Health and Social Care Budgets

Rachael Maskell Excerpts

Tuesday 14th March 2017 Westminster Hall

[Rachael Maskell (York Central) (Lab/Co-op)]

I congratulate my hon. Friend the Member for Hackney South and Shoreditch (Meg Hillier) on securing today’s debate. There must be honesty in the room. The trajectory of the funding crisis started with the Health and Social Care Act 2012, which introduced a funding formula that has failed. It also put the wrong financial drivers into the system, which has pushed us into this crisis.

I need only look to my own clinical commissioning group, which is seeking £1,150 per patient in an area of ageing demographics and increasing social deprivation. From the primary care group to the primary care trust right through to the CCG, my area has been seriously underfunded, and it is now having to pay heavily when a CCG down the road is getting over 50% more per head. That does not suggest equality across our NHS. Our CCG is now being pushed into special measures and is having to make a £50 million saving because of a governmental failure instead of trying to meet the real needs of our community. Of course, we see that reflected across the country. In addition, the STP includes a £420 million cut, and that will really affect patient outcomes.

Of course we need to agree a way forward on funding for health and social care, but public health also has to be included, because we are seeing public health funding severely cut. Public health measures and prevention are the drivers of better healthcare in future. We have seen the end of the smoking cessation programme, NHS health checks, and the ability to drive better health for future generations. The local authority will see a further £250,000 cut in that budget over the next three years and a £400,000 cut to sexual health services.

Rationing is coming into the service. Just two weeks ago, the Minister and I debated the rationing of surgery. Putting the wrong, perverse financial drivers in yet again is going to escalate costs in the medium term. We need to examine the way CCGs and trusts are handling the current financial crisis to make sure that we are not just kicking the can down the road and therefore escalating costs as we move forward.

Ensuring that we have early diagnosis in the system is also important. We have heard about waiting times for diagnoses of mental health conditions and emotional and psychological difficulties. In York, I heard from a parent who had spent four to seven years waiting for a diagnosis; support did not come forward until the diagnosis had been made. We should really be looking at functional care and supporting the family as a whole—we know that not supporting the family brings an additional cost. In any review, we need to make sure that we focus on prevention and early intervention, and its financial impact, and put the right financial drivers in the system now.

Rationing of Surgery

Rachael Maskell Excerpts

Tuesday 28th February 2017 Commons Chamber

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful for the opportunity to debate the rationing of surgery. The reason this is such an urgent issue is threefold: first, it is causing detriment to the health of the people of York; secondly, it is discriminatory; and, thirdly, the policy now reaches beyond York.

I am sure the Minister will set out how, under the Health and Social Care Act 2012, matters of clinical decision making were devolved to clinical commissioning groups to make decisions about local need, but this matter is so serious that I urge him to take action, as the Secretary of State said he would. I have exhausted all routes to getting the policy reviewed, so I am now appealing, through this debate, for a complete review. NHS England has previously been clear that even time-limited bans on particular groups of patients receiving treatment is inconsistent with the NHS constitution. In the light of that, I trust it will commit to withdrawing its support for rationing now that evidence of its detriment is coming through.

The Vale of York CCG determined to delay surgery to patients who smoked or had a body mass index of more than 30. The policy came into force on 1 February 2017. It was first proposed in September last year, but then withdrawn and reintroduced in November. The reason: to delay immediate spend on surgery. However, it is a totally false economy, and although it may delay CCG spend now, in order to meet imposed spending restrictions, the Royal College of Surgeons says that it may actually increase NHS costs if patients develop complications while waiting for surgery. The college has been clear that rationing policies, such as those implemented by the Vale of York CCG, are unacceptable.

The York CCG’s ability to make rationing decisions comes direct from the 2012 Act. The duty on the Secretary of State for Health to “provide or secure” the health service was removed from section 1 of the National Health Service Act 2006, thereby removing his responsibility, and replaced by a duty to make provision for the health service. The list of services that the NHS had to provide—a principle that had been embedded in the NHS since its inception—was also removed, meaning there no longer had to be a universal list of service provision, and that each CCG could determine its own. In other words, it became a complete postcode lottery: where someone lives determines the healthcare they can access.

Nevertheless, I was encouraged by the Secretary of State’s response to a question on rationing from the Health Committee on 18 October 2016. He said:

“When we hear evidence of rationing happening, we do something about it…we are absolutely determined to give people the clinical care that they need.”

In response to the Chair of the Committee, he said:

“When we hear of occasions when we think the wrong choices have been made, when an efficiency saving is proposed that we think would negatively impact on patient care, we step in, because, challenging though it is, our responsibility to the public is to make sure that we continue to make the NHS safer and higher quality and that it offers a higher standard of care”.

Minister, it is time to step in.

Early on, the Vale of York CCG hit the headlines and became unstuck when it rationed interventions such as in vitro fertilisation treatments—a decision that was reversed—so this CCG has form. As we saw from yesterday’s health and social care debate, the NHS financial model has failed. Not only does the funding formula fall short of real need, but the NHS now has the wrong financial drivers in place, resulting in a demand- led approach to health provision and uncontrollable spend.

I could talk more on that, but the Vale of York CCG introduced a delay on surgery as a direct result of its failure to contain its spend within budget; it now has special measures bearing down on it. The CCG receives around £1,150 per patient, when demand seriously exceeds that. CCGs just down the road are receiving 50%-plus more. York has an ageing population demographic and areas of serious deprivation. I urge the Minister to look again at NHS funding, because it simply is not working and our CCG is being penalised for that.

The Vale of York CCG took the decision to ration surgery for up to a year for those overweight and up to six months for smokers. Having worked in the NHS as a clinician—I was a senior physiotherapist—I am all too aware of the risk factors created by people smoking and being overweight, not least when it comes to surgery, and I do not need the Minister, as a non-clinician, to spell them out to me today. I would see patients pre-operatively to provide advice, and would also treat them post-operatively to address the risks through respiratory therapy and mobilisation. All clinicians understand the risk factors, which is why it is so important that money is invested in public health services—something that the Government have failed to do.

A child receives, on average, 12 minutes a year of school nursing, which includes child protection work. That means that they get only a few minutes a year of advice on diet, exercise, smoking and sex education. Clearly, that is not enough, especially as PE has also been cut. Yesterday, I met local school nurses who set out how their service was being cut, and how school nurses are being downgraded and de-professionalised to make savings in York.

