A and E Departments

Andrew George Excerpts

Tuesday 21st May 2013 Commons Chamber

[Mr Hunt]

We certainly intend to address A and E departments’ recruitment issues, which I recognise are one of the causes of the pressure. Over-reliance on locum doctors is not a long-term solution to improving the performance of A and E departments either, so those are both areas that we will be looking at.

[Andrew George (St Ives) (LD)]

The Government—Governments generally—cannot legislate to predict or control accidents or genuine emergencies, but they can direct resources. Hospital bed numbers have been cut by about 30% in the last 10 years. Does my right hon. Friend agree that it is difficult for A and E departments to function effectively if they do not have adequate bed capacity behind them?

[Mr Hunt]

I do agree, but what hospitals say is that the issue is not the number of beds, but the people in them who are not being properly discharged into the social care system. I was at King’s College hospital last week, where I was told that the hospital had probably two wards full of people who could be discharged into the social care system but had not been. Breaking down those barriers—something that I am afraid the last Government did not get round to doing in 13 years—will be an important priority.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 16th April 2013 Commons Chamber

[Mr Hunt]

As I said to the right hon. Member for Leigh (Andy Burnham) earlier, we actually hit our A and E waiting time target last year. If the hon. Lady is talking about waiting times in general, the number of people waiting for more than a year for an operation was 18,000 under the previous Government, and the figure has fallen to just 800 under this Government.

[Andrew George (St Ives) (LD)]

If there is a smidgeon of space in any of the Ministers’ diaries, is there a chance that they could meet me and representatives of the nursing profession to address not the issue that I think the Government are saying they are opposed to—mandatory nurse to patient ratios on wards—but that of adequate registered nurse levels on hospital wards?

[Dr Poulter]

Of course, I would be very happy to meet my hon. Friend to discuss this matter further. He can be reassured that I have regular discussions on these matters with representatives from the nursing profession, both in my clinical work and, more specifically, in my ministerial roles.

Mid Staffordshire NHS Foundation Trust

Andrew George Excerpts

Tuesday 26th March 2013 Commons Chamber

[Mr Hunt]

That accountability is extremely important and happens on many different levels. In particular, we have professional codes of conduct for doctors and nurses, so that in the exceptional situations where those codes are breached, we know, as members of the public, they will be held to account. Those are done at arm’s length from the Government by the General Medical Council and the Nursing and Midwifery Council, but we are talking to them about why it is that still no doctor or nurse has been struck off following what happened at Mid Staffs—I think that is completely wrong.

[Andrew George (St Ives) (LD)]

I know I repeat myself, but adequate registered nurse-to-patient ratios are often at the heart of these failings, yet on page 68 of the report my right hon. Friend rejects the idea of any kind of national benchmarking or guidelines with regard to patient ratios. Will my right hon. Friend keep an open mind and meet me, Professor Elizabeth Robb of the Florence Nightingale Foundation and others from the profession so that we can explore this issue?

Home Care Workers

Andrew George Excerpts

Wednesday 6th March 2013 Westminster Hall

[Mr Andrew Smith (Oxford East) (Lab)]

It is good to serve under your chairmanship, Mr Turner. I am pleased to have the chance to discuss home care and home care workers, because it is an incredibly and increasingly important area of service and policy touching nearly every family in the land. As the number of elderly and frail people increases, many of them with some degree of dementia, and as more people stay in their own homes, it is vital that we as a Parliament and the Government take action to ensure that standards of care are what they should be and meet the needs of older people with the dignity and quality of service that they have a right to expect, and that I am sure we all want for ourselves when the time comes.

I appreciate that there are big funding questions. I certainly want social care to be a priority for resources. Under the present austerity regime, social services departments and care providers are struggling to meet the pressures that we discussing. I also favour the full implementation of the Dilnot proposals. However, it is my intention to focus not on finance but on care and care workers and what we can do to address the present shortcomings, which must be evident to Members from all parties.

Let me make it clear at the outset that we should praise the good job that so many care workers and care providers do, often—I shall say more about this—in difficult circumstances. However, there are far too many shortcomings, as described in the recent Care Quality Commission report and the Unison report “Time to care”. We need an across-the-board drive to raise the standards, training, working conditions, terms of employment and professional standing of this most vital group of workers. It is especially important because they are on the front line. They are the first point of care and contact for hundreds of thousands of elderly people and are responsible for helping with their intimate personal needs and medication as well as day-to-day living.

On standards, the Care Quality Commission found a quarter of services to be substandard. Both the Unison report and the survey last autumn by the consumers association Which? found too many instances of rushed and poor care, as well as evidence of good and excellent care. I have been surveying constituents on the issue and have seen the same mixed picture. One daughter in the Which? survey found her mother having her face washed with a flannel with faeces on it and being dressed in the previous day’s soiled clothes. Others spoke of relatives going all day without food or drink, untrained staff using lifting equipment, muddled medication and forgotten alarm pendants. It is clear that standards must be raised to a consistent and higher level.

Training must be an important part of that. We need to listen to people like the worker in the Unison report who said:

“Three half-days’ irrelevant training was given. Then I was on my own. I had never bathed, dressed or cared for anyone before. I had to empty urine bags, colostomy bags etc. with no training. I felt very scared and was left to struggle as best I could.”

The consequences of mistakes involving such vulnerable people do not bear thinking about. We can well understand how workers in that position are being let down by those in charge of home care provision across the country.

I argue, as Unison does, for standardised levels of training and detailed minimum standards on employers to provide practical training to that level, without making the requirements excessively academic, so that we do not exclude people who are good at caring but bad at passing exams. Requirements should include communication, though, especially given the number of people whose first language is not English working as carers. Someone in Oxford told me that her mother was in a care home where just three out of 60 staff had English as their first language.

I also argue for a professional register of accredited carers, just as we have for nurses. People would qualify to get on it and gain the status that it involves, but they could also be struck off if incompetence or negligence warranted it.

[Andrew George (St Ives) (LD)]

The right hon. Gentleman makes an interesting case. How long did it take him this morning, from the moment he got out of bed, to wash, clothe himself, have breakfast and get out the door? Although I appreciate that standards for care workers must be concentrated on, does he not agree that many of them are asked not just to undertake their work on the minimum wage but to complete their tasks in an unfeasibly short time?

