisory group. In Scotland, I led on developing the quality improvement standards, which we set up in 2000 and which helped to drive up the quality of breast cancer care across Scotland. It was one of the most rewarding periods in my career, because not only did I have the incredible satisfaction that anyone who has worked in the NHS gets from looking after a patient one-to-one—it is an honour to get to do that—but I knew I was contributing every year to cranking up the standards across the country. We have annually gathered peer-reviewed data right back to 2003. It has been great to see that driven up.

The subject of the debate is the future of breast cancer, but being such an old, crusty breast cancer surgeon, I could not resist talking a little about where we have come from. When I started as a medical student, the five-year survival rate was 53%; now, it is more than 80%. That is the journey we have made—a huge journey for the patients, too. It just so happened that my first job on qualifying, and the first three units that I worked in over my first three years, were breast cancer units. I learned so much from the patients on the ward.

Those were the old days, when my light week was 75 hours and my heavy week was 132 hours. My bedroom was on the ward, so I had my tea with the breast ladies. I learned so much about what they hated: people undressing them and not covering them up while starting to talk about them; people talking over their heads. I watched women come back from theatre on a trolley, groping themselves—if they had a lot of bandages and a drip, that meant it was cancer, because the diagnosis was done at surgery. They took out the lump; it went to the lab; they looked at it; they phoned the theatre; and the woman had a mastectomy. No breast care nurse, no pre-operative diagnosis, no discussion and no plan.

There were no women surgeons in Scotland at that time; I remember one of my professors saying, “You should do breast surgery.” I thought it was a bit clichéd for a woman surgeon to do breast surgery, but I looked at my three years’ experience and I thought that the experience of those women was so awful that I could not do anything other than make it better. We have transformed that. By the mid-’80s, we were able to diagnose it at a clinic. Lots of breast surgeons were still not interested in having breast care nurses, but I was involved in the research in Glasgow into the critical need for social and psychological support for women who were going through that journey, looking at the impact of mastectomy on women.

Eventually, we learned that we are kind of not stupid. We are not stressed just because we lose a breast, but because we have cancer; we have kids and we want to see them grow up. We understood that there are two sides that create pressure on women: the change to their body image and the simple stress of the disease, and how to support that. We offered reconstruction; eventually, we moved from mastectomy to preserving the breast when we could. We also know that to support a woman psychologically is to be utterly and completely honest—not to be cruel or rude, but utterly honest. If a patient is lied to, whether by a doctor or family member, that creates a barrier. I have always tried to be utterly and totally honest about what we are facing. We should be part of the patient’s team.

In the late ’70s, tamoxifen came in. Scotland did a lot of the research on that and it looked like it did not make a big difference, until they started doing what we now call meta-analysis—putting a lot of studies together and realising that all the little gains were adding up to an awful lot of lives saved. That has been borne out. There is no magic wand that will get rid of breast cancer; it is about early diagnosis, detailed diagnosis, good surgery, good radiotherapy, good chemotherapy, good hormone treatment and good immunotherapy.

We are talking about the future of breast cancer, and genomics and personalised therapies are in all of the briefs. Tamoxifen was one of the first personalised therapies for a solid tumour to come into existence because it worked only for patients with hormone-sensitive cancers: by testing that tumour, we could tell whether tamoxifen would work. As part of the trial way back in the 1980s, the University of Glasgow did a huge amount looking at how we could test to see whether a cancer was hormone-sensitive. We now do it in a much more efficient way, which is much less time-intensive. Of course, Herceptin, which we discussed so much in the 2000s, works only on patients who carry the human epidermal growth factor receptor 2 marker that makes them sensitive to that drug. We already have that personalised medicine, and a test for it.

My MD thesis was in breast cancer immunology. I utterly believe that immunotherapy will dominate the future of cancer treatment because it is so much better tolerated than chemo and often has a much bigger impact. However, the antibody that became Herceptin was discovered in the second half of the ’80s, when I was in the lab—not that lab, but it was the talk of the steamie because it was an utter breakthrough for everyone studying cancer immunology. That drug went into general trial in 2001. In Scotland, we got access to it routinely on the NHS in 2006, and down here, south of the border, it was the following year—20 years from the bench to routine access. That is one of the challenges we will face in the future.

New treatments have come in, including many in the ’90s, with newer chemotherapy in the form of taxanes, new endocrine treatments, better surgery and better staging. All of that has added up to get us over the 80%. However, as was mentioned, our rates are below the European average.

I remember seeing an interesting paper that compared the UK with Denmark: in all the lower stages and less aggressive diseases, the UK held its own comfortably, particularly because way back in 1988 to 1990 we were one of the early adopters of breast screening whereas other European countries came on only in the second half of the 2000s. However, for the people with really aggressive or advanced disease, we were not matching up. That simply comes back to drug access.

We may get the drug discovered. Scotland plays a significant role—we punch above our weight—within life sciences research in taking things forward and finding new drugs. However, I can say, as one who was routinely involved in trials for years, that it is really demoralising to take on all that extra unpaid time to do the paperwork, sit and explain trials to patients only to find that, as soon as that drug is passed and licensed, we do not get access to it any more.

That is one of the challenges. We are talking about all the amazing new treatments that may come over the hill, but we need to look for an utterly different way of trying to bring them onstream and make them affordable for the NHS. We need a different discussion with the pharmaceutical industry. In exchange, we can offer not personalised data but real-world information thanks to having a joined-up national health service in each of our four nations while many other systems in Europe simply do not. Similarly, our cancer registries are highly accurate.

We face challenges in the future; it is not just that magical treatments will come. Access to drugs is important—and not just new ones. As the hon. Member for Crewe and Nantwich said, there are off-patent drugs such as bisphosphonates, which are cheap in the scale of things, yet only one in five commissioning groups in England are funding that. In Scotland, it is funded in all health boards—my unit took part in that trial.

The idea that something that protects against bone metastasis or strengthens the bones of those driven into the menopause could prevent the spread of breast cancer in all patients was fantastic. In comparison to all the treatments we use, and the one we would use if that patient were to develop metastasis, frankly the cost-benefit is very positive. That should be driven up in England and made routinely accessible. As the hon. Lady mentioned, the report that looked at variation across England showed shocking postcode prescribing.

One of the biggest challenges we face in general in the NHS right across all four systems is workforce. I mention it all the time. It is a challenge in every single NHS specialty, but we have a particular issue in breast cancer and a particular problem in radiology—the mammographic or MRI scanning diagnosis. Many of the consultants who went into breast cancer when screening was developed all became consultants around the late ’80s and early ’90s, and they are all retiring. We are losing a huge cohort, and apparently for every three that retire only two are lined up to replace them. Less than one in five breast screening units report having a full cohort of staff.

Patients cannot be treated in any way if they have not been diagnosed. The issue that led to patients not getting called at the end of breast screening, referred to by the hon. Member for Strangford (Jim Shannon), was partly because of slippage. If those patients had been screened on the correct date, they probably would have been called correctly, but because they slipped past the ages of 70 or 71 without being called, they missed their appointments.

We need to look at that problem, and that includes promoting this specialty. I spent 33 years in it. Yes, sometimes other surgeons are patronising about breast surgery—maybe it is not quite exciting enough for them; there is not enough blood on the floor or enough glamour—but it is one of the most holistic surgical specialties. We look at how to support the patient to recover, getting them back to normal life through exercise, integrating them into their community, providing support groups and having cancer nurse specialists. It is important that those of us in the specialty or who have been in it reach out and attract our younger colleagues to think of it as a life’s job. Cut me through the middle and it’ll still say breast cancer doctor, not MP, and that will never change.

Finally, we do not give remotely enough attention to prevention. The same things that prevent breast cancer will prevent bowel cancer, lung cancer and so many others. The public sometimes get so many conflicting messages, so they go, “Do I drink coffee or not? Do I use a roll-on deodorant or not?” I always say, “There are only five things you need to think about. Don’t do drugs and don’t smoke. If you don’t do either of them, you’ve only got three. They are: keep your booze under control, because we know that contributes directly to breast cancer; watch your diet, because we know that fats and saturated fats in particular contribute to a rise in breast cancer; and be active and healthy.”

If we were to focus much more of our attention on that handful of things that people should do, we could look at reducing the incidence of all of those cancers, whereas they are currently rising. Instead of thinking about hundreds of thousands of pounds at the end of someone’s treatment journey to try to buy another half a year or a year, why do we not try prevention in the first place?

[Mrs Sharon Hodgson (Washington and Sunderland West) (Lab)]

It is a pleasure to serve under your chairmanship, Mr McCabe. I thank my hon. Friend the Member for Crewe and Nantwich (Laura Smith) for leading this timely debate during Breast Cancer Awareness Month and for her excellent speech. It is timely because it is on the same day as Baroness Jowell’s moving memorial service, which I attended prior to this debate. I will say more about why that is relevant later.

I also thank other hon. Members for their excellent contributions—the hon. Members for Bexhill and Battle (Huw Merriman), for Strangford (Jim Shannon) and for Central Ayrshire (Dr Whitford), and my hon. Friend the Member for Lincoln (Karen Lee). I also thank the amazing campaigners, ambassadors and charities, especially Breast Cancer Now and Breast Cancer Care, for their unswerving support to us as politicians campaigning on the issue, but more importantly to the women, men and families who are living with breast cancer, before, during and after treatment.

As we have heard so movingly today, so many of us, especially those here today, have had our lives touched by breast cancer. I lost my mother-in-law to breast cancer 21 years ago—I have spoken about this before—and that is what inspired me to join the all-party parliamentary group on breast cancer when I became an MP. As the hon. Member for Bexhill and Battle so astutely spotted, I served as co-chair of the group, with the Minister and the hon. Member for Central Ayrshire, and I still serve as the vice-chair. That shows how close breast cancer is to the heart of the health spokespersons of each party and how important it is to work in a cross-party, collaborative way on such an important issue.

More women are surviving breast cancer than ever before. Around 95% of women will survive for one year and more than 80% survive for five years or more. However, the UK still lags behind countries such as Sweden, Portugal, Malta, Germany and France. It is clear that more must be done. Many different issues have been mentioned, but I will specifically talk about breast screening, the workforce and prevention, which others have touched on.

We all know how important early diagnosis is to improving the chances of survival. Breast cancer screening has a huge part to play in this, yet uptake is the lowest it has been in ten years, with stark variations across the country. According to Breast Cancer Now, increasing breast screening uptake from the current decade low of 71.1% to the 80% standard set for breast screening units could prevent over 1,200 breast cancer deaths per annual cohort of eligible women. Will the Government be taking steps to increase breast cancer screening, so that over 1,200 breast cancers deaths can be prevented each year?

The Prime Minister’s commitment as part of the NHS long-term plan to see three out of four cancers detected at an early stage by 2028 included a plan to make screening programmes more accessible and easier to use. Can the Minister elaborate on those plans? Will they include outreach services to groups who are less likely to attend screenings, such as those from certain demographic groups or those with learning disabilities?

Earlier this year it was announced that there had been a serious breast screening invitation error, which meant that over 10 years more than 174,000 women did not receive an invitation to their final breast screening appointment. A review into this error is expected to be published next month. Can the Minister provide an update on that review and is it expected to report on time?

Every year over 55,000 people in the UK are diagnosed with breast cancer, but the failure to address those increasing numbers means that, according to Breast Cancer Now, the number of breast cancer deaths is set to rise within four years. That is why pressure on the workforce needs to be addressed as a matter of urgency. Demand on the breast imaging and diagnostic workforce is set to increase over the next 10 years. We already have a workforce crisis with growing demand, but the problem is only going to get worse if it is left unaddressed. For every three breast radiologists who retire over the next five years, only two are expected to replace them. What plans do the Government have to deal with the growing pressure on an overstretched workforce?

Leaving the EU could also have an impact on our NHS workforce: 5.6% of the NHS workforce in England are from the EU. Changes to immigration rules may exacerbate existing workforce problems for breast cancer patients, particularly among the nursing workforce. Can the Minister provide any clear guarantees to EU citizens working in our NHS? What steps is his Department taking to ensure that the UK continues to attract nurses from the EU?