When the Government switched public health back to local authorities, which have had their grants slashed, public health services also suffered. The irony is that York’s council completely cut funding for smoking cessation services and for NHS health checks. It also cut the health walks programme, which was a service to help people exercise more and lose weight. Therefore, public health measures to address smoking and weight were cut first, and then patients were denied surgery because they smoked or were overweight—you could not make it up. It again shows how fragmentation creates health detriment.

GPs are now actively writing to patients to ask them whether they smoke—not that they have a smoking cessation service to refer them to. They say that it is just “for their records”. Patients who are seen by their GP and who are considered to be in need of an assessment by a specialist for surgery fill out a form. They have to declare their smoking and weight status. One would think that the surgeon would receive a letter, highlighting the risk, and then would make a clinical assessment of that risk—but no. The referral is diverted, and the patient is sent a standard letter and a leaflet, which does not reflect on their own personal circumstances, but tells them that they smoke or are overweight and therefore need to change their ways. As a penalty, they are denied surgery. The specialist never gets the opportunity to assess the patient and make clinical judgments accordingly.

I am sure that the Minister will recall the narrative, which enticed some in this House to support the Health and Social Care Act 2012. We heard that doctors will be at the heart of the NHS and that they, not bureaucrats, will be the ones making the decisions. Then there was, “No decision about me without me.” Here we have a system where clinicians are being undermined by diktats from bureaucrats; patients and clinicians have no say; and clinical evidence is left wanting.

Before I progress, let me turn to this letter that patients are sent. First, it is generic and has no personal advice about the patient’s own clinical circumstances. By the time a patient reaches the third paragraph, they are told how obesity is costing the CCG £46 million and smoking £7.2 million a year, as if that is an issue for the patient who needs surgery. The penalties are then set out. Those who are obese have to lose 10% of their weight or reduce their BMI to under 30, or wait 12 months. Those who smoke have to stop smoking for eight weeks, or wait six months. Enclosed with the letter is a leaflet entitled “Stop before your op” and a web address so that people can find out how to get support. I went through this and the convoluted website. Any public health practitioner would tell you how inappropriate and ineffective this whole system is. There is no real help available.

The Royal College of Surgeons states that denying or significantly delaying access to NHS treatment does not help patients to lose weight or stop smoking. Now those being denied surgery are paying a heavy price. I have spent much time talking to GPs and surgeons about this matter, as well as to patients. I have also talked to the CCG, which knows that the system is totally wrong, but because it is in a financial hole and NHS England has waved it through, it is just complicit. It is not standing up for patients in York.

One more point on the process: in York, patients who were referred for surgery, ahead of this policy being introduced, had their referrals sat on. The first thing that they received was their refusal letter. It is shocking that those patients’ surgery was delayed by the CCG even though their referral was made before the policy came into effect. So what is the impact on patients? Well, it is devastating. We already know that waiting times for surgery are going up, and delay in itself creates detriment. It is true that some patients are exempt—I am talking about those needing urgent care, the removal of a tumour, or trauma surgery. However, if someone requires a joint replacement because they have not mobilised well for some time due to osteoarthritis, is in pain, and, as a result of not mobilising, have put on weight, things are very different. With a new joint, they will be back on their feet. A 12-month delay in being referred will exacerbate their problems. A year of degeneration, pain and not being able to mobilise, an initial clinical assessment and then the wait for surgery will result in a surgeon presented with a more complex operation, and a physiotherapist with a patient who is less mobile and weaker, needing more input and possibly longer in rehab. Bang!—there go all the savings from rationing and more, all at a cost to the patient and a risk that the long-term clinical outcomes will be worse.

The British Orthopaedic Association said:

“There is no clinical, or value for money, justification…Good outcomes can be achieved for patients regardless of whether they smoke or are obese”.

If someone were 20 stone, they would have to drop to 18 stone before having surgery, but if they were 18 stone, they would have to drop to 16 stone 2 lbs. One person asked why surgery is safe at 18 stone in one case, but not the other. I ask the same. A patient has presented to me who was prescribed medication that had a side effect of weight gain. They were on drugs that risked weight gain, required surgery and were denied by the same GPs who gave them the drugs.

I have had a patient who is active and works full time, but is over the weight threshold. She needs surgery to enable her to conceive. She is not young. Surgery is needed now, as recommended by her GP. However, it was denied and could result in her never having a family. A patient with hypothyroidism, a chronic condition that leads to weight gain, needs surgery for gastrointestinal abnormalities but, despite their condition, will be restricted. One patient was a very fit body builder, but was refused surgery because of their high BMI. The case for delay has not been evidenced.

From talking to epidemiologists and reading academic papers on the issue, we know that there is a strong correlation between smoking and obesity, and social and economic deprivation. As the British Medical Association said, this could also be seen as rationing on the basis of poverty. Those with mental health challenges have a higher propensity to smoke, and those with chronic conditions are more likely also to have elements of depression and possible weight gain. Many people find it difficult to lose weight or give up smoking. Minister, you know the figures. This policy is totally discriminatory.

[Madam Deputy Speaker (Mrs Eleanor Laing)]

I am quite sure that the hon. Lady did not mean to address the Chair, but means to ask the Minister whether he knows the figures.

[Rachael Maskell]

Indeed that is the case.

This policy is totally discriminatory and is having further detriment for those with co-morbidities. It is creating problems, not solving them. All surgery carries a risk, and it is for clinicians to assess that risk. As the Royal College of Surgeons says,

“It risks preventing a patient from seeing a consultant who can advise them on the best form of treatment, which may not be surgery. Surgery may be needed to help someone lose weight.”

That point was also made by a patient who was able to mobilise after a joint replacement. This is why clinical decision making is needed. Patients have to be part of this too.

Public health programmes need restoring so that patients can properly engage with people to help to optimise their health. The passive approach of the CCG is setting patients up to fail. David Haslam, chair of the National Institute for Health and Care Excellence, said that rationing of surgery concerned him. He says that the NICE osteoarthritis guidelines make absolutely clear that decisions should be based on discussions between patients, clinicians and surgeons, and that issues such as smoking, obesity and so on should not be barriers to referral. These are the experts.

The Vale of York CCG has gone down this route, and others are now following, with 34% of CCGs looking to ration on the basis of obesity or smoking. Harrogate and Rural District CCG and East Riding of Yorkshire CCG target smokers and those who are overweight with a six-month delay. Wyre Forest, Redditch and Bromsgrove, and South Worcestershire CCGs ration on the basis of pain impact. South Cheshire CCG requires a BMI of less than 35—not 30—as does Coventry and Rugby CCG. The policy is spreading. Although York is the worse example of rationing, every clinician knows that it is wrong and contravenes their professional duty of care.