[Mr Smith]

Absolutely, and I am coming to that point. I could not get myself completely ready in the limited time that some care workers have; some are allocated 15-minute slots for visits.

When things go wrong, it is vital that staff speak out, yet too often care workers feel vulnerable and not in a position to do so. I note that last month, the Secretary of State for Health said that he was “very sympathetic” to extending to home care workers the duty to whistleblow that the Government are thinking of applying to nurses. I urge the Minister to do so.

It is crucial that inspection is extensive, robust and effective. It is all the more so given the importance of care and the fact that it takes place in people’s homes, away from immediate supervision. There are concerns about that in Oxfordshire right now. Our local paper, the Oxford Mail—I am sure you will remember it well, Mr Turner, from your time in Oxford—has highlighted concerns raised by our local patient voice and county councillors about the adequacy of local CQC inspection arrangements. In November, there were just two inspectors for Oxfordshire, and even now there are only five, who between them are responsible for inspecting 447 health and social care institutions and thousands of home care visits.

There is all-party concern. Conservative councillor Jim Couchman, who chairs the county’s adult services scrutiny committee as well as being a member of the health overview and scrutiny committee, said after meeting the CQC:

“We did get pretty worried by what we saw as an extremely ill-equipped organisation to deal with the responsibility accrued to it…The CQC is not a proper inspection team in any way, shape or form.”

Councillor Couchman has also told me since that apart from the enormity of the task required of such a small staff, the most surprising fact was that recruits did not need any experience or knowledge of the NHS, health care or social services. The CQC seemed more concerned about whether new staff had a background in regulation.

I was also concerned that when asked to talk to the Oxford Mail, the Care Quality Commission declined. When such worries are being voiced, it is all the more important for a body such as the CQC to come forward and answer questions as a basic responsibility of public accountability, as well as to take the chance to build public confidence rather than undermining it, as the CQC ended up doing. Will the Minister look into the position on care quality inspection in Oxfordshire? More generally, will he ensure that the commission has sufficient inspectors across the country with the right experience to do the job?

Feedback from users and their families is another important yardstick by which to lever up care standards. Our county council uses individual visits and client satisfaction surveys to inform contract monitoring. However, a wider public satisfaction rating is needed for the plethora of care agencies. One of the paradoxes of modern life is that, if advice is wanted on the standards of service providers such as restaurants, hotels and garages, or of products such as cars and electrical goods, there is no end of reviews out there to guide people, but for something as important as helping someone to find a good care provider, there seems to be nowhere to look for advice. In theory there is competition for provision, but in reality all the customers are groping around in the dark. That is a good reason not to emulate in mainstream NHS provision the privatisation that has already happened in care services.

Underpinning all that, action is desperately needed on the terms and conditions of care workers. They are doing a demanding job, often on the lowest wages and with minimal security. According to the Unison “Time to care” survey, more than half of home care workers overall and more than 80% in the private sector are not paid for travel time or costs; it has been estimated that between 150,000 and 200,000 home care workers are in effect paid less than the national minimum wage as a result. To make matters worse, more than half of private sector home care workers have a zero-hours contract with no guaranteed pay, and more than half of all home care workers reported that in the past year things have got worse for them on pay, working time and the duties expected of them.

--- Later in debate ---

[Andrew George (St Ives) (LD)]

I congratulate the right hon. Member for Oxford East (Mr Smith) not only on securing the debate but on covering such fundamentally important ground on matters that clearly need to be addressed. From the litany of issues that need to be dealt with seriously by not only the two parties in government but all parties, it is clear that if we were to construct the circumstances for a catastrophe to happen on our watch, all the ingredients are being prepared in the services being provided to people in their homes.

The right hon. Gentleman described many symptoms, and at present the health system is under extreme pressure. The last Labour Government established the £20 billion efficiency gain, now colloquially known as the Nicholson challenge. All parties know that the pressure for efficiency gain inevitably resulted in an attempt throughout the system to push costs down to the least expensive care models, which means out of hospital, into the home and care by the lowest paid people. In addition, a whole heap of management babble obscures the way in which the trend is being catapulted. The health system depends on a group of workers in people’s private homes, but we should not ignore the fact that many people work in similar conditions in residential homes for people who cannot be catered for in their own home. There is a parallel situation in nursing homes.

With pressure on the system, there will be increasing attempts to ensure that patients are discharged from hospital much earlier than in the past. Part of the management mantra is that the worst place for an elderly person is an acute hospital and that unnecessary admissions should be avoided. That is self-evidently unarguable, but is often asserted. However, at the margin an assessment must be made before making that decision. There is a feeling that older people are being denied admission to hospital because of age discrimination in the system, and that because they are older they should be kept at home when, if they were 20, 30 or 40 years younger with the same condition, they would be admitted to hospital. Many of us know that that pattern exists.

MPs have many examples in their casework, and I am sure I am not unique in this: inadequate care is provided in the home for older people who must endure unacceptably poor standards of care and circumstances. The response is often pontification from the political classes, but the care workers are voiceless. Whenever the “Today” programme runs a story about poor care, which it often does when a shocking story of poor care is revealed or a report by the Care Quality Commission is published, some of our own classes are wheeled on to morning media slots and often denigrate the character of the people who provide care, as though a failing in the carers caused the problem. They say that we must address problems with carers’ characters rather than the unfeasible circumstances in which so many of them must operate.

I intervened on the right hon. Member for Oxford East to ask how long it takes him to get out of bed in the morning and to get ready to go out of the door. All of us in the Chamber are able-bodied and do not need a hoist to get out of bed or to use the toilet. We do not need to be assisted in every way, and we are not on a cocktail of medicines—perhaps some of us are. An hour is probably a reasonable time for most able-bodied people, yet we often hear that care workers must undertake those functions for other people in less than half an hour. That is simply not feasible. People may say that carers cut corners, take risks and do not complete the job, but they are asked to undertake an impossible task.

Many carers are on the minimum wage, and in areas such as mine in west Cornwall and the Isles of Scilly the travel time between visits is often significant. If the agency employing care workers is not prepared to cover properly travel times or costs, it may take the worker below the minimum wage, as my right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) said.