The current cancer strategy for England includes a recommendation that all patients diagnosed with cancer are supported by a clinical nurse specialist, but this support is not widely available. We heard from my hon. Friend the Member for Lincoln how devastating that is and what it means in reality, when she talked about her experience with her daughter. That support is not available to the majority of the 35,000 people in the UK living with secondary breast cancer. Nearly 72% of hospital organisations in England, Scotland and Wales do not have a dedicated secondary breast cancer clinical nurse specialist. I share Breast Cancer Care’s belief that incurable should not mean unsupported. Does the Minister share that belief and what steps will he take to close the stark disparities and support between primary and secondary breast cancer patients?

[Dr Whitford]

The hon. Lady has recognised the comment I made earlier, that our patients all have the support of a cancer nurse specialist, but they do not have a title of secondary nurse specialist. That is something that requires looking into in more detail, so that we can identify places where there really is no support versus places where support is linear, and the decision has been made to follow patients through their whole journey rather than make a decision on a title.

[Mrs Hodgson]

That is an important point and the model that is used in Scotland should perhaps be looked at. I took on board the hon. Lady’s point, when she said that patients who are assigned a secondary breast cancer nurse know what that might mean, whereas if it were someone who had been with the patient on their whole journey, that would be a different experience.

[Dr Whitford]

It varies in Scotland. We are a huge and rural country, so we will have some areas where there is a cancer nurse specialist and, for example, islands where there is someone who has the training to act in that role. In Glasgow and Edinburgh there may well be nurses who are different. It was a decision that we took as a team, as we felt it would be hard on the patients to suddenly move to someone new. It is also hard to sustain the nurse, if they are only ever involved in that part of the journey and do not have other days when they see patients get discharged, be well or be diagnosed.

[Mrs Hodgson]

The challenge to the Minister is whether improvements to the breast cancer workforce will include recruiting and training additional secondary breast cancer nurses, clinical nurse specialists—whatever we may decide to call them—so that patients have the vital support they need and no one has to witness their loved ones suffering in agony, with only over-the-counter painkillers to ease the pain, as my hon. Friend the Member for Lincoln so bravely testified to earlier.

--- Later in debate ---

[Steve Brine]

Oh yes; the hon. Lady has already said Chancellor today. I am not sure about that one.

As the cancer Minister, I want a future where there is no breast cancer. The hon. Member for Strangford (Jim Shannon) mentioned that, and I think all hon. Members who have contributed this afternoon would like to see a future where there was no breast cancer. One day, perhaps—but the statistics show that we are making good progress. That is why I said that there are things to celebrate. We are ensuring that more people than ever survive breast cancer. As has been said, 10-year survival rates have almost doubled, from around 40% to nearly 80%, in the last 40 years.

I hope I do not need to say it, but cancer is a huge priority—the priority—for me. The Prime Minister chose to make it a central point of her party conference speech this month, and there was a reason for that; it is a huge priority for her and for her Government. Survival rates have never been higher, and they have been increasing year on year. Of course the Prime Minister celebrates that, but it is also why she announced a very ambitious package of measures for cancer care and treatment, showing that cancer will be absolutely central to the long-term plan for the NHS, which she has challenged NHS England to write before the end of this year and of which I will say more later. We are committed to investing an extra £20 billion a year in our NHS. The investment will build on the success we have already achieved through the implementation of the cancer strategy for England. I pay tribute to Harpal Kumar and those at Cancer Research UK who put that strategy together. We will build on that legacy and take it forward into the long-term plan.

In opening the debate, the hon. Member for Crewe and Nantwich raised a number of good points. She talked about secondary breast cancer data collection—a number of people did so, but she raised it first. She is right that the robust and timely collection and sharing of data is vital for improvements in breast cancer services. If we do not measure it, we do not know, and if we do not know, we cannot act. The National Cancer Regulation and Analysis Service, or NCRAS, collects data on all cancers diagnosed in England, with the data collection specified by the cancer outcomes and services dataset. That data collection of secondary breast cancers was mandated as part of the COSD for diagnoses from April 2013 onwards.

I remember, with my shadow Minister, taking a delegation to see Prime Minister David Cameron in No. 10 to talk about that exact issue just before Christmas; I remember our photo by the tree. It is good that that happened, but it is evident, comparing the collected data with sources in academic literature, that a large proportion of cases are still not being reported in the COSD. That is of great frustration to me. NCRAS continues to work with NHS trusts to improve the completion of the data, and we have redesigned aspects of the COSD to allow more relevant information on occurrence to be captured, but I do not for one minute shirk the fact that there is more to do in this area, and I assure the House and colleagues that I will constantly redouble my efforts in that regard.

[Dr Whitford]

I touched on the quality improvement project that we started in 2000 in Scotland, looking at many measures right along the pathway that the patient went through. In essence, it was assessing the whole team: how the team functioned, what the surgery was like, what the diagnosis was like and what the chemotherapy was like. The problem is that that sort of audit has not happened, other than for screening patients, in England for quite some time. While I welcome the collection of data on secondary cancer, we need units to have the ability to look at their performance on patients the first time around, to try to prevent that secondary cancer.

[Steve Brine]

The hon. Lady is right. That is why COSD stands for the cancer outcomes and services dataset. It is not specific to breast cancer, nor should it be, because there are sadly lots of different cancers, but she is right that it should be measuring, judging and analysing both the outcomes and the services that lead to that outcome. As ever, she is dead right.

The point was made about off-patent drugs being found to be effective in new uses. The Prime Minister set out, both in her party conference speech and when we launched the new NHS long-term plan, how a key ambition of that plan will be to speed up access to groundbreaking treatments, with a quicker translation of new breakthroughs into practice through investment in world-leading cancer research centres.

Although bisphosphonates—I always struggle to say that—are not licensed for the treatment or prevention of secondary breast cancer, clinicians can prescribe them off-licence or off-label, subject to local funding policies, if they consider them to be clinically appropriate for an individual. The hon. Lady was right to raise that point.

[Dr Whitford]

Will the Minister give way?

[Steve Brine]

Not at the moment. The hon. Lady and others also talked about the long-term funding of cancer alliances. NHS England and I are absolutely committed to the cancer alliances. We have backed them with significant funding and we will continue to support their development fully, ensuring that they have the funding that they need—in this cycle, at the very least—to transform cancer services in the long run.

I take a close and continued interest in the cancer alliances, as Members would expect. Just this week, I sat down with Cally Palmer, the NHS England’s national cancer director, to do what I call a deep dive, going through each cancer alliance in England. I want to know who runs them, where there are leadership challenges, where they struggle to meet the 62-day target and why, and I want to know their turnaround plans for that, including replacing people who are not performing. We do not expect or accept poor performance in a trust, and we do not expect or tolerate it in schools. Cancer alliances spend a lot of public money and they should not be treated any differently.

I want much greater transparency from the cancer alliances. I suspect that if I asked every Member here whether they knew the name of their local health trust chief executive, they would say that they did—and they probably have them on speed dial, as I do. If I asked those Members whether they knew the name and number of the person who leads their cancer alliance, I doubt that they would. I assure Members that that will change.

[Dr Whitford]

Bisphosphonates and other off-patent drugs are usually old drugs, which ought to be cheaper and therefore very cost-effective. The Minister and another Member mentioned that these drugs are not relicensed. A private Member’s Bill to set up a method for relicensing drugs for a new purpose was unfortunately talked out by the then Minister, the right hon. Member for North East Bedfordshire (Alistair Burt), in November 2016. We have agreement that these drugs will go into the “British National Formulary”, which will hopefully increase their use. However, I notice that the shocking increase in prices of off-patent drugs that led to the introduction of the Health Service Medical Supplies (Costs) Act 2017 has not changed. The regulations are not being used. NHS England is being charged ridiculous prices for old drugs and for specials that are made up for individuals. Why are we not using that legislation to drive down those prices, so that all women in England could access drugs that are not—or should not be—actually that expensive?

[Steve Brine]

There is so much more that I want to get on to, so I will not go into that in any great deal, but I will give the hon. Lady a note on that. Lord O’Shaughnessy, who is part of the Department’s drugs team and who speaks on health in the other place, is working on the implementation of that legislation. The hon. Lady has asked me about this before, and it frustrates me incredibly that that Act is not being implemented more quickly, but that should not be taken as any indication of a lack of desire on our part to do so. However, I take the hon. Lady’s point.

It is still right for those prescribing decisions to be made by clinicians. However, I want breakthrough drugs to make it on to the market more quickly, instead of staying in the cancer drugs fund. There are good examples of that related to breast cancer, and we want to see it happen much more quickly.

My dear hon. Friend the Member for Bexhill and Battle (Huw Merriman) spoke personally and passionately —as always—about these matters, and I thank him for that. He raised lots of issues, including the screening programme. Everyone says that the breast cancer screening programme is a critical tool in ensuring that we catch breast cancers as early as possible, when there is a higher chance of successful treatment. However, we know that there is much more to do to improve uptake. In her party conference speech, the Prime Minister set out that we would transform our screening programmes, making them more accessible and easier to use and utilising the best research and technology. Further detail on that will be set out in the long-term plan later this year.

My hon. Friend also asked about technology in screening. I will come on to the screening scandal in a moment, but it is very much our aim that in the future patients will be able to make much greater use of technology to be informed of things, such as GP or screening appointments, rather than relying on Royal Mail. Our NHS app is being piloted and will be rolled out from December this year. That is just the start of the technology revolution that we want to see and that the Secretary of State has made one of his priorities. We expect the independent breast screening inquiry to make recommendations in that area.

Several Members asked about the inquiry into the breast screening problems that we had. We expect that to report shortly. I do not have an expected date, but several Members, including the hon. Member for Central Ayrshire and the shadow Minister, asked whether it is on schedule. I believe that it is, and I look forward to that report very much. With somebody as serious as the Macmillan chief executive leading that review, alongside others, I know that it will challenge us, as it is meant to; the former Secretary of State set it up to do so.

My hon. Friend the Member for Bexhill and Battle mentioned the importance of early diagnosis. I am proud of Public Health England’s Be Clear on Cancer campaign, which I am responsible for. PHE ran its 14th Be Clear on Cancer campaign through February and March of this year, focusing on breast cancer in women aged over 70—a subject that is very close to the hearts of members of the APPG. Research shows that older women are more likely to delay presenting to their GP with breast cancer symptoms.

The campaign previously ran in 2014 and 2015, and an evaluation showed an increased awareness of the key messages that it promoted and, even more importantly, that more cancers were diagnosed during the campaign period. We are running the “Blood in Pee” campaign at the moment—I have all the glamourous things in my portfolio—and Be Clear on Cancer will go forward and from strength to strength.

Social Care Funding

Philippa Whitford Excerpts

Wednesday 17th October 2018 Commons Chamber

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

Here we are discussing this issue again when we discussed it just before the summer recess. That shows not only its importance but the fact that we are not making progress. We were promised the Green Paper last year. Then it was late last year, then early this year, then autumn 2018. I gently point out that it is now autumn 2018.

The five year forward view talked about managing demand in the NHS if there was an absolute game changer of an increase in public health to try to reduce the demand at the front door of the NHS, an increase in funding and provision of social care to stop funding haemorrhaging out the back door of the NHS. Unfortunately, what we have seen over the past five years is ongoing cuts to social care. I am sure that the £240 million for the winter from the Secretary of State is very welcome, but it is not nearly enough, and we will just keep on having this debate unless we can move forward and have a serious debate around the Green Paper.

As was mentioned earlier, Age UK estimates that more than 1.2 million people are not getting the care that they require. Need has increased by almost 50% since 2010, and yet there has been a decrease of 26% in England of local authority funded places. One third of people needing care are totally dependent on their family. It is estimated that 6.8 million people—that is one in 10 of the UK population—are involved in caring for a loved one, either full-time, part-time, or topping up care. Age UK also estimates that one third—700,000 people—receive no care whatever.

Despite an almost 9% cut in their budget, the Scottish Government spend £163 per head more on health than the UK Government—the Minister might actually want to listen to that, having made snide remarks about the Scottish Government—and £157 per head more on social care. Scotland is the only country in the UK that provides free personal care, and we have sustained that since 2002. That has led to less than one third of the increase in A&E attendances and emergency admissions in Scotland over the past five years compared with England. The system is really expensive and it is challenging, but it reduces delayed discharges and it reduces emergency admissions, and the estimate is that it is still cost-effective. I suggest that the Government might want to look at that in the Green Paper.