I am blowing the whistle on this today because the policy is directly discriminatory, clinically contraindicated and financially perverse. I would be the first in this House to advocate health optimisation programmes supporting smoking cessation or providing help to improve diet, exercise, wellbeing and lifestyles, but to leave someone in pain or without a child brings our NHS into disrepute.

This evening, I have made a clear case for why the rationing of surgery must end. As the Secretary of State said to the Health Committee, it is time to step in.

--- Later in debate ---

[Mr Dunne]

The hon. Lady has made the point that she is referring to different conditions. If she would like to write to me about that, then I can give her a considered answer in relation to her CCG.

We firmly believe that decisions about treatments should be made by clinicians as they determine them to be in the best interests of patients. I will go on to develop what I mean by that in this context. We agree with both hon. Members that blanket bans on treatment are not acceptable and that they are incompatible with the NHS constitution. Every person in England entitled to NHS care has the right to receive treatment that is appropriate to his or her needs, and not to be refused access on unreasonable grounds. CCGs have a statutory duty to meet the reasonable health needs of their local population. They also have a duty to have regard to the need to reduce health inequalities, and to act with a view to improve the safety outcomes of the services they commission. To ensure that they commission cost effectively, CCGs must have regard to NICE guidelines.

I am aware that, as both hon. Members have said, some CCGs have changed their commissioning policies in a way that may have been misunderstood. The hon. Member for York Central referred to specific changes to commissioning policies on surgery, and the manner in which those changes were announced and introduced—in particular, asking patients who smoke or are obese to try to give up smoking or to lose weight in order to ensure that they have the best chances of successful treatment without complications.

It is not for me, particularly as someone without a clinical background, to comment on any of the individual cases that the hon. Lady mentioned. She did not go into specific detail, but she touched on a number of patients who have been offered an alternative pathway treatment—I think that is how the NHS would express the changed circumstances in which their treatment was offered. It is right that clinicians make decisions on an individual basis about the right treatment options for their patients as they present. In some cases, that may involve a direct route to surgery, while in others it may involve some other intervention that might put the patient into a better place to be able to respond most positively to the treatment. If that involves surgery in due course, putting themselves in a better place may lead to better outcomes.

To give an example, tomorrow I am hosting a roundtable on maternity with clinicians and leaders of the all-party parliamentary group on trying to prevent stillbirth. One of the key messages that we try to give expectant mothers is to stop smoking, because, as the hon. Lady recognises, there is a clear correlation between smoking, including smoking prior to pregnancy, and harm in pregnancy. As an ardent non-smoker, I am absolutely convinced that giving up smoking is a desirable outcome for as many of the population as possible who are able to do so. However, it is not for politicians, even those, if I may say so, who have been clinicians, to seek to take over the clinical pathway decision making for their constituents—although of course the hon. Lady was not trying to do that. It is right that clinicians make those decisions based on the individual circumstances.

In relation to Vale of York CCG, I understand that the policy development that the hon. Lady described was developed by Dr Alison Forrester, who is the CCG’s healthcare public health adviser. It was agreed by the CCG clinical executive under the responsibility of Shaun O’Connell, who is the GP lead on the CCG. It was reviewed by NHS England, so the review of the Vale of York CCG’s proposals that the hon. Lady has called for has taken place. NHS England has been working with it to ensure that its policies are in the best interests of patients.

[Rachael Maskell]

The reality is that since the policy has been introduced clinicians have not had jurisdiction over which pathway their patient should follow and which they believe is in their best interests. They are being diverted off that path due to the policy. Clinicians are therefore saying that they should be able to determine the right assessments and treatments for those patients. Also, as part of the NHS constitution, patients need to be part of the co-production of their own healthcare in the future.

[Mr Dunne]

I cannot speak for the CCG. I presume that the hon. Lady’s comments are based on her conversations not only with the clinicians to whom she has referred, but with the CCG management. I assume that the CCG in her area is predominantly led by GPs, as is the case in most other areas. I have referred to the GP lead on the CCG and GPs are involved in making these decisions.

The hon. Lady has rightly said that patients who need an urgent intervention will not be affected by the policy. Patients who may have a need and are supported by their clinicians have an opportunity to apply for an individual funding request. She might like to encourage some of the patients to whom has referred to do that, to see how that process goes. That might be a route for some of those individuals.

I am in danger of breaching my promise to conclude my remarks before the set time. I want to give the hon. Lady an appreciation of the pressures that her own area is under and put the issue in a national context. We recognise that the Vale of York has had some financial pressures in recent years. Its budget increased to £394 million this year—that 3% increase is close to the average across England—and it will rise to £402 million next year. However, we recognise that the CCG is in deficit this year. It was subject to directions from last September, as part of which an interim accountable officer was appointed and is working with NHS England to put together a medium-term financial strategy. NHS England recognises that there have been pressures in the area and it is seeking to get on top of them.

On procedures, across England as a whole—this gives an idea of the demand—there were 11.6 million operations in 2016, which was 1.9 million more than in 2010, meaning a 16% increase across the country. More locally, the York Teaching Hospital NHS Foundation Trust performed more than 106,000 operations in the last financial year, which was almost 53,000 more than in 2009-10.

[Rachael Maskell]

rose—

[Mr Dunne]

I am afraid that I have to conclude. As far as the performance of referral to treatment is concerned, the Vale of York has performed better than many other areas in the country. The percentage of patients seen within 18 weeks of referral in the Vale of York was 94% in December 2015, compared with 92% in the north of England. In 2014, the figure was 95% compared with 94% in the north of England and 93% across England. It is therefore outperforming its peers in the area and across the country. I hope that the hon. Lady recognises that.

Question put and agreed to.

Health and Social Care

Rachael Maskell Excerpts

Monday 27th February 2017 Commons Chamber

[Meg Hillier]

That is one reason that we need to be really clear that we are looking at a long-term integrated health and social care system. Social services support should be there for people—whether they are a frail older person, someone with a particular disability and need, or someone with a mental health challenge—when they need it to prevent them from going to A&E in the first place.

[Rachael Maskell (York Central) (Lab/Co-op)]

Will my hon. Friend give way?

[Meg Hillier]

I will, but I will then make some progress.