We must address the issues that the right hon. Member for Oxford East has properly listed. All the ingredients are there. As we go forward, the pressure will continue. Bed reviews will be undertaken as the new clinical commissioning groups swing into action in the next month. They will look at how many community beds there are in their area, assess whether they are affordable, and look for new ways of working and new pathways. They will use the usual language to argue that there are better ways of providing the care that is currently provided in community hospitals, that local communities should not be obsessed with bricks and mortar, that they can provide better care in the home, and that people should relax and understand that the number of beds can be reduced even when the population is ageing and the number of people needing care is increasing. Reducing the number of beds will increase the pressure on remaining beds. People will be discharged much earlier to their homes with assurances that adequate care packages are in place when we all know that those care packages are marginal and that the people providing the care will be asked to undertake work that is often unfeasible.

I often resist calls for diminution in the number of community hospital beds in my constituency, and I am sure that other hon. Members do the same. We used to know the number of beds in our local hospitals, but the service that used to be provided is becoming increasingly invisible. The problem is that the service can then be cut, denuded and reduced over time in ways that are very difficult for us all to properly assess, because people will not able to see or understand how it operates. Parts of the service will be shaved off in the same way that local authorities have redefined access to support from moderate to critical, and so on—as I know that many local authorities have done.

I have visited a number of agencies in my constituency. I am really pleased that we have some excellent agencies working in west Cornwall. Many of them are impressive agencies, but of course they are all competing, and there is a risk of a race to the bottom. Local authorities are commissioning on the basis of price, and the fear is that they are not necessarily looking at quality as much as they should be when they make assessments.

[Mr Andrew Smith]

I made the point about competition in my remarks. Does the hon. Gentleman agree that a very important dimension is that a lot of clients are paying for care themselves, and they have very inadequate information on which to judge one agency or provider against another?

[Andrew George]

Absolutely. Minimum standards and agreements across agencies—or if the Government will not establish minimum standards, baseline standards—would give people reassurance. What we understand is happening, as part of achieving the efficiency gain that all parties want, is that not only is there an attempt at constructing a clinical and patient interest argument that patients are better off being discharged to their home, which is better for them, because it is where they want to be—the mantra that is often used; but there is cost-shunting as well. Obviously, if a patient is in hospital, the state is paying for them. There is an increasingly harsh attempt at identifying what continuing care is and is not—in other words, the state continues to pay for that patient in their home—but what ultimately happens is that the sooner the hospitals can get patients out to their home, it is the individual, if they have any assets at all, who meets the bill.

In terms of standards, in my view, we should be encouraging agencies that are providing care to offer at least a living wage for workers—£7.20 per hour and, I think, £8.30 in the London area. Travel time between visits should be part of salaried time. A mileage rate should be set and understood, and everyone should share a mileage rate; in my area, the rate paid to travelling care workers varies between 35p and 40p a mile. There should be a minimum visit time of 45 minutes in very exceptional cases, and at least an hour for most visits, especially if it involves at least two of the following procedures for non-ambulant or semi-ambulant clients: getting out of bed; dressing or undressing; toileting; feeding; washing and mobility support.

An efficient and effective arrival and departure reporting and recording system should be introduced, because there is some dispute between agencies and local authorities on that issue. Registration of care workers is very important, and I hope there will be cross-party support for it. The Select Committee on Health, of which I am a member, has been pushing for it for some time. It would ensure that there is adequate training, proper registration and recognition of the significant job that home care workers do. With that kind of support, I believe that we can give home care workers the proper status and support that they richly deserve.

--- Later in debate ---

[Andrew George]

The hon. Lady makes an excellent point about recording arrival and departure times. Often the system simply fails, not only in rural areas, where mobile coverage is poor, but when using the cared for person’s telephone. Carers often cannot get through and calling becomes a greater obsession than providing the care itself.

[Lilian Greenwood]

The hon. Gentleman is absolutely right. I remember well the representative from the High Peak area constantly making that exact point, which was that there was poor mobile phone coverage. They talked about how much of their time would be spent dealing with the telephone instead of focusing on the person who required their assistance. There were also worries about travel time.

I particularly remember the concerns of people who worked alongside private sector care providers where, they reported, staff training was often inadequate and there was often a high turnover of staff. They also reported that the care providers frequently did not provide personal protective equipment; they talked about the lack of rubber gloves and the like. We often had discussions about which tasks home helps were given time to carry out. They often pointed out that their service users wanted and needed things that might not be what the carers were commissioned to provide.

Unison’s “Time to Care” report and the Care Quality Commission’s “Not Just a Number” inspection programme made me wonder whether we should have listened more closely to the concerns and issues raised by those Derbyshire home helps 20 years ago, particularly when, in describing the current context, the CQC talked about the

“increasing pressure on social care budgets and the rise in the number of people with complex care needs and dementia.”

In describing its key findings—as my right hon. Friend the Member for Oxford East said, a quarter of services fell below the standards expected—the CQC said:

“What is concerning is that our findings come as no surprise to people, their families and carers, care workers and providers themselves.”

The findings really do not come as a surprise, because they are exactly the issues that have been raised over many years.

The CQC highlighted several problems, including service users

“not being kept informed about late arrivals, different care workers from one visit to another, not having their preferences clearly documented, a lack of support for care staff to carry out their work, and failure to address the ongoing issues around travel time.”

Those are responsibilities of not just this Government but the previous Government, but the pressure on social services that are commissioning care services is even greater now, and we need to look again at what is required.

There is great similarity between the findings of the CQC and Unison’s “Time to Care” report. Although the care and welfare of service users is the most important focus, the CQC found that staff felt

“unsupported by their management teams and not…able to deliver care in the right way because they are too rushed, with no travel time and unscheduled visits added to their day.”

It also reported a lack of planning and supervision for staff. Training needs were not identified, staff were not confident in using their equipment, and inductions were not always completed following recognised standards.

As the hon. Member for St Ives (Andrew George) said, the voices of care workers are often not heard in debates such as this one. We ought to address that today. I was pleased to see that Unison’s report included many quotes from individual home care workers. It provided an opportunity for them to have a say and to talk about their experiences. My hon. Friend the Member for Wirral South (Alison McGovern) has already quoted one of the home care workers who contributed to the report, saying they did not have time to spend with their service users and they had to rush between calls.