[Mr Paul Sweeney (Glasgow North East) (Lab/Co-op)]

In my constituency, the Barchester Alexandra Court Care Home has closed, with 53 residents losing their places. That was because Glasgow City Council’s funding has been cut by 10%, yet the discretionary spend for Scottish companies has been cut by only 5%. Surely that is a disproportionate cut in social care in Scotland. Although the objectives are laudable, we have seen continued pressure on social care in Scotland as in the rest of the UK.

[Dr Whitford]

There is no question but that there is pressure. There is no question but that all the systems face the pressures of increased demand, workforce and money, but if the hon. Gentleman would like us to match funding down here, then we will remove £881 million from our health budget and, obviously, that £157 a head from our care budget. We spend more per head of population in Scotland—considerably more. [Interruption.] That is one of the mantras that is always heard down here, but may I point out that, for a Barnett consequential of 9.3%, the Scottish Government have to manage one third of the UK landmass—that is roads, rail, GP practices, hospitals and schools.

[Several hon. Members rose—]

[Dr Whitford]

No, I am sorry, I will not give way. Members want to make speeches, but if they intervene on me, there will not be any.

In Scotland, we have been working for the past five years on integrating health and social care. I can say that it is an awful lot harder than the job that we did of integrating primary and secondary care, simply because one side is tax-funded and the other involves multiple private companies and is means-tested. We are already working on that. Our integrated joint boards manage one half of our health budget along with local authority funding. It is about shifting money from hospital into primary care, mental health, community care and social care.

There are three particular groups who need social care. The frail elderly mentioned by the Secretary of State, the number of whom will escalate massively in the coming 20 years, need support and comfort, and most of them would like to be at home. The home care hours in Scotland have doubled over the past seven years, which allows people with more complex needs to be cared for at home, so as not to end up in a care home or to land acutely in hospital.

As was mentioned by the hon. Member for Bridgend (Mrs Moon), who is no longer in her place, end of life is a critical issue; it is a point at which time is of the essence. Since 2015, all Scottish local authorities have provided free personal care to people defined as having a terminal condition—facing the end of life—even when they are under 65. The Government should look into such a measure, as it provides dignity.

Working age disability accounts for a huge chunk of social care funding. These people want to be mobile and to be allowed to participate in society, and it is important that that is what they do—that they are not just stuck away somewhere, as might have been the case many years ago. From April, under Frank’s law, which was named after the footballer Frank Kopel, under-65s with degenerative conditions, not just disability, will be able to receive free personal care. That includes people with early dementia and multiple sclerosis. We ask that the DWP does not then rob these families of that money by cutting other disability allowances.

I mentioned the workforce, which is an enormous challenge in the health service and one with which every local authority, integrated joint board, company and care home is struggling. Despite the workforce in Scotland increasing by 11% over the last three years, it is becoming harder to recruit. Brexit only makes that harder because a significant proportion of social care staff are from Europe.

We need to make social care a career—to be decent to carers by paying them the real living wage, not the pretendy one, and by paying them for all the hours they work, even at night. It is important to treat people with dignity if we want them to treat our loved ones with dignity. Carers should have job satisfaction from having time to care. Having 15 minutes to flit in and out does not provide job satisfaction, and it does not provide satisfaction or continuity for the patient or the carer. There needs to be a career structure. Caring should be looked upon like nursing, with training, investment and a way of staying in that career. It should not just be some job that people do until they get a job on the checkout at Tesco because that pays better.

We have talked about being able to discuss the Green Paper, but unfortunately there is no sign of it. It is meant to offer an opportunity to rethink care. The Nuffield Trust suggests looking at the Japanese system or the German system, which has already been mentioned. It is noticeable that levers have been built into the Japanese system so that demand can be controlled, and that means that eligibility may well change. On the plus side, the system is Japan is a holistic one and it looks at the global wellbeing of the older population—so if we do look at these other systems, we should look at them in their entirety.

The German system is based on social insurance. Well, does that not ring a bell? We used to have national health insurance, but then the “health” was dropped. Maybe we should think about whether national insurance should really stop when people retire. Perhaps we might set a level above anyone who is living only on the state pension, because there are pensioners who are very well off and who suddenly stop paying national insurance exactly at the point when their health, care and social needs start to increase. We need to look at all these options, but it is crucial that there are no sudden changes—that we do not have a WASPI situation, whereby the goalposts suddenly move with only a couple of years’ notice, and that we do not have a measure like the one in the Conservative manifesto last year that was then labelled the dementia tax.

We need to discuss this issue as adults, to look around the world and to look at the demands ahead. Older people and people with disability across the UK need to be able to live a life of decent quality, with dignity.

Draft Medicines and Healthcare Products Regulatory Agency Trading Fund (Amendment) (EU Exit) Order 2018

Philippa Whitford Excerpts

Thursday 11th October 2018 General Committees

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

I, too, have a life sciences park in my constituency. Regardless of whether Members have them in their constituency, drug access is of course critical to all our patients. The EMA has made a huge difference in the access to drugs: the speed at which they leave the bench, are developed and arrive in doctor’s surgeries or the NHS. If we look at Canada and Australia, we see that the delay is between six months and a year.

The problem is that the MHRA can be strengthened by itself, but that does not replace collaboration. It is not a matter of going into one’s own little corner and having more money or equipment if collaboration is not possible. As well as licensing, the EMA has driven research, particularly on rare or congenital conditions such as childhood cancers. We have made huge progress on these conditions in the last decade—much better than in several decades previously.

My party, too, does not object to the fine print of this legislation, but it does not sit by itself. Our concerns are about how it fits in the wider context, what support will be provided to the MHRA and how exactly it plans to bring drugs on, because it can still take quite a considerable time for new drugs—between licensing through the EMA and within the UK—to be routinely available through the NHS. I am hearing from pharmaceutical companies that it will not take three months, six months or a year. They feel that, when a drug is expensive, it will not be used by the NHS. What is the point in their paying to go through a separate, expensive process, if it will be another three years before the drug is likely to be commonly used? We could therefore see considerable delays, and, if the drug is not licensed in this country, it will not be something that doctors can prescribe as an exception, or that the National Institute for Health and Care Excellence or the Scottish Medicines Consortium can recommend. That will put us way behind: if we are not using what is recognised as current gold standard, we cannot take part in gold standard new drug trials. Therefore, having been a major player in medical— particularly pharmaceutical—research across Europe, the UK could fall a long way behind.

I also want to ask quite a simple question, because the Minister said that the MHRA is able and expected to use those trading funds to fund all its operations. As the hon. Member for Ellesmere Port and Neston pointed out, having bid for 36 rapporteur contracts this year, the MHRA was awarded only two, because it was felt that it could not guarantee completing them before 29 March 2019. That means that there will be a huge drop in income for the MHRA, which will not only have to carry out the investigations it has done in the past—between 25% and 35% of EMA work—but will have to go through a duplicate process for the UK. Do the Government envisage—if there are no new activities and no rise in fees—a return to a Supply process in which they fund the MHRA? The order does not specify how the MHRA will be funded.

[Steve Brine]

There are lots of wider points, but we have gone off-topic. The order is very specific and seeks to make sure that the agency can still function after Brexit, regardless of the deal or no-deal scenario. The shadow Minister, the hon. Member for Ellesmere Port and Neston, asked about the impact on the NHS and on NHS funds. As I have said, the MHRA is self-funding, and this will not impact the NHS at all. It is not as if the MHRA is going to come and ask for its slice of the £20.5 billion extra funding that we will be giving the NHS every year from next year as a result of the new funding settlement in the long-term plan.

It is self-evident that we cannot have the vast significant change of leaving the European Union without there being a change in our relationship, but as we have made very clear—the Prime Minister made it very clear in her Lancaster House speech and subsequently—the UK is seeking active participation in the EMA, as part of the future economic partnership. That is still very much subject to negotiations, but it is where we want to get to.

As a trading fund, the MHRA is required to cover its costs by charging for its work. The hon. Member for Ellesmere Port and Neston therefore asks an important question, but as part of the Brexit contingency planning, the agency is working in conjunction with the Government and the Department to ensure that it has a balanced budget post-Brexit, irrespective of the outcome. The majority of its licensing activity and the associated income derive from domestic—national, not EU—licensing.

The future trading relationships for the agency were outlined as part of our no-deal preparation planning. On 4 October, the MHRA opened a consultation on EU exit no-deal listed proposals. That is a live consultation which seeks views on how the agency’s legislation and regulatory processes would have to be modified in the event of the UK not securing a deal, and it covers no-deal proposals on medicines, clinical trials and medical devices. That live consultation closes at quarter to midnight on 1 November, so it would not be appropriate for me to pre-empt what it will say, but I am not concerned that the MHRA will raid NHS funds. Of course there are concerns—and we share them—about the change in relationship, but the UK has made clear that it seeks a new relationship, one of associate membership and creative partnership, with the EMA, as part of the future economic partnership.

[Dr Whitford]

I thank the Minister for giving way. I am sure that he is well aware that no “associate membership” of the EMA exists. It is one of the agencies that simply does not have any opportunity for associate membership, so expecting it to set up an entirely new structure for a member that is leaving seems over-hopeful. The Minister is still talking about no new activities and no rise in fees. It is still hard to understand, particularly if the consultation is still open, how he is able to give that guarantee and yet tell us how the MHRA will have funding to go forward.

[Steve Brine]

I am not giving the hon. Lady that guarantee. I am saying that it is a live consultation and it would not be appropriate for me to pre-empt it. I do not share the hon. Lady’s half-full view of our ambition for the future, which the Prime Minister set out in terms of our relationship with the EMA. The EU does not have a relationship with the UK as a third country at the moment. That is why we have set out an ambitious proposal for our new relationship with the EU and its agencies, including the EMA. I am hopeful, as are the Prime Minister and the Government whom I speak on behalf of, that we will secure a good deal. We still think that that is the most likely outcome. That includes a new relationship with the EMA. We should remember that the expertise that we have in this country, and the work we do with the EMA, will not suddenly change because it is based in Amsterdam. It will still need that expertise and that relationship. I am ambitious about the future, which is why I say what I say.

The matter before the Committee today is technical, to make changes to enable the agency to function after exit day.

Dangerous Waste and Body Parts Disposal: NHS

Philippa Whitford Excerpts

Tuesday 9th October 2018 Commons Chamber

[Stephen Barclay]

The Chair of the Health Committee raises an important point regarding residents in the areas where the sites are located, and I see the right hon. Member for Normanton, Pontefract and Castleford (Yvette Cooper) in her place. The Environment Agency has confirmed that the waste is being stored safely; it is the amount of waste that is the issue. Many of our constituents are waiting for operations on these sites and will want reassurance that those operations can continue in a timely fashion. That has been a key focus of the Department, and I pay tribute to the work of officials in the NHS, the Department of Health, DEFRA and the Environment Agency, who have ensured that that strategic objective has been maintained.

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

This situation does indeed sound graphic and horrific. Equally, I recognise that much of this waste will be cytotoxic, including drugs and syringes. We are talking about materials that are contaminated with faeces, infectious material and blood. We are discussing five sites across England. HES also has two sites in Scotland, both of which have been checked and do not have overstorage.

We hear that HES was served with 13 warning notices and two compliance notices over the past year. If that information was not accelerated up to the Department of Health, should it have been? HES says that it has been reporting its issue with incineration to regulators for quite a long time, yet the Minister says that there is no issue of capacity, so could not the Department have responded by directing HES to all this extra incineration capacity that apparently exists? As more local authorities are going towards zero-waste and incinerating material that would have been in landfill, the pressure will increase. There is probably ageing infrastructure and a need to expand, so do the Government plan a waste incineration strategy?

Integrated Care

Philippa Whitford Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Wollaston]

Coming back to why integrated care does not happen, there are many deeply ingrained structural divides. Since the inception of the NHS 70 years ago, we have had a system that is free at the point of use for the NHS, but means-tested for social care. That presents an extraordinary hurdle when systems are trying to join up. It is not just that; it is different contractual arrangements and working practices. Good integration comes down to individuals and teams being prepared to work together, but it often feels like they are working together to achieve integration despite the systems around them, not because of them.

We need a system where everybody is focused on helping the right kind of integration to take place, and we need to go back and look at that fundamental structural divide between the systems. I ask the Minister to look again at the joint report, “Long-term funding of adult social care”, because that is an important issue that goes to the heart of the barriers to joining up services. It is about contractual differences, different legal accountabilities and payment systems that work against the pooling of budgets, and financial pressures within the NHS.