[Rachael Maskell]

I thank my hon. Friend for her excellent speech. I am disturbed when I hear that the Government are putting more money into mental health, yet I have just received the figures on Vale of York CCG mental health funding, which will be cut in the next financial year. The budget is dropping from £46 million to £45 million next year in a city that has real challenges around mental health, which shows that services are not catching up with what the Government insist is trickling down into the system.

[Meg Hillier]

My hon. Friend puts a face on the real challenge faced by many trusts and commissioners: they are having to make choices about where to spend the money. Despite the pledges about parity of esteem, there is a squeeze on mental health funding nationally.

The reality of the overall picture is that growing demand is outstripping the ability of the NHS to supply needs, which is having a direct impact on patients. There are now longer waiting times for GP appointments. I alert colleagues to the Public Accounts Committee’s hearing on GP services next week; any thoughts from hon. Members’ areas are welcome. People are waiting longer to see specialists, with the 16-week target being breached, and A&E targets are being breached too often. There is a real challenge.

NHS Improvement is a welcome body for trying to encourage best practice, because there is regional variation. It is quite right that any body as large and expensive to taxpayers as the NHS looks to perform as efficiently as possible but, once again, we are seeing NHS Improvement mask what look like cuts. A 4% efficiency savings target is once again being imposed. It was imposed in the previous Parliament by the then Chancellor, the right hon. Member for Tatton (Mr Osborne), and was acknowledged by the head of NHS Improvement, Jim Mackey, as particularly challenging. Worryingly, the reality was that everyone in the system knew that the target was too challenging, but there is a real lack of a culture of whistleblowing and calling it out in the NHS. It is difficult for people to speak truth to power, as we see over and over again. The head of NHS Improvement again acknowledged to our Committee recently, as mentioned in our report, which was published today, that the 4% efficiency savings required as part of the transformation programme are “challenging.”

Our report also describes a worrying correlation between the financial performance of trusts and their Care Quality Commission ratings, stating:

“Trusts that achieved lower quality ratings had poorer average financial performance, and the 14 trusts rated ‘inadequate’ together had a net deficit equal to 10.4% of their total income in 2015-16.”

That is a real issue.

I will touch on workforce planning before beginning to draw my comments to a close. We hear a lot about the cost of locums. Very often in the national debate, I worry that we fixate on smaller issues when we really need to look at the bigger picture. We often hear about the very high rates per hour or per day paid to individual locums. That certainly is a problem—paying someone several thousand pounds a day or a shift seems ludicrous—but the key issue is the sheer volume of locums needed.

Each year, the trust structures are set to meet the budget sent down to them from the Department of Health—our tax money, but not enough of it. From the beginning, they are just not set up well enough to meet demand. Trusts have to buy in locums to meet the needs of their populations, but that is not sustainable in the long term. There were challenges, with a reduction in the number of nursing places in the last Parliament, which is coming through now. We have recently seen the loss of the nursing bursary, which we hope does not mean a reduction in the number of nurses in the future. However, many women, particularly lone parents, in my constituency welcome the opportunity to better themselves and contribute to our NHS by taking that on. I hope the Minister will give us an update on the numbers of people going into nursing training now and, crucially, on whether the people taking those training places will stay and work in our NHS, especially given Brexit and immigration issues.

Community Pharmacies

Rachael Maskell Excerpts

Wednesday 2nd November 2016 Commons Chamber

That this House notes that community pharmacies are valued assets that offer face-to-face healthcare advice which relieves pressure on other NHS services; welcomes the Government’s proposals to further integrate community pharmacy into the NHS, including through the Pharmacy Integration Fund, and make better use of pharmacists’ clinical expertise, including investing £112 million to deliver a further 1,500 pharmacists in general practice by 2020; supports the need to reform the funding system to ensure better value for the taxpayer; and welcomes the establishment of a Pharmacy Access Scheme which will ensure all patients in all parts of the country continue to enjoy good access to a local community pharmacy.

[Rachael Maskell (York Central) (Lab/Co-op)]

On a point of order, Madam Deputy Speaker. Has the Secretary of State for Environment, Food and Rural Affairs given notice of whether she intends to make a statement to this House in the light of today’s High Court judgment, which found against the Government for the second time on the matter of being in breach of air quality standards and putting in place an inadequate air quality plan? I am sure that you will appreciate the level of interest in the outcome of those proceedings, given that between 40,000 and 50,000 people in our country die prematurely each year as a direct consequence of the Government’s failure to reach those air quality standards.

[Madam Deputy Speaker (Mrs Eleanor Laing)]

I understand the hon. Lady’s concern about the matter and thank her for raising it, but she and her colleagues will understand that it is not a matter for the Chair. If she wishes a Minister to come to the House, the correct procedure is to submit a request for an urgent question. I am sure that if the hon. Lady believes that she has sufficient grounds for asking for an urgent question, she will submit a request and Mr Speaker will give it due consideration.

Kentmere Mental Health Ward, Westmorland General Hospital

Rachael Maskell Excerpts

Monday 13th June 2016 Commons Chamber

[Tim Farron (Westmorland and Lonsdale) (LD)]

Kentmere ward is the 12-bed adult mental health ward at Westmorland general hospital. It provides essential in-patient acute mental health services to people in South Lakeland and beyond. Four weeks ago, the Cumbria Partnership NHS Foundation Trust, which looks after mental health in the county, proposed to close the ward by the end of June, with new admissions ceasing at the end of May.

This is the second time in my time as our Member of Parliament that the ward has faced the threat of closure. Ten years ago, similar proposals sparked a huge outcry from local residents. Thousands of people signed petitions and wrote to health bosses, and about 3,000 of us marched through Kendal town centre in pretty shocking weather to voice our opposition.

The campaign took many, many months, but we won. Our victory in saving the ward was a hugely important moment for our community. Mental health is often a taboo, so the suffering of those living with mental health conditions, and of their families, often happens in silence and in private. In the face of a threat to the services that those with mental health conditions rely on, far too many people would choose to look the other way—but not in South Lakeland. The campaign showed that local people were prepared proudly to stand up in solidarity with those living with mental health conditions and with their families. I am therefore extremely proud of my community. In the face of this latest threat, the character of our community is once again shining through.