One of the most important issues is about older people. I imagine that many hon. Members have this experience when they are out canvassing in their communities: they knock on the door of an older person, and perhaps the Member is the only person they have spoken to that day. Their priority is to talk to someone who is willing to listen. That was well recognised by one of the care workers who contributed to the report, who said that

“care is not just about duties but communication and many providers do not allow for this…How can half an hour be enough to get someone up, dressed, meds given and have a chat? People are being failed by a system which does not recognise importance of person-centred care.”

There are many quotes in the “Time to Care” report, which I am sure the Minister has read. I hope that he listens to the voices of home care workers and the issues that they raise.

It is vital that, like the director of social services in Derbyshire back in the 1990s, we listen to the voice of home care workers, because they meet service users every day. Most of them are incredibly committed to providing a good-quality service and ensuring that people receive the support that they need. It is also vital that we do not simply listen to them, but act. Will the Minister meet home care workers and their representatives to discuss the findings of Unison’s “Time to Care” and the CQC report? Will he set out today how he intends to respond to the findings of those reports?

--- Later in debate ---

[Liz Kendall]

Care and communication is vital for people with all sorts of frailties and conditions, but particularly for those with dementia, as carers try to keep their memories and brains going. Those people often feel lost in a fog, and having some kind of contact is vital to keeping them going, so it is important.

We have heard about the problems of call cramming, with carers being rushed, getting late to one client and leaving early for the next. Older people are worried when they are left waiting on their own, and staff are frustrated that they have to rush in and out.

The third issue that has been raised is zero-hours contracts. As hon. Members have said, such contracts are very bad for workers, because they find it difficult to budget and plan their lives. Zero-hours contracts make it hard to attract people to the sector. They are also terrible for the users—older and disabled people who do not get continuity of care. I cannot imagine someone coming round to get me out of my bed and take me to the shower. I would be naked and they would be washing me, but I would not know who they were, because they would often be different people each time. We would not put up with that for ourselves, and we should not expect it for older people either.

The fourth issue is the lack of training, which is a real problem in dementia care. It is only since having known people with dementia that I have fully understood why they are seen to get aggressive: they do not, but they are frustrated because they cannot remember things. Carers need detailed training for that.

The fifth issue is the vicious downward spiral or vicious circle that leads to poor care for users of services and real problems for staff. The last UK Homecare Association report states that vacancy rates are at 21%, so we are simply repeating the problems.

In my remaining time, I want to make three comments about why that is all happening and what we need to do. Clearly, demand has increased in recent years. However, as my hon. Friend the Member for Wirral South (Alison McGovern) said, when local councils’ budgets are being cut by a third, when adult social care is 40% of their budget on average and their biggest discretionary spend, and when the money that the Government say they have transferred from the NHS has not been ring-fenced, it is inevitable that care budgets are being cut. Figures from the Department for Communities and Local Government—the Government’s own figures—show that more than £1.3 billion has been cut from older people’s social care budgets since the coalition came to power.

There are a few deeper things going on. First, the caring profession is mostly delivered by women and is low-skilled. Such professions have always been neglected in the past, so that is a concern. Secondly, the problem is invisible: it concerns isolated staff and isolated, frail older people who do not have a voice. In talking about the care crisis, I always tell people that I have received five letters about the care crisis in my constituency and 99 about saving forests. I am passionate about forests, but getting only five letters on the care crisis shows that this is an issue of isolation and we should stand up about it.

[Andrew George]

Like the hon. Lady, I have shadowed care workers in my constituency. One point that often comes across is that when I ask those who pontificate from on high—criticising poor care standards and implying that it relates to the character of the people providing the service—whether they would be prepared to do this job, no one wants to do it, even at twice the salary.

[Liz Kendall]

I completely agree. That is why Unison’s report, “Time to Care”, which has given people a voice, is important.

The third fundamental issue is that our NHS and care system have not kept pace with changing demographics—people living longer—and changing needs and expectations. Families cannot always cope with caring for elderly relatives, and older people want to stay in their homes for longer. In the past, it was not the business of the NHS and social care to think about the home; its business was always about sending people to institutions.

What should be done? I want to raise four matters with the Minister. First, I know that the Low Pay Commission has looked at the minimum wage. Will he confirm, however, that as my right hon. Friend the Member for Oxford East said, Her Majesty’s Revenue and Customs has ruled that it is not legal to pay for travel time? If that is the case, what is being done about that? What action has been taken? In any other area, there would be legal action to enforce the minimum wage, so what is being done?

Secondly, I know that the Minister wants a shift to commissioning for outcomes, rather than by the minute. That is the Government’s policy, but how will he make that work in action? What are his levers over local councils? Thirdly, it is time to have a national strategy for improving training for home care workers. What are the Government’s plans?

Finally, although the announcement on the Dilnot cap is a step forward, Dilnot has always said, as the Minister will know, that proper funding is needed in the current system, which this Government have not produced. I know that he will be in intense conversations with the Treasury over the future budget. If, following the Budget, the Government decide to pull over more money from the NHS to social care, will he ring-fence that money this time?

NHS Commissioning Board

Andrew George Excerpts

Tuesday 5th March 2013 Commons Chamber

[Norman Lamb]

According to my recollection, at the last general election all three parties committed themselves to any willing provider. The degree of hypocrisy that we sometimes encounter beggars belief.

[Andrew George (St Ives) (LD)]

Because I had feared that the regulations as currently drafted would result in an NHS driven by profit rather than concern for patient care, I welcomed my hon. Friend’s statement. However, he said that he would base the future draft on the principles set out by the last Labour Government, who favoured the private sector over the NHS. Can he reassure me that the redrafted regulations will enable commissioners to encourage collaboration and the integration of health services, and that that will trump competition on many occasions?

[Norman Lamb]

I am grateful to my hon. Friend for that question. I should make it clear that we have enhanced the position that we inherited by absolutely reinforcing the importance of co-operation and integration for the first time—that was not part of any legislation under the previous Labour Government. Our Government are totally committed to legislating on and then enacting the importance of co-operation and integration, as he rightly says.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 26th February 2013 Commons Chamber

[Norman Lamb]

I would be happy to look into that further. I recognise the significant concern that the hon. Lady raises. Often the diagnosis of epilepsy is not good enough and there needs to be much better co-ordinated care. The issue that she raises is important and I am happy to look into it further.

[Andrew George (St Ives) (LD)]

In spite of my right hon. Friend’s earlier comments, I am afraid that the regulation that implements section 75 of the Health and Social Care Act 2012 does not maintain the assurances previously given and risks creating an NHS that is driven more by private pocket than concern for patient care. Will the Secretary of State please withdraw that regulation and take it back to the drawing board?