A certain amount of financial pressure can encourage systems to come together to pool their arrangements and provide a more efficient service, but as the Minister will know, when the elastic is stretched too tight and the financial strain becomes critical, we see the opposite—systems are forced apart. I have seen that happen in my area, where people suddenly feel that they have to retreat to their organisational silos to fulfil their legal obligations. There is no doubt that, for the process to work effectively, we need the right amount of funding—and sufficient funding—and tweaks to the legislative arrangements to allow people to come together, so it does not feel as if they are working together despite the system.

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

I am grateful to the Chair of the Committee for giving way. Does she agree that when there is an attempt to elicit change through turning off the financial tap, what happens in fact is that people cut what they think is easiest to cut, which is often the most innovative solution, rather than step back with a clear head to consider where they want to get to in the end? Does she also agree that we often find that the result of that kind of cost-cutting is a backward step rather than a forward one?

[Dr Wollaston]

I thank the hon. Member for that intervention and for her own service to the Committee previously—she is very much missed. Her remarks are typical of the constructive input that she has always made to the health debate in emphasising the need to take the long view. Financial pressures so often force us into short-term solutions, not only in the way she set out but through the salami-slicing of services.

One of the points that our Committee feels strongly about and that I was going to make to the Minister is the need to ring-fence transformation funding, because it is so easy for that funding to get lost. I welcome the uplift in funding—a 3.4% increase will be very helpful—alongside a 10-year plan. However, we have to be realistic about what that uplift can achieve, because there are very many demands on that budget, as the Minister will know and as we have seen in the past. We saw it with the sustainability and transformation fund, which tended to get sucked into sustainability and not into transformation. That has been the pattern of recent decades. There is good intention to ring-fence money for transformation, but that money disappears because of other priorities around deficits and, as I have said, the many other calls on the funds available.

That is why we feel that, in order to prevent the continuation of that cycle of past mistakes, it is important that the pattern is recognised and that funding is earmarked for transformation—not only for capital projects but for things such as double-running.

I will give an example from my area. There will be a complete destruction of public trust in new models of care if money is not set aside for double-running. The community was prepared to accept that there would be a new facility—nobody wanted the closure of the local community hospital in Dartmouth, but there was an assurance that there would be a new facility. Unfortunately, despite many of us opposing the closure of the old facility, what happened was that it was closed and then there was a breakdown in the arrangements for the new facility. The community was left with nothing and there has been a huge destruction of public trust in the process, which unfortunately will have ripple effects across other communities. Had we received the money to keep the existing service while the new service was built and got up and running, it would have left us in an entirely different situation. I am afraid that we see that too often across health and social care. There is good intention, but without double-running, which is part of having a ring-fenced transformation fund, I am afraid that the system has broken down too often in the past. I would like the Minister to focus on that when he makes his remarks.

The Committee is also looking forward to the 10-year plan—we look forward to working alongside both NHS England and the Department of Health and Social Care to examine how that plan emerges—but is important to draw attention to legislative changes. Our Committee made a recommendation that legislative proposals should come from the service itself rather top-down from the Department, which would immediately run into difficulties. However, as a Committee we also offered to subject such proposals from the service to pre-legislative scrutiny.

As the hon. Member for Kingston upon Hull North (Diana Johnson) pointed out in her intervention, we need to build cross-party consensus at every point. As it has not been covered in the formal response to the Committee’s report, will the Minister say in his closing marks whether the Government would support the Committee conducting pre-legislative scrutiny?

I am pleased to have had a conversation with Simon Stevens, the chief executive of NHS England, who has confirmed that, as it emerges, the NHS assembly will consider that within its remit—NHS England hopes to produce proposals in draft form before Easter 2019. Nevertheless, as I have said, it would be helpful to receive the Minister’s assurance that proposals will come to our Committee for pre-legislative scrutiny as part of the process of building consensus.

--- Later in debate ---

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

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I thank the hon. Member for Totnes (Dr Wollaston) for securing this debate and for her outstanding leadership of the Health and Social Care Committee. As a GP and a public health doctor, I have a lot of experience of care that has not been adequately integrated. Too many times, I have seen patients repeat their story again and again to different health and care professionals. Too many times, I have seen doctors, nurses, managers and secretaries waste time searching for information that has not been passed from one part of the system to another. Too many times, I have seen dedicated community nurses, social workers, GPs and therapists all providing care that either overlaps with or contradicts care provided by other health workers.

Integrated care, as the Committee has acknowledged, is a very laudable aim, and the Government have some credible plans on delivering more integrated care. I will use my speech to focus on where those plans need to be strengthened. I will talk about resource, about what success should look like, a little bit about legislation and governance, about keeping the NHS as a public sector organisation, and about leadership.

First, integrated care needs to be properly resourced. The new care models pilots have had significant resource to facilitate change, as the hon. Lady indicated, and that may be a key factor in any reported success. Greater Manchester has also had significant investment of extra funding. Can the Minster assure us that, as other areas move towards integration, we will not see what usually happens: the pilots get extra resources and then the roll-out fails because of a lack of extra resource?

[Dr Whitford]

I am glad that the hon. Gentleman has highlighted that problem, which we have been seeing for literally decades. Early adopters are well resourced and well supported and have the ear of the health board or the Government, but during roll-out, all the people who did not have that experience are told to do it out of existing budgets, and it fails.

[Dr Williams]

I thank the hon. Lady for emphasising that point.

My second point is on what the broader health goals of an integrated system should be. The NHS is focused on reducing unplanned hospital admissions. Although that is important—it is especially important because of the financial costs to the service of unplanned hospital admissions—I want to see integrated care providers trying to achieve broader health goals. Success should not be measured by a reduction in secondary care activity alone, although I agree that in many cases the use of unplanned secondary care is a failure of prevention. ICPs will provide healthcare for a population of people. They need to take a population needs-based approach to healthcare, and they need to be prepared to invest outside the traditional medical model of care, including investing in the voluntary and community sector. We know that loneliness, social isolation and bereavement can have a huge impact on health, and we need integrated care not to be integrated medical care, but integrated holistic healthcare. I consider that integrated care providers will have succeeded if resources are focused on improving the health of the members of our population who have the greatest health needs.

Health needs are often not expressed. The inverse care law tells us that those with the greatest needs often have the least access to healthcare. A clever healthcare system does not just react to the people who turn up; it works with communities to identify and address needs within communities. For example, many people with mental health problems simply do not access healthcare, and it is not only their mental health that suffers as a result; their physical and social health suffer, too. On average, people with learning disabilities die 15 years younger than those without. They do not die because of those learning disabilities; they die because they are not accessing healthcare, both preventive and curative. We know about the health issues suffered by people living in poverty and other vulnerable people, including those with substance misuse problems, homeless people, veterans and vulnerable migrants.

Overall, I will consider integrated care to be a success if the share of healthcare expenditure that goes to preventive care, community care and mental health care increases year on year. Also, prevention must be prioritised, and I am pleased it is one of the three named priorities of the new Secretary of State for Health and Social Care. We need prevention at all its levels: better early detection, better immunisation and screening coverage, better prevention of falls, and better prevention of mental health problems, including investment in prevention right at the beginning of life—the first 1,000 days—where it has the greatest impact.

My third test for success is that performance, quality and safety are all maintained within a system that is taking out competition. There is a genuine risk that taking away some of those internal market forces might take away some of the incentives to keep waiting lists and waiting times down and to improve quality. As we integrate care, we need to ensure that we maintain those things.

--- Later in debate ---

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

I, too, welcome the opening speech of the hon. Member for Totnes (Dr Wollaston), who is a superb Chair of the Committee. The marketisation in NHS England goes back more than 30 years—it has certainly been happening for most of my career. It started with terms such as “resource management”, and in 1990 the internal market—the purchaser-provider split—was introduced. In the early 2000s under Labour, private companies started to introduce independent treatment centres. The Health and Social Care Act 2012 turned it into a massive external market and created the pressure to put all possible contracts out to tender.

The problems are well known. If we base a system on competition and not on collaboration, we inevitably create fragmentation and destroy integration. That has broken up patient pathways and made the system very confusing, to the point that CCGs were looking to employ what they called primary providers, which would have been another layer of cost and health organisation, to try to join things up for patients. Thankfully that has been shelved, because there is a sense of going in a different direction, but up to now there has been a repeated sense that everything can be solved through a healthcare market. That is why, in Scotland, we have grave concerns. One of the 24 powers coming to Scotland is power over public procurement—we do not see the market as the solution to everything.

Just five years on from the actual on-the-ground changes of the Health and Social Care Act, NHS England is facing another big reorganisation. As other Members said, unfortunately the rushed sustainability and transformation plans and the lack of consultation with both the public and staff has created anxiety and fear. As is now recognised, the term “accountable care organisations”, which was copied from the American system, was a PR mistake of the highest order.

In 1999 in Scotland—after devolution—we simply went in a different direction. We merged trusts and then abolished them in 2004. We got rid of primary care trusts in about 2009. We already had an area-based health service for the entire population—not just for people registered with their GP—based on per-capita funding. That meant that we could start to look at how to integrate acute hospitals with community hospitals and even local village hospitals for step up and step down—not everyone who is unwell and cannot be at home needs to be in some big, shiny 10-storey block, and might just need a bit of extra care for a few days, so there is an argument for community hospitals.

In 2014, we started looking at integrating health and social care. Because of the fragmentation in NHS England, it will be necessary to integrate health first, and then integrate social care. Integrating social care is much more challenging because it is made up of different players in the market and is done in a different way. As the hon. Member for Totnes pointed out, the overarching difference between free healthcare and means-tested social care creates major challenges.

[Andrew Selous]

The hon. Lady used the term “village hospital”, as well as the term “community hospital”. “Village hospital” is a new one to me. Could she elaborate on what it means?

[Dr Whitford]

It is not a particularly formal term. I simply mean that there has been a tendency to think that, because community hospitals cannot provide the full range of acute healthcare, they have no place, whereas someone might require only a low-level of in-patient care, such as an elderly person who has a urine infection and lives on their own may need intravenous antibiotics, fluids or extra care. Such hospitals allow us to have much more healthcare—things such as minor injury units—close to the public. The more we take forward to people, the less worried they will be about the fact that we are coalescing specialist services. If they see services coming towards them, they will not have the sense that everything is being taken away. We have utterly failed to impress on the public that healthcare is not about buildings, but very much about people and services. That is what integrated care should be about.

[Diana Johnson]

I am very interested in what the hon. Lady is saying about Scotland. Does she know that areas of England have integrated financial plans involving local government and health to try to bring together that continuity and put patients at the centre?

[Dr Whitford]

That is exactly what we have in Scotland—it was introduced in legislation in 2014, and all areas were up and running by the beginning of 2016. More than 60% of the budget goes to what are called integrated joint boards, which use innovative solutions to deal with all sorts of local groups to try to prevent people who do not need to be in hospital from ending up there, and to try to allow people to come out of hospital when they are ready. It has led approximately to a 9% per year decrease in things such as delayed discharges. Those two measures—acute admissions that could have been avoided and delayed discharges that lead to people being stuck in hospital—are very much looked at. In my early career, if someone was in a bed and ready to go home, they would be told, “Well, it’s your problem. We don’t have room.” There was always friction between secondary and primary care, and between health and social care. That is where we are, but it is not easy—it is not even as easy as integrating within health.

There is no escape from legislation. Some legislative change is critical for NHS England to be able to take the barriers out of the way. At the moment, as the hon. Lady mentioned, people are trying to work around those barriers, but when things change in an informally integrated care system, the acute hospital is put into financial difficulties. It is being asked not to admit people, but the existing tariff system rewards the hospital only when it admits people, so when it starts to get into difficulties, we are asking it informally to sacrifice its budget line for the greater good. I am sorry, but tariffs need to be reformed. It is a bizarre system if the aim is not to admit. Hospitals make money on the people who almost do not need to be there and lose money on the sickest, who do need to be there.

[Diana Johnson]

Again, that is very interesting. A good model of that, which is already happening in England, is in my own backyard: Hull. The hospitals have agreed that they will take a sum of money and will not look for additional money from the CCG if they need to treat more people. That is an integration of social care—the local council—and the acute sector, which is important in making this work. It can be done without legislative change, but overall I agree that change is vital.