Westmorland general hospital is the main hospital serving the Lake district, the western Yorkshire Dales, Kendal and much of the rest of rural southern Cumbria. I have learned over the years that the tendency to overlook the health needs of rural communities such as ours means that I need to be permanently vigilant in my defence and promotion of our hospital. The campaigns we have run to win new cancer services, to prevent the closure of the hospital itself and to increase surgery at Westmorland general are testament to the fact that ours is a special community, which will fight with unique energy and tenacity for mental and physical healthcare that is high quality and accessible. Once again, it appears that we must roll up our sleeves and fight to defend our services.

As I said, the ward provides 12 beds, the majority of which are usually full at any given time. The people occupying these beds are often suffering from the most serious mental health conditions. For much of the time, the majority of patients staying on the ward are under section.

The apparent trigger for the proposed closure came after the Cumbria Partnership NHS Foundation Trust was inspected as part of Care Quality Commission’s comprehensive inspection programme last November. Its report, which was published in March, awarded a rating of “requires improvement” to the Kentmere ward. In particular, the CQC highlighted concerns relating to privacy, access to outdoor areas and the internal physical structure of the ward. Having visited the ward myself, most recently on Saturday, I have to say that the quality of staffing and patient care is absolutely outstanding. In fact, the CQC itself was surprised that the trust’s response to the report was to close the ward, believing that the upgrades needed to meet required standards were perfectly feasible. Let me be clear: this ward is providing excellent care from outstanding staff in a physical setting that requires some improvement. It most definitely does not require closure. Indeed, the CQC has been clear that it did not recommend closure, or anything of the sort.

As I said, the ward is situated in Westmorland general hospital. The partnership trust that is responsible for mental health in Cumbria is a tenant of University Hospitals of Morecambe Bay NHS Foundation Trust. The hospital is a fairly modern building, with plenty of car parking and a beautiful setting looking out towards the Lakeland fells and the Howgills. Put bluntly, if you have to go to hospital, I cannot think of anywhere more pleasant you could be, and that is not unimportant when supporting people living with mental health conditions. The hospital building is not full. There is a great deal of space on the site, with ward space that is not used or under-used. There are enormous opportunities, with a little bit of imagination, to seek more spacious, more suitable, better-quality accommodation elsewhere in the hospital.

It is clear, then, that Kentmere ward needs upgrading. It is not ideal that it is on the first floor. There could do with being more space for the unit as a whole and greater privacy for the patients. There will be projected costs of a completely new building to meet the requirements of an upgrade. The Minister may have seen those projections. They will no doubt be expensive, and the conclusion that he is probably meant to draw from whatever scary numbers he has been given is that the only affordable solution is to close the ward. He is expected to read his brief and fob me off. However, I know him well, rate him highly, and know that he has much better judgment than that.

The reality is that the needs of patients in South Lakeland could be met on the current Westmorland general hospital site. An immediate project should be launched, alongside the hospitals trust, to ensure that there is a larger unit with ground-floor access that has greater levels of gender segregation, greater privacy, greater dignity, and greater safety. If there is a will, then the way is staring us in the face. Whatever the challenges, which we acknowledge, in upgrading this unit, it is obvious from my conversations with patients, their families, staff, the CQC and the trust that there are serious concerns about the incredibly detrimental impact that closure will have on patients’ conditions.

[Rachael Maskell (York Central) (Lab/Co-op)]

What the hon. Gentleman is saying very much echoes what happened in York when the hospital closed nine months ago. The consequence has been loss of life to my constituents. It seems that primacy in decision making is given not to clinical need, but more to the physical environment, and that has to be wrong, does it not?

[Tim Farron]

I am extremely grateful to the hon. Lady for her intervention and wish to express great solidarity with her in the campaign that she is running in York. It is of great concern to me that the CQC will make recommendations that will require improvements, and potentially not offer solutions to maintain a plausible and sustainable provision instead. The judgment we have to make is, “Is a good service that is not perfect better than no service?”, and of course the answer is going to be yes.

As I said, the quality of care in Kentmere ward at Westmorland general hospital is excellent, as stated in the report, and the staff are excellent. The ward needs upgrading—that is a given—but its closure would harm the health of some of the most vulnerable people in our community. It is utterly unacceptable that those people will have to be shipped off to Barrow, Whitehaven or Carlisle rather than being treated much closer to home in Kendal. What is more, there is no guarantee that those far distant wards will have the capacity to accommodate them. Already, patients sometimes face the immense journey to Manchester, for example. For many less well-off residents, a round trip to these alternative wards of up to 100 miles, with many hours on the bus or train, will put family and loved ones beyond easy reach. It is the patients who would be harmed if they were cut off from their families and friends and missed out on all-important visits. Instead of the reassurance of familiar faces and surroundings, they would face this dark time alone and in an unknown place.

Junior Doctors Contracts

Rachael Maskell Excerpts

Monday 25th April 2016 Commons Chamber

[Mr Hunt]

I am absolutely prepared to talk about anything that could be improved in the contract that will be introduced and, indeed, extra-contractual things such as the way in which rota gaps are filled and the training process. However, at the moment we do not have such a dialogue, and that has been the problem. The imposition of a new contract is the last thing in the world that we wanted as a Government. It followed 75 meetings—it was a totally exhaustive process—but in the end we found that our counterparty was not interested in sitting down to talk about this; it just wanted a political win. We had to make an absolutely invidious choice about doing the right thing to make patients safer. I wish we had not got to that point. We have got to it and we need to carry on, but the door is always open for further talks and discussions.

[Rachael Maskell (York Central) (Lab/Co-op)]

The Secretary of State is the one person who can stop this strike. Why will he not now take a step back, engage the services of ACAS—specialists in negotiations—remove the conditionality and address the remaining issues? Proper dialogue will get a resolution.

[Mr Hunt]

Had Nye Bevan given way to the BMA there would be no NHS.

Junior Doctors Contracts

Rachael Maskell Excerpts

Monday 18th April 2016 Commons Chamber

[Mr Hunt]

I will tell the hon. Gentleman one of the things we are doing, which is turning around the hospital in his own constituency, which is no longer in special measures because the quality of care has improved dramatically. What else are we doing? Over three years, there have been 75 meetings, 73 concessions and three different independent processes. We have tried everything to get a negotiated outcome, but in the end we have to do the thing that is right for patients.

[Rachael Maskell (York Central) (Lab/Co-op)]

The Secretary of State needs to face reality: there is a recruitment and retention crisis of junior doctors in paediatrics, A&E, intensive therapy units and acute medicine. Those specialisms demand seven-day working and people working unsocial hours. The junior doctors know that these contracts will make the situation worse, so why is the Secretary of State not doing everything in his power to get people to sit around the table—even if that does not include him personally or David Dalton—to have negotiations to address the real issues concerning junior doctors?