[Norman Lamb]

We are looking at this extremely seriously. Clear assurances were given in the other place during the passage of the legislation, and it is important that they are complied with in the regulations.

Ankylosing Spondylitis

Andrew George Excerpts

Monday 25th February 2013 Commons Chamber

[Andrew George (St Ives) (LD)]

As the hon. Gentleman knows—we have discussed this on a number of occasions—I also suffer from AS and many of my experiences mirror his, although I have never experienced the compassion of those in the Whips Office. Although the condition affects many esteemed people, it also affects many humble people such as me. I was also involved in the campaign for anti-TNFs. Does he agree not only that proper and effective diagnosis is critical, but that it is vital that medicines are properly prescribed and made freely available to those who are suffering very badly from the condition?

[Huw Irranca-Davies]

That is absolutely right. The hon. Gentleman makes a very important point and I will touch on it when I describe my mini manifesto for how we should move forward on AS. Different sorts of treatment will be appropriate for different people with AS.

Arthritis Research UK is currently funding research into other aspects of AS, including the award of more than £1.3 million to seven experimental arthritis treatment centres that aim to fast-track the most promising treatments to market, research into the genetic factors of AS, and even education resources to help families affected by AS. It is tremendously commendable work.

The Minister is not here just to listen to my or anybody else’s sob story, or to help me regain my prowess on the badminton court or at the cricket crease. I want the Government to help other people with AS, now and in the future, to get the best care, so here is my wish list.

First, we should increase the awareness and recognition of AS. AS has always had a low profile among both the medical profession and the public. Because back pain can have a number of causes, it is easy for AS to be misdiagnosed or to go undiagnosed.

Secondly, we should improve the way in which people with AS are referred. GPs may focus on trying to manage people with lower back pain and not consider referring them on to appropriate specialists such as rheumatologists.

Thirdly, please can we use MRI, not X-rays, for early diagnosis? Clinicians now agree that MRI scanning is a far better option because it can pick up the early joint damage due to AS before it is evident on an X-ray. X-ray changes because of AS may take years to show up.

Fourthly, we should improve access to the right specialists. Experts in other forms of spinal pain are not necessarily skilled in treating inflammatory back pain and associated conditions. For the best outcomes, it is vital that people with AS are managed by the right specialists as part of a multidisciplinary team.

Fifthly, we should improve access to the best medical and surgical treatments. The last decade has seen much improvement in imaging, which is vital to improving the safety and effectiveness of surgery, and treatments that offer better symptom control and quality of life. Early access to those is critical.

Sixthly, we should implement long-term follow-up and management. For the right decisions to be made at the right time, people with AS need long-term monitoring by appropriate experts and ready access to advice or treatment when necessary.

Seventhly, we should develop quality standards and clinical guidelines for AS. In the absence of those, perhaps the Minister will say what can be done now to focus local clinical decision making on AS.

We also have a range of things that we want from GPs. We want them to consider AS as a possible diagnosis if patients have symptoms of back pain and stiffness that are not improving. GPs should refer patients to a rheumatologist as soon they suspect AS. MRI scans should be part of that process. There should be access through GPs to specialists, including rheumatologists, physiotherapists and specialist nurses. There should be access to physiotherapy sessions, either as part of a group or individually. Information should be provided in GP surgeries. There should be access to expert surgical assessment and treatment for people with severe spinal deformity who may wish to have surgery to correct it. There should be regular follow-up appointments and ready access to expert reassessment, including monitoring for bone health, osteoporosis and cardiovascular risk. Finally and critically, there should be information on, and access to, sources of support including physiotherapy, financial advice and psychosocial services.

I say to the Minister, on behalf of 200,000 people who have AS, that that is our manifesto for improved diagnosis, improved treatment and improved quality of life. Despite my late diagnosis and early mistreatment, I am pleased to say that thanks to great, if late, support from tremendous NHS clinicians and staff, I am currently active, sporting and able to be a thorn-in-the-side— or should I say constructive critic—of the Government whenever the need arises.

I am part of a team alongside great friends and campaigners such as Gillian Eames who are taking part in the worldwide “Walk Your AS Off” event for the next month promoting exercise as part of the self-management of the condition. On 1 and 2 April, I will be walking 50 miles at the age of 50 to raise awareness of AS and funds for the National Ankylosing Spondylitis Society. I invite the Minister to join us. Take a walk in our shoes, as people say, and we will show how a little support goes a long way, reduces health and social care costs, helps people to stay active and in work for longer, and gives people a far better quality of life. If he cannot make the walk, perhaps he will agree to meet me and a delegation from NASS and Arthritis Research UK to discuss further our ideas. I thank the Minister for listening and hope for a positive response.

Health Services (Cornwall)

Andrew George Excerpts

Tuesday 11th December 2012 Westminster Hall

[Andrew George (St Ives) (LD)]

I am delighted to have secured this debate on health services, which are important in Cornwall—and, I am sure, in the rest of the world as well.

The national health service was created in 1948. It looks forward to its 65th birthday while facing the biggest challenges in its history, and nowhere more so than in Cornwall and on the Isles of Scilly. The previous Labour Government set a demanding target of £20 billion efficiency gain by 2015, something not advanced for any other health system on the planet, and the present Government have introduced the biggest reorganisation since the NHS was created.

As the Minister knows, I have argued, and voted, against the Government on what is now the Health and Social Care Act 2012. However, we must face up to what the Government have done, to ensure that, irrespective of the wisdom or otherwise of the policies, the Act does not undermine our vital local health services in Cornwall and on the Isles of Scilly.

Along with the significant financial challenges, which are a great deal more significant in Cornwall and on the Isles of Scilly than in the rest of the country, I hope to raise some of the many other challenges that the local NHS faces, including the consequences of the loss of the helicopter service to the Isles of Scilly.

I want to mention the important campaign that Sandra Cousins, one of my constituents, launched a year ago, following the tragic death of her daughter Mercedes Curnow, which led to the setting-up of the Mercedes Curnow Foundation. Mercedes died on 14 December 2011, aged 23. She and her mother had sought to highlight the need to strengthen the systems for detecting and treating cervical cancer in young women—particularly those under 25, who are denied screening in many circumstances.