[Dr Whitford]

That is fine in one place with good leadership and good relationships, but if things got tight it would be very difficult for one chief executive to accept the failure of their budget in order to keep the whole system going. Legislative change is crucial, towards more per-capita funding and away from tariffs, and towards more area organisation of that integrated care partnership.

Reform of section 75 of the Health and Social Care Act 2012 is crucial, because it pressures CCGs to put out to tender all possible contracts. In Surrey, six CCGs were sued by Virgin not for breaking a contract but for not renewing one. We estimate—actual figures are hidden behind commercial confidentiality—that more than £2 million ended up away from the frontline, instead going into Virgin’s pockets, which is not helpful.

In fact, the administration of the bidding and tendering market is estimated to cost between £5 billion and £10 billion, which contributed to the debt that NHS England got itself into by 2015, a mere two years after the changes in the Act came into effect in 2013. Before that, by looking down the back of the sofa and scraping around, and with a little bit of moving money around, the NHS in England usually managed to get to the end of the year in balance.

Moreover, that debt has led to rationing. The problems are not hypothetical ones on a piece of paper. They result in older citizens—we will be having a lot more of them—being held back from hip or knee replacements, cataract surgery and other things that allow them to see or walk, get out and meet friends and keep active, which is crucial.

Finally, it is critical for the accountable care organisations or whatever they are called now to be statutory. The model contract published last August would still allow a private company to bid for and run an entire integrated area. The report states that that is unlikely, but it should be simply ruled out in order to get rid of a huge amount of concern about a threat that might lie around the corner or down the line. Without that statutory basis, a company could hide from freedom of information requests and use its commercial sensitivities even though it is being handed billions of pounds of public money and getting to decide what is delivered to the population in its area. I am sorry, but that cannot be a private company and has to be a statutory body.

There are challenges ahead and we all face similar ones—increased demand, workforce and tight budgets—but we have talked about that before. At the moment, however, the structure for NHS England is hampering the staff on the frontline who are trying to look after people. The challenge of merging a free system with a means-tested system will not go away; it will have to be addressed. In Scotland, we have a slight advantage because we have free personal care, which takes away one of the problems, because it allows us to keep more people at home—in their own home, where they want to be—rather than in hospital.

Even though it is only five years since the last big reorganisation, NHS England is at another major crossroads, so there will be a lot of upheaval. It is important to get that right and to do it in a measured way in the House. Legislation should allow innovation in different parts of the country but get rid of the barriers. We should be radical and, as Members have said, to put the patient or the person right in the middle of the design. That involves more than just the delivery of treatment. Health is not given by the NHS—the NHS catches us when we fall and ought to be called the national illness service, but we would have even worse workforce challenges if we called it that. I echo the call for health in all policies, within the integrated systems and in the House, so that we are actually investing in the health of our population.

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[Stephen Barclay]

The Chair of the Committee is absolutely right. We have always been clear that integration is about improving patient care, and that the NHS will remain free at the point of delivery.

A number of key points arose from the debate. Remarks were made about ensuring that the service is patient-centred, and concerns were expressed about whether transformation funding may be diluted. I will come to pre-legislative scrutiny, to which the Chair of the Committee referred, and primary legislation.

The hon. Member for Central Ayrshire (Dr Whitford) raised concerns about private firms and the role of GP-led organisations. The hon. Member for Stockton South (Dr Williams) and my hon. Friend the Member for South West Bedfordshire (Andrew Selous) referred to focusing on prevention and taking a wider needs-based approach. A number of Members referred to information sharing, leadership and the lessons from Liverpool Community Health NHS Trust—the hon. Member for West Lancashire (Rosie Cooper) performed a great service by highlighting that. That is reflected in the work I have commissioned from Tom Kark on the fit-and-proper test.

[Ms Karen Buck in the Chair]

Members focused on the need for a patient-centred approach, which the hon. Member for Kingston upon Hull North (Diana Johnson) emphasised in her intervention. In our approach to integrated care, we seek to build a healthcare solution around what is best for the patient and, in the words of the Chair of the Committee, why it matters to patients. That is very much the Government’s intention.

As the Committee Chair said, financial pressure can both incentivise and impede integration. She will be aware that the up to £20 billion a year that will go into the NHS as part of the Prime Minister’s commitment to funding the service will be front-loaded—there is more in the first two years in recognition of the importance of the double-running to which the Chair of the Committee referred. According to past National Audit Office reports, there have been a number of cross-party initiatives under successive Governments. As she and other Committee members set out, sustainability trumps transformation, which is one of the key challenges for the NHS family as it brings forward its 10-year plan. For the first two years, an extra £4.1 billion will go in, with front-loading of 3.6% compared with the average over the five years of 3.4%, which very much reflects the concerns she articulated.

The tone of the debate was one of broad consensus, and we will realise that first by asking the NHS itself to lead on the legislative changes required. The NHS will bring forward its proposals through the 10-year plan. We will not mandate, but let local areas decide what fits their locality best. That will be informed, for example, by health and wellbeing boards. I met the chair of the Lancashire health and wellbeing board yesterday—that speaks to the concern raised about the need for Health Ministers to take a wider approach rather than, as the hon. Member for Stockton South said, looking purely at the NHS element. We are looking much more widely and bringing in local authorities. Indeed, the Department’s name has changed, and the work of the Care Minister reflects the wider integration in our approach.

Although we welcome the Committee’s work on testing the NHS proposals as part of the long-term plan, we will wait for the NHS proposals before confirming the specific pre-legislative scrutiny arrangements. I hope the approach I have taken in discussions with members of the Committee underscores the importance I place on working in a cross-party way. The approach we have set out very much reflects that.

[Dr Whitford]

Can the Minister commit to looking at legislative change? It is fine for designs to come from the NHS, but if those designs are based on existing barriers, they will not reach their full potential.

[Stephen Barclay]

The Prime Minister has set out that it will be for the NHS itself to come forward, rather than for the Government to specify legislative change in a top-down way. As part of the long-term plan, the NHS will determine what can be done within the existing framework and whether change is needed. That will flow from the work that comes forward later in the autumn from Simon Stevens, Ian Dalton and others in the NHS, who are best placed to lead.

--- Later in debate ---

[Stephen Barclay]

Indeed I will, Ms Buck.

I draw the hon. Gentleman’s attention to the Committee report, which states:

“There is also little appetite from within the private sector itself to be the sole provider of…contracts…There are several reasons why the prospect of a private provider holding an ACO contract is unlikely…Integrated care partnerships between NHS bodies looking to use the contract to form a large integrated care provider would have an advantage over non-statutory providers that are less likely to have experience of managing the same scope of services”.

The hon. Gentleman himself referred to the desire not to rule out GP-led organisations, which are independent. He also mentioned GP-led organisations becoming NHS bodies. I am happy to meet him to explore exactly what he means. It is not the Government’s intention for private firms to run ICP contracts.

[Dr Whitford]

The Minister says that that is unlikely and that private firms do not want to run such contracts, but we are talking about a 10-year plan. Does he therefore recognise that it should be ruled out to give surety? We do not want another Hinchingbrooke, where a private company takes a contract on and an entire area faces a private provider walking away from an integrated care partnership.

[Stephen Barclay]

These arguments were explored at the Committee, which addressed that question. The fear of privatisation has been overplayed.

We are taking a people-centred approach and letting the NHS lead on shaping it. We have said we will respond to the points the NHS raises and act on them, but integration will enable services holistically to deliver better care for patients—as the hon. Member for Strangford (Jim Shannon) said, that includes better data sharing—and put the needs of patients front and centre. That is reflected in the report and in the cross-party consensus on how we want to take integration forward.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 24th July 2018 Commons Chamber

[Stephen Barclay]

My hon. Friend is right to draw the House’s attention to the fact that there are a number of benefits from leaving the EU, not just in terms of the dividend to which he refers, but in terms of flexibility, for example in—[Interruption.] Labour Members do not seem to want to hear about the opportunities: opportunities on life sciences for example, in terms of getting medicines through in shorter timescales; opportunities on immigration; opportunities on professional qualifications; opportunities even on food labelling. It is important that we take those opportunities, as my hon. Friend says.

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

I too welcome the Secretary of State to his place. Membership of the European Medicines Agency has enabled early access to new drugs for UK patients through a single Europe-wide licensing system for a population of 500 million. Can the Minister clarify whether it is still the Government’s intention to remain a member of the EMA, and perhaps explain why on earth they voted against the EMA amendment last Tuesday?

[Stephen Barclay]

As the hon. Lady will be aware, we accepted the amendment, and it is our intention to work as closely as possible on that as part of taking that forward—[Interruption.] To correct the—[Interruption.]

[Stephen Barclay]

This is a near instantaneous correction, Mr Speaker, to recognise that what I should have clarified is that, following the vote in the House, it is our intention to work as closely as possible with that, and we recognise the point the hon. Lady makes.

[Dr Whitford]

It is still rather hard to understand why the Government voted against it in the first place. There is no current associate membership of the EMA for the UK to re-join as a third country, so if it is not possible to stay in the EMA what is the plan to avoid delays of up to a year in the licensing of new drugs for UK patients?

[Stephen Barclay]

There are a number of things that can be taken advantage of. We can use the flexibilities we have in terms of assessments with shorter timescales so that we can prioritise UK drugs that are bespoke to the UK market. There will be opportunities as part of this, as well as our working closely with European colleagues.

NHS Whistleblowers

Philippa Whitford Excerpts

Wednesday 18th July 2018 Westminster Hall

[Geraint Davies (in the Chair)]

I call Dr Philippa Whitford to move the motion. I know it is a bit early, but we are all here.

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

I beg to move,

That this House has considered NHS whistleblowers and the Public Interest Disclosure Act 1998.

It is an honour to serve under your chairmanship, Mr Davies. Gosport, Morecambe Bay, Mid Staffordshire and Bristol Royal Infirmary are NHS scandals that all have quite a few things in common: they went on for a long time and often whistleblowers who might have brought the issue to an end and saved lives were punished or ignored. They were certainly intimidated. The anaesthetist who raised the issue of baby cardiac surgery at Bristol Royal Infirmary ended up in Australia.

The term “whistleblower” suggests a pressure cooker—a build-up of pressure to the point where someone cannot resist it any longer and feels the need to come forward. We are trying to decompress some of that impression by having audit of patient safety through such systems as Datix, where staff get used to reporting every little aspect that does not go smoothly, which therefore creates the habit of coming forward. We still have issues. They often relate to the whole system, the trust or perhaps the behaviour of certain medical or clinical staff. There is no easy way to come forward, and the people seeing that behaviour take a long time to be listened to or to step up.

In the investigation into Mid Staffordshire, which was the worst NHS scandal, Sir Robert Francis’s report spoke about developing a “freedom to speak up” culture, to make doing so normal. Sir Robert suggested only minor changes to the Public Interest Disclosure Act 1998 but, as I will come on to later, I think it needs major change because it underwrites everything else.

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

I congratulate the hon. Lady on securing this timely debate. I had two cases in Coventry, going back 10 or 15 years, in which consultants were suspended for whistleblowing. On the one hand, the Government encourage whistleblowers, but on the other the national health service seems to have a different definition of whistleblowers. One of those cases ended up in court. I do not know the exact figure, but it cost between £3 million and £4 million, and went on for at least 10 years. Meanwhile, back at the ranch, the individual was losing their skills. What does she think about that?

[Dr Whitford]

Obviously, I am unaware of the individual case and the rights and wrongs of it. However, a review of the cost of whistleblowing as it stands shows that having an effective system and effective law would save us money overall.

Sir Robert Francis envisaged “freedom to speak up” guardians in each trust, to whom whistleblowers could go informally to seek advice and support. Such guardians are in all trusts across England. They include a wide range of people, and the appointment system is not altogether clear or transparent. We will have to look at what kinds of staff work best, whether appointments have been appropriate, and whether whistleblower guardians can recognise, if they are clinicians—which many of them are—that there might be a conflict of interest, because the issue might be in their department. The national guardian has been in place since 2016, but her position is non-statutory and sits inside the Care Quality Commission. Her role is described on the website as “leading cultural change” rather than deciding individual cases.