[Mr Hunt]

That is exactly what we have been doing. Indeed, there are a number of changes in the contracts that will be beneficial for people working in A&E departments, as has been recognised by the president of the Royal College of Emergency Medicine, Cliff Mann. The difficulty we have had in terms of morale is that we have been faced with the BMA, which has consistently misrepresented the contents of the new contract to its own members. Nothing could be more damaging for morale than that. What we will need to do, I am afraid, is wait until people are on the new contracts, and then they will actually see that they are a big improvement on their current terms and conditions. That is the right thing for doctors and the right thing for patients.

Mental Health Taskforce Report

Rachael Maskell Excerpts

Wednesday 13th April 2016 Westminster Hall

[Rachael Maskell (York Central) (Lab/Co-op)]

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

I thank the hon. Member for Halesowen and Rowley Regis (James Morris) for setting out the framework of this excellent report by Paul Farmer and his taskforce on addressing concerns about mental health. What stood out for me was that it was a very practical report—with time lines and specificity about how the debate should be taken forward, the resources required and the instruments we put in place to make the report a reality—but the hon. Gentleman was absolutely right: it is important that it should be accountable at every step of its journey. I will come to that later.

The report also sets out a clear action plan for some of the areas that need a focus, including the setting of key targets. I welcome the ambition in the report to improve access to services and reach a much wider community than they do now. It sets out a new chapter in this journey about how we build capacity for mental health services in future. I doubt that there will be disagreement in the Chamber about some of the emphasis in the report on funding and the requirement to put more resources into the service. What stood out for me was the startling figure that poor mental health costs us, economically and socially, £105 billion, a figure that compares with only £34 billion being spent on the service.

There is a lot of opportunity to move the debate about funding and finances forward, as well as addressing issues to do with facilities. That has been a particular issue for us in York, as we have seen the closure of our acute service and the slow rebuilding of that service, with more emphasis on community delivery. It is important to ensure that we have the right number of beds as we put in a new facility for the people of our city. When we look at capacity issues, we should not look backwards at how a service was delivered, but look forward to the future needs and requirements of the service.

It is also important to reflect issues of workforce planning. We have seen a serious shortfall in people working across the mental health services. I welcome the recommended drive-up of, for example, 1,700 therapists. Will the Government be producing an action plan, as they did for health visiting, to ensure proper mentoring and support in the system to ensure that those therapists come online, while also ensuring a proper regulatory framework for the health professions across mental health? We do not have one currently, and I know that many of the professions are calling for proper regulation.

The other figure that really stood out for me concerned when people require support, with 50% of mental health problems established by age 14 and 75% by age 24. What stands out for me is the need to shift resources into early intervention and prevention services. I welcome the investment to be made into perinatal mental health, but we need to build up from those services, as we look at the provision that will be needed into the future.

In particular, if we are looking at that focus, I know from talking to teachers in my community that too much of the burden is being placed on them. We need to ensure that it shifts to the real professionals in the service, who are properly trained to provide support, diagnosis, signposting and screening for young people. There is urgent need to look across services for young people as they move out of school. We have also had specific issues with transition, and I still think there are cliff edges, as commissioning and service provision are done by different bodies. As a result, we get cliff edges—not smooth transition—based on a date of birth rather than clinical need. That really needs to be addressed.

In the short time remaining, I want to mention the raising of concerns in mental health services. The current system is quite inadequate—HealthWatch has contacted me today specifically about this issue. There are too many places where concerns can be raised. We have the Care Quality Commission and NHS Improvement; we also have regulators who look at the professions and other places, such as the healthcare safety investigation branch. There are so many different places. We need one place where concerns can be raised, so that service users and staff know where to go and can get a clear response. I hope the Minister will address that as well.

BMA (Contract Negotiations)

Rachael Maskell Excerpts

Monday 21st March 2016 Westminster Hall

[Helen Jones]

I am grateful to my right hon. Friend for defending the university in his town. I am sure that he is right.

Any experienced negotiator will say that beginning negotiations by insulting the staff is never a good tactic. That is part of what the Government have attempted in muddying the waters: first, by drawing conclusions from the research that are not there, and secondly, by not being clear what they mean by a seven-day NHS. They have constantly said, “We need a seven-day NHS”. What they fail to tell us is whether they want a seven-day emergency service, which we already have but everybody accepts that it could be improved, or a seven-day elective service, which will require a huge investment not only in doctors and nurses but in diagnostics, support staff, lab technicians and so on. That failure to be clear has made doctors very wary of what the Secretary of State is trying to achieve.

[Rachael Maskell (York Central) (Lab/Co-op)]

There is also a real issue around capacity for a seven-day service. If elective surgery is increased over the weekend, where will those patients go, because hospitals are already at capacity?

[Helen Jones]

My hon. Friend makes a very good point, and she is right.

The Government need to make clear what they are trying to do, then they need to negotiate with the staff in good faith. Unfortunately, there is not much good faith around at the moment. That is why 90% of junior doctors have said they would consider leaving the NHS if the new contract is imposed on them. I do not think for one minute that 90% of junior doctors will go, but the Government have proceeded—as they do in a lot of cases—as if those junior doctors had nowhere else to go. Unfortunately, in this case they do: they can go to Scotland, or to Wales; or they can go and work abroad, where their skills are in high demand and where they will find, in many cases, they are paid more and work fewer hours than they do here. If even a small percentage of junior doctors go, what will the Government do to fill the gaps? We already have gaps in certain specialities, such as A&E, and paediatrics. What is the Government’s plan?

--- Later in debate ---

[Helen Jones]

It is a real failure, given the commitment of doctors and other staff to the NHS.

This dispute is taking away energy and focus from dealing with the real problems facing the NHS. The NHS is under huge pressure and many trusts have big deficits, yet the service as a whole is still expected to make over £20 billion worth of so-called efficiency savings, which no one with real knowledge of the NHS thinks can be made without cutting services. One in 10 people in A&E now wait longer than four hours for treatment, which is the worst result for a decade.

There is also huge pressure from the Government’s ill-conceived cuts to local council budgets, which has led a slashing of social care and which the Government were warned at the time would have an impact on the NHS. The real problem those cuts are causing is more admissions to A&E, often of elderly people who have had falls or who have become ill because of lack of care. There is also the problem at the other end, whereby people cannot be discharged because there is no care package in place for them.