There are many other issues. Nationwide, there needs to be a greater emphasis on registered nurse-to-patient ratios in some acute settings, and the need in Cornwall is significant. There is the risk of regional pay, the need to ensure adequate community hospital beds and primary care services, and the public health agenda, which must ensure adequate levels of NHS dentistry. That might be far too many issues to fit into the limited time available.

I am very reassured that highly professional and dedicated clinicians are already working hard to ensure that our local health services are the best they can be in the circumstances. In 2013, the new service in Cornwall will, as in the rest of the country, be largely led by local general practitioners. I am delighted that the shadow Kernow clinical commissioning group—“Kernow” is Cornish for Cornwall—chaired by Dr Colin Philip, was only this afternoon authorised by the NHS Commissioning Board to be responsible for the £700 million for commissioning health services across Cornwall.

The group is very open to working with the local community in ways that are extremely encouraging. For example, the Cornish campaign group 38 Degrees is already working with the group and suggesting amendments to its constitution to ensure that local health services are protected in ways that any local community would wish them to be protected. It is well on the way to creating new structures, challenging as they are, that will shape how the NHS operates in Cornwall.

A big challenge nationally is to ensure that the NHS really effectively puts patients before profit. The previous Government rolled out the red carpet for private health companies in Cornwall, as elsewhere, and gave them opportunities to profit their shareholders by delivering some of the less challenging elements of NHS work. I have questioned the basis on which tariffs will be awarded for procedures. After I raised questions with him about the risk of cherry-picking, the new Secretary of State told me, in a letter dated 30 October 2012:

“Under these new rules, commissioners should adjust the tariff price if a provider limits the type of patients it treats…resulting in lower costs than the average of the tariff category. As a result, providers undertaking only the more simple interventions—for example, because they do not have the proper facilities to handle more complex cases—would be paid a suitably lower price.”

That is certainly the case in Cornwall, where a number of private providers deal with some of the easier and less complex cases—for example, patients without anaesthetic risk and those without co-morbidities. If those providers are offered a lower tariff price the question that needs to be asked is whether that might have the unintended consequence of commissioners driving patients into the arms of the private providers that cannot provide the range of services that the Royal Cornwall Hospitals Trust, for example, excellently provides for our local community.

There is also fragmentation, which although a nationwide issue is a particular risk in a peninsula that depends on core services and has no alternatives. Although patient choice might well apply, and is welcome as a luxury beyond the core services, the risk is, of course, that it will not necessarily help services if it results in their fragmentation.

On the role of the private sector, my hon. Friend the Member for Truro and Falmouth (Sarah Newton) and I have raised concerns with the Care Quality Commission about what we detected had been going on with the out-of-hours GP service in Cornwall. The CQC, in its report in July, found—as the Minister will know because of the significant national ramifications—that there had been some manipulation of some of the data records, and inadequate staffing. The primary care trust, in its report on 20 September 2012, identified that it had deliberately altered data 250 times between January and June this year, which had the effect of inflating its published response times. That is not particularly encouraging. The problem is that in a very competitive environment there is an increased risk that that might happen.

Cornwall must ensure that it gets a fair share of the cake. Our allocation is significantly less than what the Government say we deserve—their stated target—and they should take account of the underfunding we have had in recent years. For example, between 2006 and 2012 Cornwall has received £201 million less than its target. That is a significant amount, and I would be surprised if anywhere else in the country had been allocated so much less than what the Government said it should get. This year, 61 primary care trusts will receive a total of £1.3 billion over target, while 88 PCTs, one of which is Cornwall and the Isles of Scilly, will receive £1.3 billion below target.

Added to that, Cornwall receives less money for each medical procedure within a national tariff, using the market forces factor framework as the index. The Royal Cornwall Hospitals Trust receives the lowest payment of any acute trust in the country. It inherited debts from troubles that originated in 2006-07, which rose to £46 million in 2008-09. Although repayments have reduced the debt to £22 million, it will be passed on to the new quasi-independent foundation trust, which we hope will be established next year.

Although we have had disappointing responses from Ministers so far, my hon. Friends the Members for Truro and Falmouth and for North Cornwall (Dan Rogerson) and I are still arguing that the debt should be written off to give that foundation trust a clean slate on which to begin its work next year.

I entirely support and thoroughly endorse the trust’s response to the latest revelations with regard to concern in the obstetrics and gynaecology department. I make it clear, so that there is no equivocation or uncertainty, that I entirely endorse the actions the trust has taken with the external review, and we hope that that will be brought to a conclusion as soon as possible. The trust is certainly doing all it can to reassure patients in Cornwall. The trust has high standards, and we entirely support the work it is doing. We hope that patients who may be concerned will contact the trust.

Sandra Cousins of the Mercedes Curnow Foundation has been working tirelessly. Although I have written to Ministers on this issue over the past year and have received helpful and instructive replies, a large number of young women are still dying, unnecessarily in my view and certainly in the view of Sandra Cousins and her many supporters across the country.

Sandra is also concerned that, even where GPs are prepared to undertake a smear test—smear tests for young women under 25 have to be authorised by a doctor—laboratories, apparently, are not always following through by undertaking work on those tests. She argues that laboratories must accept and follow through the necessary tests. She draws a comparison with Australia, where the cervical screening limit is 18 and where, since 2009, the human papilloma virus vaccination has been available for those up to 26 years old, which is much higher than in this country. The mortality rate from cervical cancer in Australia is half the UK’s.

Sandra Cousins says:

“I also feel regarding the hpv vaccination that it should be done nationwide in schools. Cornwall is a prime example of low uptake of the vaccination, 49% compared to many counties that are 89%, because it is done at G.P. practice not in schools.”

She advances the case for schools, but she is also concerned about the 18 to 26-year-old cohort, because HPV vaccination ends at the age of 18 and there is no cervical screening for those under 25. Her daughter, of course, fell into that cohort, and I certainly believe she has a strong case for advancing the points that she is making.

Of 20 cervical smear and HPV tests that the Mercedes Curnow Foundation has funded, 18 were positive. Those women went on to have further investigations and treatment. Sandra Cousins cites other examples where that is an issue that needs to be addressed in more detail.