Through all the publicity, there has been quite a change in atmosphere and tone. The whole issue has had a significant airing. In Scotland, we have an alert and advice line run by Public Concern at Work. It is interesting to see the changes from the second half of 2016 to the first half of 2017. The number of concerns that the hospital, or the health board as it is in Scotland, admitted immediately were valid—instead of their having to be proved, or their being put off—went from 0% to 14%. The number of those that were ignored or denied dropped by 30%, and those reported to a manager or a senior manager went up by 30%. That suggests quite a difference in practice. The numbers are quite small, but they suggest a pattern. The data showed that, naturally, the most common group to report is nurses—they are the biggest employed group within the NHS—and the most common reason was still patient safety.

The problem is that that is all still legally underpinned by the Public Interest Disclosure Act, which was passed in 1998. It was a private Member’s Bill very similar to one that had been introduced a few months before. It therefore did not have a Second Reading, and it had only one day in Committee. At the time, it definitely was ahead of what was going on elsewhere, and was a recognition of the importance of whistleblowers, but that was 20 years ago. It really is time for change.

[Mike Hill (Hartlepool) (Lab)]

Does the hon. Lady agree that workers are still put off by responses to whistleblowing allegations and, under the legislation, the threat of disciplinary action if the complaint is perceived to be malicious?

[Dr Whitford]

I utterly agree. It is important to be clear that a disclosure in the NHS, which is what we are focusing on, regarding patient safety as opposed to employment issues, which are quite separate and dealt with differently, is in the public interest. The problem is that in cases where whistleblowers have been punished and have suffered detriment, what starts as reporting becomes a bullying and harassment issue that ends up in a normal employment tribunal setting, and the original concern is not dealt with.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Lady on bringing this matter to Westminster Hall for consideration. Some 7,000 staff raised concerns about bullying or patient safety in 2017-18. Over the same period, some 356 whistleblowers said that they had experienced repercussions, ranging from subtle persecution, such as career opportunities being closed off, to being fired unjustly. That is truly shocking. Does she agree that the Minister may have to look at a full investigation into just how far-ranging these matters are?

[Dr Whitford]

I thank the hon. Gentleman for his intervention. I hope that this is just the first little step towards putting the matter on the agenda. The tragedies at Gosport brought the whole issue back. A nurse had come forward years and years ago, and could have saved hundreds of lives had she been listened to. Not being listened to is almost the least that can happen to a whistleblower, in that often they suffer detriment or reprisals and even lose their jobs.

The one change that Sir Robert Francis suggested to PIDA that has been made in England and Scotland is redress for discrimination regarding new employment—that is, applying for a new post within the NHS. Work is under way to introduce that in Wales as well. However, the main Act remains as it was. The first key weakness of PIDA is that it does not ensure an investigation of the whistleblower’s concern. Given the risks they take when they come forward, the detriment they may face, and the months or years of tribunals or other stages, it is crucial that the concern that made them step forward is not either overshadowed or completely ignored. I think that is their biggest frustration.

The Act most certainly does not protect whistleblowers. It describes itself as protecting whistleblowers from detriment, intimidation and reprisals, but PIDA can be used only for litigation after the detriment. Once someone has lost their job they can take their employer to an employment tribunal and attempt to have redress. The problem at that point is that the whistleblower has to prove that it was their disclosure—their coming forward and speaking up—that drove the loss of their job. Of course, employers will find all sorts of other excuses, such as, “Oh, they didn’t get on with their colleagues,” or, “They were a trouble maker,” or, “They were late for work.”

The success rate of litigation under PIDA is 3%, which is appalling, and shows how utterly weak the law is. Whistleblowers suffer further detriment while going through litigation. They know that they may face being landed with the costs. They may face bankruptcy, and stress that could go on for extended periods. Furthermore, between 2013 and 2017, people had to pay for employment tribunals. That, of course, closed that avenue off to many whistleblowers.

I make the simple case that we need a new public interest disclosure law. It should not sit inside employment law. It should not be a tweak to what we have now. We should recognise that the Public Interest Disclosure Act covers all sectors. The NHS may be one of the most common sectors to have whistleblowers, but the Act covers finance, research and business. We need a specific law.

It must be utterly clear that such disclosures are in the public interest, and that is where I disagree with the hon. Member for Stirling (Stephen Kerr), who may speak later. I do not agree with paying bounties to those who would disclose. Whether or not it creates a conflict of interest, it certainly gives the impression of doing so. It is utterly important, in the defence and protection of whistleblowers, that they can show that the only reason they have come forward is to protect patients or whoever the consumer is in their service.

[Stephen Kerr (Stirling) (Con)]

Just for clarity, I am not advocating bounties. It is one of the options to be looked at, but there are reservations about it, which I know the hon. Lady shares.

--- Later in debate ---

[Dr Whitford]

I thank the hon. Gentleman, who has set up an all-party group on whistleblowing and on the Public Interest Disclosure Act 1998. I welcome that, but one of my concerns is the issue of bounties.

It is important that we have a new PIDA law and an independent, statutory body that is equal to other bodies and can take on the NHS, NHS Improvement and the CQC. It must not be a department in one of those regulators; it must be separate from the NHS to ensure real independence, and it must investigate and act on concerns. If a local investigation has failed or is failing, there should be a mechanism to report that to an independent body. If we get to the point where there is simply a slanging match within a trust, there will never be a satisfactory resolution, so arbitration needs to come in and look at the cold facts and the original facts of the disclosure. Often, what is looked at is the process, but not whether the whistleblower was actually right to raise an issue in the first place.

It is critical that whistleblowers are protected from detriment from the moment of speaking up. They should be protected during the investigation, and they must not be picked on either subtly, as the hon. Member for Strangford (Jim Shannon) said, or blatantly—they must not lose their jobs. It is important that legal penalties for reprisals against whistleblowers can actually be enforced.

There should be a system of redress for whistleblowers that does not involve litigation. Litigation is expensive for the NHS and the whistleblower, and is utterly confrontational. That means that, at the end of the process, even when a whistleblower has been proven to be right and genuine, there has often been such a breakdown in relationships that it is not possible for them to go back to their previous role.

[Mr Jim Cunningham]

I thank the hon. Lady for giving way once again. The case I outlined actually ended up in the courts, and the hospital was told to take the individual back. Well, it never took him back. There was a long, drawn-out process over a number of years, and it was eventually settled through litigation. That individual—Dr Mattu—was a well-known consultant.

Some of the older Members will remember the case, going back 10 or 15 years. We had debates and got the support of Mr Speaker. The hospital tried to use letters I sent to it, in which I raised issues that had been raised with me, in the courts, and the judge ruled it out of order. The hon. Lady is right that we need an independent body, but where it finds that the hospital is guilty, as it were, and that the whistleblower was doing their job, it should have the power to order reinstatement—that is the nub of the matter—to ensure they are not victimised.

[Dr Whitford]

I agree that there should be protection to ensure that whistleblowers are not victimised, but the problem is that if the relationships have been allowed to break down because the system is so confrontational, often even the whistleblower does not consider it possible to go back. That is a tragedy, because it often means losing someone talented, particularly at a time when we are so short of staff in all four NHS systems in the UK.

The body obviously needs to be statutory so it has enforcement powers, but it should also be responsible for developing standards and training to show hospital trusts, health boards and hospitals, regardless of the system, what good looks like. Setting up, speaking up for and reporting on a body structure for the NHS will be for all four nations, because health is devolved, but PIDA still sits above that. It needs to be the underpinning statutory law that gives the body force.

In Scotland, we are still working on our system. Obviously, the Francis report looked at the system in England. We have whistleblower champions in our health boards, but we are working on setting up the independent national whistleblowers office. The difference between that and the national guardian in England is that it will be statutory and independent of NHS Scotland. It will sit in the office of the Scottish public services ombudsman, so it is utterly outside the NHS and clearly sends a message of independence. It will be able to adjudicate in individual cases. Normally, that will be when all local processes have been exhausted, but provision is being considered to allow an earlier referral when the local system has simply broken down and the concern about patients has been lost in the conflict-driven system.

Standards are being developed for all health boards so there is a consistent approach. The standards that sit above everything else are that whistleblowers will be listened to, that their concerns will be acted on and that they will be supported. The former Secretary of State, who is now away to sunnier climes or travelling the world, used to keep saying in the Chamber that whistleblowers are central to patient safety. I have to say that I slightly disagree.

When someone is forced to blow the whistle, it is because the patient safety systems have failed. In Scotland, we have a national patient safety programme, which is the first in the world that is right across the system. People cannot pick and choose whether they do the huddle at the start of an operating list or whether they do the World Health Organisation checks before operating on somebody. It looks at the frontline to try to reduce errors, but we know that there will still be situations that are not ideal, so someone will need to come forward. That is the thing: whistleblowers are a backstop. The patient safety system, the Datix system or the auditing may need to be improved, but whistleblowers provide a backstop to prevent us from going over the cliff, to prevent more people from dying and to allow timely action.

The problem is that, although doctors have a duty of candour laid on us by the General Medical Council, we also see the landscape littered with people’s careers and jobs, as the hon. Member for Strangford said earlier. For an individual, that is really difficult. They think, “If I speak up and step forward, it may be the end of my career. I may be out of a job. I may be out of this hospital.” For patients’ sake, we need a change, we need to get it right, and we need a new public interest disclosure law. We should start work on that now.

--- Later in debate ---

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is, as always, a pleasure to serve under your chairmanship, Mr Davies.

I congratulate the hon. Member for Central Ayrshire (Dr Whitford) on securing the debate and on her powerful and knowledgeable contribution. As always, she drew on her many years of experience in the national health service. She listed a series of scandals in the NHS and raised themes common to them all. They lasted too long, and too often those who blew the whistle paid a high personal price for their actions. She raised the real risk of clinicians finding themselves with potential conflicts of interest, which requires further thought, and rightly highlighted the fact that the current legislation does not create an obligation to investigate the original complaint—it is primarily concerned with protection after the event.

In his analysis, the hon. Member for Stirling (Stephen Kerr) suggested that PIDA was intended to be a deterrent but that, given the way it has operated, it is not that at all because whistleblowers are still being punished. Both he and the hon. Lady pointed out the woeful success rates in employment tribunals, which should give us all pause for thought about whether the legislation is fit for purpose. The hon. Member for Stirling talked about how litigation can sometimes be a war of attrition and employers can be very defensive at times, and how at the bottom of all this is an individual—sometimes a highly skilled individual—whose talent has been wasted and lost because they have blown the whistle.

My hon. Friend the Member for Hartlepool (Mike Hill) spoke with great passion and no little knowledge of some of the experiences of those who have blown the whistle. He was right that some employers have not embraced the spirit of the legislation; in fact, they contrive policies to run contrary to what we are trying to achieve here. Having met many of the staff in the NHS, I know they care deeply about the work they do and they want to do the best by their patients. That is why it is so important that we provide an environment where they are able to raise their concerns about things they may be worried are going wrong, without fear of repercussion or unfavourable treatment. They must also be confident, once they have raised those concerns, that action will be taken.

However, despite some notable advances in the protections available in recent years, it remains the case that even the best run organisations, with the most comprehensive policies in place, can still feel very daunting for individuals who want or need to blow the whistle. I know from my many years working as an employment lawyer—although not one who lined his pockets in this particular area—that it is extremely difficult for an employee to raise those issues. As we have heard already, the consequences of doing that can be hugely damaging. They can face anything from being shunned by their colleagues to summary dismissal on spurious charges, and the impacts of the kinds of things they deal with can last much longer than the period of employment to which we are referring.

In that respect, it was deeply concerning to read in the Francis report about staff who were on the brink of suicide because of the treatment they had received after speaking out. One of the few criticisms on the record of the NHS is the fact that many promising careers have lain in tatters as a result of ineffective protections under this legislation, while other people have spent years languishing in the legal system, with the taxpayer racking up tens of thousands in legal fees in the process.

Of course, while protecting whistleblowers is vital across all professions, it should be pointed out that NHS staff also have a professional duty to raise concerns. The NHS England and NHS Improvement policy states:

“If in doubt, please raise it. Don’t wait for proof… It doesn’t matter if you turn out to be mistaken as long as you are genuinely troubled.”

We cannot say that enough; I just wish it was easier to see that delivered in practice.