[Rachael Maskell]

I thank my hon. Friend for giving way again; she is being incredibly generous with her time. Does she agree that it causes real concern that the specialisms that require people to work longer and unsocial hours are also the ones that are most difficult to recruit for, and that the contract is therefore putting clinical safety at risk?

[Helen Jones]

My hon. Friend is quite right, and I will come on to that point later. There are staff shortages in the NHS that the contract may well make worse.

In the end, as in any dispute, the issues can be resolved only by negotiation, and in truth the two sides are not all that far apart. Huge progress was made when Sir David Dalton was brought into the talks, but there are still outstanding issues to be resolved. For instance, the Government trumpet a 13.5% increase in basic pay. What they do not say is that that increase will be paid for by cuts elsewhere. For example, payments that are made as a reward for length of service will go. I have yet to hear from the Government their assessment of what impact that change will have on retaining staff in the NHS, or how it will work for members of staff who take time out, whether for academic study—we need doctors who are both academics and good clinicians—or for maternity leave. What will happen to women who work part time, and so on? If we lose a number of women doctors in the NHS, the service will be in a great deal of difficulty.

Guaranteed pay rates when people change specialties are also going. In the past, if someone changed specialty later on in their career, their pay was guaranteed. That will not be the case any more. That change is bound to have an effect on recruitment in areas where we are already short of doctors, and I have seen no real impact assessment of that yet.

Of course, the big issue for many doctors is the change to standard time and premium time. The Government are increasing standard time from 60 hours a week to 90 hours a week. In the past, doctors were paid extra for working between 7 pm and 7 am, and for working at weekends. Standard time will now increase to run to 9 pm on weekdays and 5 pm on Saturdays. Doctors who work more than one in four weekends will get a premium payment. It is difficult to work out the effect of that change on individual doctors; it depends on how many weekends they work now, what their specialty is and so on.

The Government’s pay guarantee lasts for only three years, and given the Secretary of State’s remarks, junior doctors fear that the change is a back-door way of introducing longer hours. It certainly makes it cheaper to roster doctors at weekends. The Government say they will fine hospitals that roster people for more than a certain number of hours, but the doctors say that offer is not good enough. That is not an unbridgeable gap; it could be resolved. However, the result of what has happened and the Secretary of State’s comments is distrust and suspicion among doctors about what his real motives are. That is combined with a disastrous drop in morale in the NHS. The latest NHS staff survey shows that the percentage of junior doctors reporting stress has risen from 20% to 35% in five years. The proportion of staff saying that they feel pressurised to come into work when they are ill has gone up from 16% to a whopping 44%.

That loss of good will and drop in morale matters, because NHS staff are known for going the extra mile, working longer than they are paid for and doing things they do not have to do. That extends from the consultants who come in on their day off to see certain patients to the nurses and support staff who bring in a birthday card for an elderly person who has got no one else. I well remember that when my son was born, I was there for three shifts in the maternity department. After he was born, the registrar from the first shift came back to see me, to check that I was all right and to see whether I had had a boy or a girl. It is impossible to put a price on such things, and the Government risk losing all that and doing huge damage to the NHS if they do not solve the dispute.

--- Later in debate ---

[Rachael Maskell (York Central) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Sir David.

It is a privilege to be able to say that I worked in the NHS as a physiotherapist for 20 years—I remain on the professional register—and to bring that experience to the debate. The service that I worked on was changed to cover seven days. The complement of staff was the same, but spread over the whole week. To provide a full seven-day service with every specialism in place would require a massive investment of resources on a scale nothing like what the Government are talking about, given that they are set on making £22 billion of efficiency savings. Before being elected to Parliament I had a dual career, because I was also head of health at Unite, representing more than 100,000 health workers. I therefore have real experience of dealing with the Government and of how the Department of Health handles disputes.

On 5 December 2011, proposals were introduced to cut unsocial hours for all “Agenda for Change” staff. The proposals were discussed with NHS employers throughout the country and with the trade unions. We sat around tables and discussed the proposals, and they were turned away, but the fear is that they could be coming back on to the table. The NHS Pay Review Body report said that the Department of Health and NHS employers recognise that

“the cost of the unsocial hours premia makes the delivery of seven-day services prohibitive”.

That is why the whole NHS is worried: the real prize for the Government is the savings they will make from cutting unsocial hours throughout the NHS.

If the Government are planning to expand services to cover seven days, if only in name, they will need more people to work at weekends. The cost of having more people working at weekends cannot currently be met, so if the service is to be expanded, obviously the prize the Government are after is the NHS’s “Agenda for Change” staff, who are often very low paid. According to a survey I conducted of these professional NHS employees, they are giving eight hours of unpaid overtime to the NHS every week, doing the many things we have already heard that NHS staff do. Why? Because they care, because they are professional, and because that is what happens in the NHS.

I do not recognise at all the caricature painted by the hon. Member for Morley and Outwood (Andrea Jenkyns). What she described is not my experience of some of the most highly professional people in our land. They deserve our respect and awe, not to be degraded as she degraded them today and as the Secretary of State has previously. I am ashamed to have heard her comments. I had a meeting with junior doctors in my constituency on Friday and listened to their concerns. They are seriously concerned about recruitment and retention in the medical profession, particularly in accident and emergency, where there is a serious recruitment and retention problem in my local hospital.

They explained to me that as junior doctors are leaving they are being replaced by locums. That destabilises the multi-professional team. It destabilises the ability of clinicians to work in teams where clinicians know one another, which is the safest way to operate. All the tutoring, mentoring and other input that staff so value and need—learning on the job right through their professional careers—is lessened by that destabilisation. They are seriously concerned about recruitment and retention because they want to get the best professional development so that they can give the best service to patients. That is why we are seeing junior doctors applying to work overseas: they want to ensure that their careers are enriched so that they can give patients the best care.

We should be really concerned that there are such problems with recruitment and retention in many of the specialisms that require weekend working and are involved in emergency services. We are not discussing some of those services that, frankly, could operate according to clinical need during a Monday-to-Friday service because the demand is not there for such professionals to be there at the weekend. We should be very worried, as should the public, because the reality is that if doctors are not in A&E, who is going to care for us in our time of need? That is the reality of what is happening.