I have mentioned regional pay, and I am pleased that MPs across the south-west met the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) last week. We were reassured by his response, and he will be writing to the south-west consortium. Indeed, those south-west MPs will be writing to the chief executives of the 19 trusts engaged in that consortium to encourage them to get back to national negotiation.

I urge the Government to consider nurse staffing levels. With all the stories about poor care and nursing in hospitals, few are prepared to consider the resources that are going into the hospital wards themselves. On many occasions, nurses are running around unable to fulfil all of their duties because there is an insufficient number of them on the ward. There are mandatory registered nurse-to-patient ratios in places such as Australia and they work well, with good outcomes.

The commercial helicopter service to the Isles of Scilly ceased just over a month ago, and it is already having an impact on services to my constituents on the Isles of Scilly. Blood samples and patients are unable to get over to the mainstream health services on the mainland, and I hope the Minister is prepared to look closely at that and perhaps work with the Department for Transport to help find a solution. Cross-departmental co-operation is required.

We have low levels of NHS dental provision in Cornwall, and I am concerned that the local authority might put the director of public health not on the chief officers board of the local authority, but under one of those senior officers. There are major concerns across Cornwall that Peninsula Community Health, the community interest company set up last year, is unable to provide the necessary staff to staff community hospital beds. It is important that we front-load community and primary care to get the balance right between those acute hospitals seeking to discharge patients earlier than they are able and avoiding unnecessary admissions to those hospitals.

I am sorry that I have gone on for a minute longer than I intended. There are many challenges, but the biggest that we face—I hope the Minister will take this on board—is Cornwall’s unfair funding deal: £200 million of missing money over the past six years alone.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

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

I congratulate my hon. Friend the Member for St Ives (Andrew George) on securing this debate and on raising what can only be described as a rich pot-pourri of topics relating to the state of the health service in his county and to his constituents, whom he serves not only in St Ives and across Cornwall but on the Isles of Scilly.

I assure my hon. Friend that the total revenue allocated to NHS Cornwall and Isles of Scilly increased by 2.8% in 2012-13, which is entirely in line with the 2.8% overall increase nationally. That represents an additional £26 million to invest in front-line care in his local area. Indeed, the total budget for NHS Cornwall and Isles of Scilly is £941.8 million for 2012-13. On top of that, I am advised that the local NHS expects to achieve efficiencies of 4%, totalling £36 million, with those funds being made available to support improved services to patients in Cornwall and the Isles of Scilly.

I understand that the independent Advisory Council on Resource Allocation has been developing a new allocations formula. I am told that allocations to clinical commissioning groups for 2013-14 will be announced by the NHS Commissioning Board later this month and that ACRA’s final recommendations are due to be published alongside those allocations.

It is not for me to say whether Cornwall should receive more or less money—it is difficult to think that Cornwall could possibly ever receive less—but if there are some inequities, I am sure my hon. Friend and his colleagues from the county will do their best, as they always do, to put forward those arguments with full force. I assure him that they will continue to be listened to.

[Andrew George]

The Government are clear that Cornwall receives less money than they say it should. I gave the figure earlier that Cornwall received more than £200 million less than the Government said it should.

[Anna Soubry]

Indeed, but it is for ACRA to come up with a new formula, and it is hoped that that can be advanced. The formula might, of course, be to the benefit of the county.

There is a rich number of topics to address, and it is difficult to know where to begin, but I will start by saying that I am disappointed that my hon. Friend chose to vote against the Government’s excellent NHS reforms. In his area, as he has already told us, the CCG was authorised yesterday. I will give some examples of how that movement of power and determination into the hands of front-line professionals will benefit his constituents.

The CCG has secured more than £500,000 from the Government’s dementia challenge fund to improve the lives of people in Cornwall living with dementia and their carers. The funding will be spent on improving dementia care in residential and nursing homes and in the community, and increasing peer support in communities and hospitals. Those are just some of the things that that successful application for £500,000 will achieve. The CCG is also investing £300,000 to expand the acute care at home programme. I have many other examples, including four services in Cornwall that have been expanded through the “any qualified provider” scheme: psychological therapies, back and neck pain treatments, adult hearing services and ultrasound and MRI diagnostic services. My hon. Friend raised concerns about the march of the private sector, but if there is such a march—I have no evidence of it—it would seem that in his county, it is by no means to be feared; indeed, it is to be welcomed.

My hon. Friend mentioned the loss of the helicopter from Penzance to the Isles of Scilly. I know that the service has ceased, and I understand the worry that that causes him and many of his constituents. I understand that the service previously fulfilled all non-emergency health transportation needs, but I am informed that emergency transport is usually carried out by RNAS Culdrose, so any interruption to routine travel affects only non-emergency appointments. The islands are also served by a passenger ferry, and the NHS has back-up arrangements in place to use a cargo ship if needed for medical samples.

In response to the ending of the helicopter service, I am told that the Isles of Scilly Steamship Company, which runs the fixed-wing aircraft Skybus and the passenger ferry Scillyonian—forgive me for not pronouncing it correctly—

--- Later in debate ---

[Andrew George]

The Scillonian.

[Anna Soubry]

My hon. Friend knows it better than I. The company has enhanced its services to accommodate NHS needs, and has committed to purchasing a second aircraft to enable it to increase flights. I hope that those arrangements are of some assurance to him.

On registered nurse staff ratios and the skill mix, we know that patient care in the 21st century is different from what it used to be. Hospitals report that the type of demand that they face is changing. In particular, the average lengths of hospital stays are about one third shorter than they were 10 years ago. It is true that the number of nurses has been decreasing, but the total number of professionally qualified clinical staff in the NHS is rising.

Planning the number of nurses and the shape and size of the work force must be based on the needs of the people in our care. Services must be properly designed around the care and treatment that people need. Those decisions could result in a need for nursing numbers to change, but that must be based on properly redesigning services, not just on affordability. Changes must be decided at a local level, based on evidence that they will improve patient care. It is important to use this valuable staffing resource wisely, in properly constructed multi-professional teams with appropriately blended skills focused on the care and treatment needed by patients, families and communities.

The Government are committed to improving quality standards in the NHS. Our role is to clarify the standard of patient care demanded of the NHS through the mandate and to underpin it with robust external monitoring and validation by appropriate bodies. We are not here to impose management solutions.

[Andrew George]

I am interested in what the Minister says. However, is she saying that she and her fellow Ministers are content that registered nurse staffing levels are currently adequate in all settings within the NHS?