The Minister recently brought forward regulations to provide some additional protections for the present and future employment prospects of whistleblowers, which we welcomed. I raised a number of concerns during that debate and the Minister was good enough to write to me afterwards setting out some of the responses. However, one issue that I do not think we have got to the bottom of was protections for other workers who support whistleblowers. There is a worrying gap in the existing legislation. It is easy to envisage circumstances, particularly in the health service, where two or more employees might have an issue of concern that they jointly notice, but only one of them, in law, can make that protected disclosure.

When I raised that point to the Minister, her response made clear that the only remedy available to such associated parties would be to register a grievance under their employer’s grievance policy. That is a very worrying omission from existing legislation and I ask the Minister to consider whether she will look at that again, as well as at the many points that have been raised about the deficiencies of the existing legislation.

Another lacuna in the existing law was exposed much more prominently by Dr Chris Day. On 10 January 2014, Dr Day made a protected disclosure about critically low staffing ratios during a night shift on an intensive care unit at the Queen Elizabeth hospital in Woolwich. Unfortunately, the trust and Health Education England decided not to act on his concerns and terminated his contract, based on what Dr Day believes were false allegations, thereby stalling his progress to consultant.

Sadly—like many whistleblowers, as we have heard today—rather than having his rights protected by his employer, Dr Day was instead forced to defend them via legal redress at an employment tribunal. This is because Health Education England contended that

“even if the facts alleged by Dr Day were true, HEE could not be liable in law for any acts causing him detriment.”

That was significant because, while not acting directly as the employer, HEE recruits doctors in training, supplies them to various trusts and appraises them. The result was a wholly unnecessary and extremely lengthy legal battle, whereby Health Education England, which is a body of the Minister’s Department, effectively sought to move around 54,000 doctors out of whistleblowing protection. Despite the clear principles at stake, the Government consistently refused to become involved in the case to prevent the costly and embarrassing outcome that we have now arrived at.

In September 2017, in a written parliamentary question, I asked about the cost to the NHS of defending the legal action brought by Dr Day. I was told that the total legal fees incurred by Health Education England stood at over £100,000, while Lewisham and Greenwich NHS Trust had incurred costs of £30,000. In May this year, Health Education England was ordered to pay Dr Day’s solicitors’ legal costs of £55,000 after it backed down and accepted that it should be considered an employer after all.

After four years and more than £200,000 of taxpayers’ money spent, Health Education England has accepted its responsibility and made a statement that I consider frankly astonishing:

“Having never wished to do anything other than facilitate whistleblowing for doctors in training, HEE is happy to be considered as a second employer for these purposes if it removes a potential barrier for junior doctors raising concerns.”

I ask the Minister to explain why this situation was allowed to go on for so long, when the case was refuted not on the basis of the facts, but on a technicality that flies in the face of everything we have tried to achieve today.

[Dr Whitford]

As in the case of Dr Day, the issue of poor staffing levels or rota gaps is a common incidence for people blowing the whistle because they feel it is unsafe. Scotland has just passed a safe staffing law, and I wonder whether, as with Datix and other systems, we need staffing level reporting to be seen not as whistleblowing but as something that should be done routinely. Whistleblowing would then start to become a smaller and smaller part of what staff might feel they had to do.

[Justin Madders]

That is an important point; we should see reporting issues such as staffing levels as something that would not be such a big deal. As is happening in Scotland, the safe levels should be ingrained not only into law, but into the culture of the workplace.

In conclusion, I repeat the same point that I made when the recent statutory instrument was discussed: that we now have a two-tier whistleblowing system, which provides some NHS employees with a greater level of protection than others working in the health and social care sector—social care workers, construction workers or anyone else who does not happen to work within those particular areas. Social care in particular is an issue. Public Concern at Work found that more than half of whistleblowers also reported some kind of victimisation, with 23% saying they had been dismissed after raising concerns. I ask the Minister, who is of course also responsible for social care, whether she considers that a satisfactory state of affairs.

Whistleblowers should be not just protected, but celebrated for the role that they play in defending the safety of others. Nobody making such a disclosure should do so in fear, wherever they work, nor should they face the risk of having their livelihood taken away. We owe it them to ensure that those protections are as effective as they can be.

[The Minister for Care (Caroline Dinenage)]

It is a great pleasure to serve under your chairmanship, Mr Davies.

I start by thanking the hon. Member for Central Ayrshire (Dr Whitford) for bringing forward this important debate on a vital issue and for the keen interest she has shown in patient safety across the board. I always listen carefully to what she says, not only because her contributions come from her perspective as a clinician—something that should be incredibly valued—but because, as a Member, I respect the practical, constructive and calm way she presents information to the House. It always makes an enormous difference as a Minister when information is given in that way. I also thank her for the role she has played in the pre-legislative scrutiny of the health service safety investigations Bill—another piece of legislation we are introducing to ensure that our health systems are continually learning and making a difference when things go wrong.

I also put on the record my thanks to my hon. Friend the Member for Stirling (Stephen Kerr) for setting up the all-party parliamentary group on whistleblowers. I am delighted he has taken that step. There are all-party parliamentary groups on a range of different issues, and one often wonders where they are coming from. However, I welcome his wholeheartedly, and I am keen to hear its considered recommendations. I am also delighted that the new Secretary of State for Health and Social Care has already stated his commitment to the health and social care workforce. The work of my hon. Friend’s APPG will go to the heart of that.

The Government are committed to building a culture of openness and transparency in the NHS, which is part of achieving our goal of making it the safest healthcare system in the world. We need to make sure that people who work in the NHS feel safe to speak up. We want that to become routine, and it is a key part of our commitment to ensuring patient safety and improving the quality of services. The NHS should support and welcome all staff—be they permanent employees, agency workers, volunteers or other contracted staff—raising concerns, wherever they have them.

The importance of people in healthcare speaking up has been demonstrated by many brave champions of patient safety, such as Helene Donnelly at the Mid Staffordshire NHS Foundation Trust. It is through the bravery of Helene and those like her that we can fully recognise the changes that have to happen in our health and care services. As the hon. Member for Central Ayrshire has said today and in the past, people blowing the whistle is a sign that the system has failed somewhere earlier on—that something has gone wrong and has not been put right. We want a culture in which we do not need whistleblowers like Helene because stronger preventions and better patient safety measures are in place, because people feel confident to admit when something has gone wrong, and because people feel protected and supported and are willing to raise concerns in the workplace as a norm.

Hon. Members will know that I am the Member for Gosport. I have recused myself from speaking as a Minister on the situation there so that I can continue to represent my constituents in that case, which I have been involved in for the last eight years. However, the case amply demonstrated the risks of not listening to those who raise concerns. It is clear that much of the pain and suffering experienced by families could have been avoided had those whistleblowers been listened to earlier.

Speaking up and raising concerns should be routine in the NHS. As the hon. Lady said, whistleblowing legislation has been in place for 20 years, and all hon. Members have been vocal about its limitations. I am not averse to reviewing the legislation, and I am keen to hear any proposals that the new APPG and other Members feel would be appropriate. Evidence on the legislation’s effectiveness—or ineffectiveness—would be helpful. Hon. Members know that reviewing that legislation does not fall within the gift of either myself or the Department; the Department for Business, Energy and Industrial Strategy holds the control there. However, I am more than happy to speak to Ministers in that Department about this.

We are aware that improvements to our health and care system are needed to ensure that workers feel safe to speak up about problems. Responses to our call for evidence in 2013 highlighted that whistleblowers did not feel that way, which is why we legislated in the Small Business, Enterprise and Employment Act 2015 to require prescribed persons to produce an annual report on whistleblowing disclosures made to them by workers. The regulations to implement that reporting duty are now in place, and the prescribed persons’ first annual reports, covering 2017-18, are due to be published in the next few months. That is aimed at increasing public confidence that prescribed persons take whistleblowing disclosures seriously, through greater transparency about how they handle disclosures, and particularly that they investigate and take action where necessary.

[Dr Whitford]

The Minister mentions prescribed persons. The fact that Members are also prescribed persons shows how difficult and confusing it can be for whistleblowers to know where they should go. I suggest it would be difficult and confusing for an MP to know what to do with such information and where to go. I recognise that the NHS, as one of the major generators of these cases, perhaps needs its own structure. However, if we had an independent body that covered all other sectors, everyone who wants to blow the whistle would at least know where to go, because a lot do not at the moment. As my hon. Friend the Member for North Ayrshire and Arran (Patricia Gibson) said, they may blow the whistle in the wrong way and to the wrong person, and they will suddenly not be covered by PIDA at all.

[Caroline Dinenage]

The hon. Lady makes a valid point, which we will take into consideration.

As the hon. Lady knows, the National Guardian’s Office was established in 2016, and the independent national guardian, Dr Henrietta Hughes, was appointed to support NHS whistleblowers and to improve the NHS reporting culture. The National Guardian’s Office also provides leadership, training and advice for a network of more than 750 “freedom to speak up” guardians based in all NHS trusts and foundation trusts. There have been more than 6,700 cases of speaking up in the last financial year. The National Guardian’s Office is looking to extend a network into primary care later this year.

The ability of the National Guardian’s Office to effectively engage the system is already helping it to make recommendations to trusts, arm’s length bodies, the Government and providers of services to the NHS to help drive this cultural change. Its role in the system is as an influencer of change, rather than an imposer of requirements. Organisations should rightly remain responsible for tackling their own cultural issues.

The NHS is one of the largest employers in the world and makes a large investment in its workers. We do not want to lose great people from the NHS because they face discrimination for doing the right thing. That is why we introduced protections from discrimination for people seeking NHS employment who are perceived to have previously blown the whistle. That regulation came into force in May and will support NHS Employers in being an exemplar to others in fostering a culture of openness and a willingness to report problems with care. Separately, we also extended the definition of “worker” within the whistleblowing statutory framework in the Employment Rights Act 1996 to include student nurses and student midwives, meaning that those people are now protected under the Act.

Aside from statutory protections, on 1 April 2016 NHS England and NHS Improvement published a single national integrated “speaking up” policy to provide clarity and consistency across the system. In March 2017, NHS England also launched the whistleblowing support scheme—a nationwide pilot to help workers in primary care who have spoken up. A similar pilot was launched in September 2017 by NHS Improvement for people who have made a disclosure in secondary care. The schemes offer a range of services to support people back into employment. It is too soon to say how the pilots are progressing and how effective they have been. The aim is to ensure that any future scheme is fit for purpose and meets the needs of people who require support after making a disclosure.

We have also made changes at the regulatory level of the health and care system to better protect whistleblowers. The CQC has a legal duty to report on whistleblowing disclosures, and it has revised the “well-led” domain of its inspection assessment framework to include how organisations are progressing with implementing the recommendations from “Freedom to Speak Up”. It is important to mention the link between an organisation’s CQC rating and how seriously it takes speaking up, with 100% of organisations rated as outstanding by the CQC having guardians who reported that speaking up is taken seriously in their organisation, in contrast with only 36% of trusts rated as inadequate.

NHS staff who are prepared to speak up are an important asset. We want NHS staff to feel confident that, when they speak up in the public interest, it will not have a negative impact on their career. Supporting those who speak up in the NHS is utterly crucial to achieving those aims.

[Dr Whitford]

I appreciate how consensual the debate has been, and I hope the Minister recognises the points raised. As was mentioned, NHS structures will be different in each of the four nations, but PIDA sits above that. Perhaps, in trying to work together to tackle those differences, we can also share good practice from each country that sits within the NHS. We simply cannot go on as we are, because people die, and then people lose their careers. We are running without looking. I hope that the Minister takes this forward, both with the APPG and other Members.

Question put and agreed to.

Resolved,

That this House has considered NHS whistleblowers and the Public Interest Disclosure Act 1998.

Department of Health and Social Care and Ministry of Housing, Communities and Local Government

Philippa Whitford Excerpts

Monday 2nd July 2018 Commons Chamber

[Dr Wollaston]

I absolutely agree. This is about not just funding for public health, but the policy levers. We do not need lots of talk about the “nanny state” that denigrates important national public policy drivers, because although we need funding for local services, as the hon. Lady says, this is also about the policy environment that is necessary to make important changes. Investing in public health makes a huge difference for people.

One of the problems here is that when the public are asked where they would like the priorities to fall, we often hear, understandably, about the importance of cancer outcomes, mental health and emergency waiting times. Public health is often bottom of the list because nobody necessarily knows when their life has been saved by a public health policy. The reality is that the major changes and achievements relating to life expectancy have arisen largely thanks to public health policy, but we rarely turn on the television and see a programme called “24 Hours in Public Health”, which is a shame.