Psychiatry is another profession that is currently finding it difficult to recruit, as are other areas of emergency medicine and the intensive therapy unit at my local hospital. They face real challenges, and they have concerns about the new regime that is being introduced to try to deter hospitals from making doctors work long hours—the new guardian of safe working role. They are concerned because the new regime is like the trust marking its own homework. If doctors report that they are working excessive hours, the trust will be fined, but the fines will go into a training and development fund, so we will just see less money going into that fund in the first place. It is a case of playing with the accounts and shuffling the deckchairs on the Titanic as it is sinking under the proposal.The reality is that it will not be an effective measure for preventing people from working longer hours, and doctors have real concerns about it.

[Dr Whitford]

I, too, have concerns about the hours guardian, because it will require junior doctors to complain. The NHS is a hierarchical system, and those doctors, who are often on the lowest rung of the ladder, will have to step up and make a noise. Something that depends on their whistleblowing on their own hours will not provide strong protection.

[Rachael Maskell]

The hon. Lady is absolutely right. Although Government Members say that the NHS has a much more open culture, the reality on the ground is that it is difficult to raise concerns in the NHS. Shopping the boss if they are making someone work longer hours will be difficult. The hon. Lady makes an excellent point.

We want to maintain the best in our NHS; we do not necessarily want to give that gift to the world. That is why it is so important that we return to the negotiating process. There was pressure from the Opposition to ensure that there was a process of independent arbitration so the talks could be resumed. When Sir David Dalton became involved, the dynamic of the dialogue changed, so a deal could be brokered and progress could be made. All that we ask—hundreds of thousands of people who understand industrial relations have written to us about this—is for professional dialogue with professionals to ensure a proper negotiating process so we can find a solution to this dispute. That is how negotiations work. That is the process of industrial relations. It is about sitting around a table and working through the difficult issues before us. When great minds come together, solutions can always be found.

I urge the Minister not to impose the contract and to withdraw from that position. Of course it is possible to do that. Anything is possible if the will is there. Withdraw, calm down, stand back and let some dialogue continue. We need to find a solution that is good for NHS employers, for our doctors—do they not deserve a solution to this dispute?—for the rest of the NHS, for patients and for the public. Why not make that small concession and open talks immediately?

[Thangam Debbonaire (Bristol West) (Lab)]

Thank you, Sir David, for allowing me to make my first speech on my return to Parliament after a nine-month absence in the care of the NHS. [Applause.] Thank you. Forgive me if I am a little unsure of the procedure. I thank my hon. Friend the Member for Warrington North (Helen Jones) for making an excellent opening speech and other colleagues for their contributions. My constituents asked me to speak in this debate on behalf of patients, junior doctors and other NHS professionals in Bristol West, and I am grateful for the opportunity to do so.

Junior doctors in my constituency told me that they already work in a seven-day NHS, and so do other NHS professionals. Although the subject of this debate pertains to junior doctors, it is relevant to mention other NHS professionals. As other Members have said, pushing this contract onto junior doctors appears to be a proxy for pushing for a fully seven-day NHS—indeed, that is what Government Members seem to be hinting at—so it will affect all NHS professionals.

I have had a lot of opportunity recently to observe at first hand, and at close quarters, over nine months how hard NHS professionals, including junior doctors, work and how dedicated they are to all of their patients. During my treatment for breast cancer, the radiology department found just after Christmas that it was under severe pressure. There was a backlog of patients who all needed daily radiotherapy. I was one of them. People cannot just wait for radiotherapy to happen; it has to happen when it needs to happen. The staff worked out a way of meeting patient needs by offering extra appointments at evenings and weekends. Indeed, I went for my radiotherapy at 8 o’clock in the morning on a Saturday, such was my dedication to my treatment.

Much more important than my approach was what the staff did. The doctors went out of their way to help and advise me and other cancer patients. For instance, I received text messages from my surgeon over a weekend and inquiries on my progress following an infection from a breast cancer nurse in the evenings. All the staff seemed to me, and to the breast cancer and other cancer patients around me, to routinely go out of their way to meet patient needs.

All of that is by way of explaining to Government Members that my experience and that of other patients is that NHS professionals are dedicated, professional, caring and willing to be flexible about working over seven days. As other hon. Members have said, there already is seven-day care for patients. The junior doctors I met individually in Bristol West confirmed that that was the case, and the BMA representatives I consulted told me that they wanted a negotiated settlement. The Secretary of State appears not to understand that there are more than 56 medical specialties, each with different work patterns. They all need rostering, and they do not all work in the same way. Lab technicians, nurses and others, such as receptionists and cleaners, would all need to work weekends for the proposal to work. I have not seen any sign from the Conservative party that the Government would provide funding for that. If they would, I urge the Minister to tell us about it.

My overwhelming conclusion is that the Government do not seem to be aware of where they are starting from or where they are going to. They definitely do not know how to work respectfully and honourably with the people they need to work with professionally to make the changes they want to make, whatever they are.

[Rachael Maskell]

My hon. Friend is making an excellent speech. On the delivery of a seven-day service, where are the professionals going to go, as we have a recruitment crisis and have to use agency staff?

[Thangam Debbonaire]

I thank my hon. Friend for that excellent point. The Opposition are only too aware of that.

NHS: Learning from Mistakes

Rachael Maskell Excerpts

Wednesday 9th March 2016 Commons Chamber

[Mr Hunt]

This, I am afraid, is the problem with some elements in the BMA, who are putting politics ahead of patients. As we have heard today, that is the problem in the Labour party as well.

[Rachael Maskell (York Central) (Lab/Co-op)]

Action on Sir Robert Francis’s “Freedom to Speak up” review is very welcome. There are so many cases I could cite, but when a senior junior doctor reported unsafe levels of care in an intensive therapy unit, he was subject to unacceptable behaviour such as bullying and blacklisting, and now can only work as a locum. When he wrote to the Secretary of State, the Secretary of State refused to engage, listen and learn from his experience. Learning cultures have to start at the top with the Secretary of State. Will he set out how he will address retrospective cases of whistleblowing when people have been subject to discrimination?

[Mr Hunt]

I hope that the hon. Lady is not quoting selectively from my reply to the person concerned, because when people raise issues of patient safety with me, I usually refer them to the CQC, which is able to give a proper reply. I would be very surprised if I had not done that in this case. Retrospective cases are particularly difficult, and much as we want to help, it is difficult constitutionally to unpick decisions made by courts. We are trying to separate employment grievances from safety grievances and make that the way that we solve these difficult situations.