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

In the air quality debate last Thursday, I touched on the need for health in all policies. From active transport to quality of housing, is that not where we need to drive public health?

[Dr Wollaston]

The hon. Lady is absolutely right. Health in all policies means using every opportunity to maximise public health. When Departments work together, such as on the childhood obesity strategy, we need maximum engagement across the whole of Government to make that effective. The way it was put to us when the Committee visited Amsterdam was that it should be viewed as a sandbag wall, and if any part of it is missing, we are not going to achieve what we want. That applies to all of public health.

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[Nigel Huddleston (Mid Worcestershire) (Con)]

It is a pleasure to follow the hon. Member for Bristol South (Karin Smyth). In fact, all the speakers so far this evening command the respect of both sides of the Chamber for obvious reasons given what they have said. I, too, agree with a large amount of what has been said. It is also a pleasure to speak in this very week of the 70th anniversary of the NHS.

We are talking this evening—it is in the Order Paper—about NHS expenditure summing to greater than £120 billion. That is a staggering sum and it just shows how important the NHS is not only to the Treasury and the Government, but, perhaps most importantly, to the public. Certainly, this is the top topic of interaction for my constituents. It is very, very important to them. The NHS is right up there with the royal family and the armed forces in making the Brits proud to be British, and for understandable reasons. I therefore very much welcome the £20.5 billion increase in real terms spending on the NHS. It is not only obviously needed because the population is ageing and the cost of healthcare is growing, but also desired by the British public. Some 86% of the British public say that they feel the NHS needs more spending. They are also willing to pay for it. It is very important that we listen to the public very carefully when they say that they need more spending on the NHS and that they are willing to pay for it. We will come in a moment to how they should pay for it. The British public are not stupid. They are fully and well aware that Government expenditure all comes from taxation, either now, immediately, or in the future in terms of debt. That is important, as they recognise that we cannot magic money out of thin air. We must also be very responsible and careful as politicians that we respect the fact that, whenever we decide that we wish to increase Government expenditure, what we are effectively doing is reaching into the pockets of hard-working people in this country and saying, “We’ll take some of that out, thank you very much.” We have to be really respectful of that and explain why we are doing it and what we are doing it for. The laziest thing to do in politics is pretend that other people are going to pay for all this and to promise the world to everybody. It is a dangerous route to go down and the British public will eventually see through that approach.

If we are going to be straight with the British public, how will we achieve this increased expenditure? I am sceptical, but not as sceptical as my hon. Friend the Member for Totnes (Dr Wollaston), about the Brexit dividend. I do, however, like to talk about a deficit dividend; as we reduce the massive amounts of interest that we are paying over time, there will be a benefit to the UK population. We have to be honest about where the money could come from, and hon. Members have mentioned other ideas about how it could be generated, including by looking at council tax, tax-free allowances and the pension age.

We do need to look at the pension age very carefully again. We have already increased the pension age to 67 and 68, but as the population ages and we all live longer, it is not unreasonable to expect us all to work longer. As we work longer, we generate more taxes during our lifetime, and that is pretty important. We have to consider whether it is reasonable that we should all be living 15 or more years after we have retired without paying more tax.

[Dr Whitford]

Is the hon. Gentleman aware that the increase in life expectancy is actually stalling and not continuing to soar? Unfortunately, it is another inequality between richer areas and poorer areas, and the danger is that people in deprived areas will get no retirement at all.

[Nigel Huddleston]

The hon. Lady makes a perfectly valid point. The differentials in life expectancy concern me greatly, but we have come such a long way. Pensions were first introduced in 1908 for people aged 70, when the average life expectancy was 48 for men and 52 for women. Life expectancy increased slowly as the century went on, but I believe that it is now—quite staggeringly—78 for men and 82 for women. This is well beyond the average age at which we retire, so we have to look at the situation carefully.

Rather than directly tax people more, I would like to see economic growth, which was mentioned earlier. Every 1% increase in economic growth adds £7 billion to the economy, whereas every 1p increase in income tax raises just £5 billion. We have to look at having a good mix. The more that we can grow the economy the better. Owing to the growth in the economy, HMRC receipts actually increased from £414 billion in 2010-11 to £594 billion last year, so the more that we can do for economic growth, the better for us all.

Alternatively, we could shift Government expenditure from one Department to another, but that is very difficult to do in the age of austerity and perceived austerity. As a Conservative, I believe in Government spending that is as small as it can be, but as large as it needs to be. The message that I heard from my constituents at the last election is that they believe that it probably needs to be just that little bit bigger, particularly for health, social care and education.

The British public are now respecting and accepting the fact that Conservatives are very careful with their money and are respectful of taking tax and money out of their pockets. They know that we are not going to spend money willy-nilly. More than 60% of the British population—across all demographics, including party political persuasions, age groups and income groups—support a taxation increase to spend more money on the NHS, and we need to listen to that.

But we need to move the conversation away from being all about inputs. Everyone in this House needs to commit to avoiding this kind of arms war, whereby there is always a debate and a fight about who can spend most. Instead, we need to put much more focus on the outputs, such as improving diagnoses, treatments, survival rates and other matters in the NHS. That is part of the debate. I was glad that the Health Secretary focused on that while introducing the additional spending. It is an important factor to consider; productivity very much needs to be part of the deal.

We need to continue focusing on an NHS that is free at the point of need, but we need to be clear with people that it is not free. The NHS never has been free and never will be free. It comes at a cost and we all have to pay for it. We need to ensure that we keep focusing on cost, look at other areas of savings and educate the public that there is a cost when they miss an appointment, when an ambulance goes out unnecessarily and when people go to A&E but do not really need to do so. We should all play our part in ensuring that NHS money is spent as wisely and carefully as possible.

There is still a lot of work to do on social care and public health, as my hon. Friend the Member for Totnes said. We should try to put together a cross-party royal commission, as other have said, and investigate moving the NHS out of party politics as much as possible, but that is a debate for another day.

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

As many Members have mentioned, we are approaching the 70th birthday of both the NHS and the social care system. I was shocked to work out that I graduated in the first half of that period, when the NHS was a youngster of only 34. That was a bit depressing; how did I get so old?

Most patients in all four UK health systems will have a very good experience, because they interact with dedicated and caring staff. But all four systems face three big challenges that we have talked about before: tight finances, workforce shortages and increasing demand. As others do, I welcome the £20 billion extra funding that will be there by 2023. Over the next five years, that equates to a 3.4% uplift each year. That is double the 1.2% that the NHS has been experiencing over the past eight years, but it is below the 3.7% that has been the average since 1948. So it is welcome, but to call it a windfall can make people complacent that the challenges within the NHS and social care have simply gone away.

I agree with the hon. Member for Totnes (Dr Wollaston) that it is very disappointing that this is again only NHS resources, with no money for public health, for training or for capital or maintenance and, most importantly, no funding for social care. Trying to fund a health system without supporting social care is like trying to fill a bath with the plug out.

The other question is of course: where is the money coming from? I am afraid that I am also in agreement with the hon. Lady that I do not see much chance of a Brexit dividend; I know that I am Irish, but I do not really believe that there is a pot of gold at the end of the rainbow.

The Secretary of State for Health and the Secretary of State for Scotland have both mentioned that Scotland will get a £2 billion windfall through the Barnett consequential, and that would of course be hugely welcome, but in fact no detail has been sent back in response to the letter from our Finance Minister, and we will simply have to wait for the autumn statement, because the Barnett consequentials are not always as they appear. When NHS England got £337 million to prepare for winter pressures, naturally NHS Scotland was hoping for £32 million; in fact, by the time all the other cuts were applied to it, £8.4 million made it over the border.

The Scottish Government have increased health funding by 45% since coming to power in 2007, and despite an 8% cut in the Scottish budget since 2010, we still invest £163 a head more than is invested in people in England. We focus on things like quality improvement, and we have the first national patient safety programme. That has reduced costs, and it has a massively reduced mortality. It also helps to avoid litigation, which is at a much lower level in NHS Scotland than here in England.

The next issue is the workforce. There is no extra funding for Health Education England, although it is expected to educate 1,500 more medical students and train 5,000 more GPs. Despite 36,000 nursing vacancies, the nursing bursary has been removed, and this House voted to remove the postgraduate nursing bursary just last month, so it is difficult to see how we will tackle those challenges. Even before Brexit, we are losing EU staff. In the NHS in England, 19% of its EU doctors are in the process of leaving. Unfortunately, Scotland is also seeing 14% of its EU doctors going. We have registered a drop of 90% in the number of EU nurses willing to come to work in the UK system, and we have had the issue involving more than 2,000 non-EU doctors being turned away and refused tier 2 visas in the first five months of this year. I welcome the fact that that situation has now changed, but this is about the message that that sent out. It is about the need to have an immigration policy that will deliver the people we require. Social care workers will be a particular issue, because they will not qualify for tier 2 visas. They will not be classed as highly skilled enough, and they will not earn enough.

A further challenge is increased demand. Public health has received no extra money, and it has already faced cuts. That has resulted in cuts to services such as smoking cessation and tackling addiction, inactivity and obesity. I called earlier for health in all policies, and tackling issues such as poverty and adverse childhood experiences is really important. They drive a huge amount of mental and physical ill health. We often blame increased demand on the ageing population, but I would point out, having graduated in 1982, that I worked in Victorian hospitals, on Nightingale wards, and I remember the first CT and MRI scans. Since then, we have modernised not all but many of our hospitals and increased the availability of technology and expensive new treatments. We are now entering the age of gene therapies, which will be incredibly expensive. The chief medical officer in Scotland has formulated a policy called realistic medicine. It advises that, as doctors, we should not presume that every patient always wants the latest brand new treatment or to be put through an operation. We should not presume; we should just ask them what is important to them.

One of the things that is important for everyone is keeping their independence. I do not just believe in independence for Scotland; I believe in independence for older citizens. That involves not rationing hip, knee and eye operations, as is still happening here in England, but investing in them. If we delay people’s hip or, particularly, knee replacements, their muscles waste, the end result is poorer, and they will have become more dependent in the meantime. Rationing cataract operations, as is happening in two thirds of units in England, increases the risk of falls. That will simply cost more in the long term. We are trying to get people operated on at an earlier stage, so that they can stay more independent. If people can see and walk, and if we give them a bus pass and get them out and about, they will cost us less in the long term.

The most important missing item in the statement on NHS funding was, as has been said, funding for social care. The hon. Member for Hertford and Stortford (Mr Prisk)—I used to live there when I was a teenager—talked about providing free personal care. That is something that we do in Scotland. Someone in a care home there will pay accommodation costs, which are means-tested, but regardless of whether someone is in a care home or at home, we provide free personal care. That might seem more expensive, and indeed it is—we spend £113 a head more in Scotland than is spent here—but by comparison to being in hospital, it is incredibly cost-effective. Over the past five years, Scotland has seen just one third of the rise in A&E attendances and emergency admissions that has been seen in NHS England, and that is a cost that is worth getting back.

Members have talked about funding the service and the need to look at interesting ways to do so, and I agree that national insurance needs to be reconsidered. It used to be called national health insurance, but it of course covers many other things, such as benefits, pensions and so on. However, it is something to consider, because the threshold actually starts quite low when people are earning poorly and then starts to thin out when people are earning well. That does not seem fair. It is the same for retired people who have a generous pension and do not really go on paying national insurance. That cannot be right when they are entering the most important years.

In Scotland, we believe in integration, not competition. It is estimated that the healthcare market in England wastes £5 billion to £10 billion just in administration. The NHS in England faces reorganisation anyway as it moves through sustainability and transformation plans into accountable care organisations or systems or whatever they are to be called. Perhaps the Government should consider getting rid of section 75 of the Health and Social Care Act 2012 that forces services to be put out to tender, resulting in outsourcing and fragmentation. England needs integration and co-operation, not financial competition. Tariffs that reward a hospital only for admitting someone instead of trying to keep them home are counterintuitive.

I agree that place-based planning is the best approach for reorganisation, but it must be centred on patients, not budgets. It must start with designing what is required for the long term, not at the bottom line and then working back. In this next reorganisation, the Government should be radical and get rid of the healthcare market and, as the NHS turns 70, think of moving to a unified, public national health service.