[Anna Soubry]

With great respect, I could not possibly say either yea or nay to that, because I do not know what they are, but I always look forward to the continuing representations made by hon. Members urging Ministers to raise or change the numbers.

I turn to the concerns expressed about the financial situation of the Royal Cornwall Hospitals NHS Trust. I hope that those concerns will now be allayed; the trust is forecasting a surplus of £3.8 million for 2012-13, and is progressing well on its path to achieving foundation trust status. Yesterday, through a video link, I spoke to one of the trust’s officers, who told me with much encouragement about plans for the future of the hospital and said that the trust believes that it is now on top of its financial situation. By way of example, I asked specifically about the trust’s preparations for winter, as it looks like we are going to have one of the hardest winters in this country for a long time. I was heartened by not only the trust but the PCT and others to whom I spoke about the high level of preparedness in Cornwall and Devon, two counties that are used to unusual snaps of weather, quick changes and sudden emergencies. I was left with a feeling of great confidence that those two counties are doing everything that they should to be ready. For what it is worth in this short time, I urge all counties to be in as great shape as Cornwall and Devon are.

In my remaining few minutes, I will turn to one particular point. My hon. Friend may have raised others. If I have not answered them, I will write to him. He rightly talked about a foundation trust set up by one of his constituents in memory of another of his constituents. I did not catch their names, so if he will forgive me, I will not make a hash of them, as it is a serious matter and a young woman lost her life. I am told that 80% of eligible women in Cornwall and the Isles of Scilly took part in the NHS cervical screening programme in the previous five years. That uptake has increased from the previous year and exceeds the percentage of women who took part nationally.

My hon. Friend’s point was about screening for women under the age of 25. He said that it concerns him, and asked why the age should not be reduced. In May 2009, the advisory committee on cervical screening reviewed the screening age specifically and considered all the latest available evidence on the risks and benefits of cervical screening in women aged between 20 and 24. The committee was unanimous in deciding that there was no reason to lower the age from 25, which happens to be in line with the World Health Organisation’s recommendations. The committee gave a number of reasons, which I cannot read out given the time available. I am more than happy to supply him with a list of those reasons.

That is not to say by any means that my hon. Friend and his constituents should cease their campaign to achieve better levels of screening and awareness among young women about the fact that cervical cancer can affect them even though they are young. I say that as the mother of two daughters, one aged 21 and one 22. It may be of some interest to him that by complete coincidence, I was stopped today by my hon. Friend the Member for Loughborough (Nicky Morgan), who approached me because she too, unfortunately, had a constituent under the age of 25 who died of cervical cancer. She raised the same issue with me. I gave her an undertaking that I am more than happy to meet with her and her constituents to discuss it further, and I extend that invitation to my hon. Friend the Member for St Ives and to his constituents who are campaigning. It may well be that the matter should be revisited. As I said, the advisory committee considered the issue in 2009. The technology may have changed—I know not—but it is certainly a matter that needs to be considered, and I am more than happy to meet hon. Members to talk about it and see whether anything can be done.

It would appear that I have dealt with all the items on my list of notes, and so—

Oral Answers to Questions

Andrew George Excerpts

Tuesday 27th November 2012 Commons Chamber

[Dr Poulter]

I fully agree with the hon. Lady and I take her concerns on board. However, because of the additional freedoms introduced by the previous Government, local employers in foundation trusts throughout the NHS have additional freedoms to set their own pay, terms and conditions. Under the rules introduced by the previous Government, it is impossible for us to intervene directly in the matter, except by continuing to encourage trade unions and NHS employers to meet the national agreements. If national terms and conditions are agreed to, I am sure that they will be endorsed at a regional level by the south-west consortium.

[Andrew George (St Ives) (LD)]

I am very pleased that the Minister will be meeting a cross-party delegation of MPs from the south-west next week to discuss this issue. In view of his answer to the hon. Member for Bristol East (Kerry McCarthy), is he confirming that Health Ministers have no powers at all to intervene in the negotiations between employers and their staff?

[Dr Poulter]

It is worth putting it on the record that it was the previous Labour Government who introduced foundation trusts in 2003 and set them free from direct accountability to Ministers. That includes the ability to set their own pay, terms and conditions. It was Labour that removed the power of the Secretary of State to direct foundation trusts, and it is Labour, not the Government, that needs to decide whether it supports the legislation that it put in place in government. We endorse national pay frameworks and will do all that we can to preserve them.

--- Later in debate ---

[Mr Hunt]

What this issue is addressing—it was legislation introduced by the hon. Lady’s Government in 2006—is a clearly unsustainable situation with South London Healthcare. The proposals have to look at making sure that there is sustainability throughout an entire local health economy. I have not made any decisions at all. I will wait for the proposals to come to me at the end of the year, and I will then make my decision in January.

[Andrew George (St Ives) (LD)]

T6. There is mounting evidence that clinical care failure is as much to do with inadequate staff levels as anything else. In view of that, do Ministers agree that it is worth looking at the merits of establishing mandatory registered nurse to patient ratios across secondary and tertiary care wards?

[Dr Poulter]

I thank my hon. Friend for that question. This point has been raised before and although it sounds like a good idea in principle, the problem is that different aspects of care in different wards—for example, an older people’s ward compared with a ward that looks after younger people—will have differences in the intensity of nursing. Therefore, a mandated ratio would be difficult to implement. A ratio may be counter-productive to making sure that we can give more intensive nursing cover where it is needed, and could even encourage a race to the bottom.

NHS Commissioning Board (Mandate)

Andrew George Excerpts

Tuesday 13th November 2012 Commons Chamber

[Mr Hunt]

As the right hon. Gentleman will know, we are losing 24,000 people unnecessarily every year by not properly recognising the symptoms of diabetes. That is incredibly important. We have made it clear that reducing mortality rates—preventing avoidable mortality—is a major priority of this Government, so I expect this to be a key priority for GP practices and for local authorities throughout the country.

[Andrew George (St Ives) (LD)]

I welcome my right hon. Friend’s statement today and the mandate, and note that it is based on the NHS constitution, which states that it is founded on a common set of principles and values. So in a week when GPs have become millionaires by selling off their interests in parts of the NHS, may I suggest a further test, beyond the friends and family test—a patients before profit test? Will that be introduced?

[Mr Hunt]

The outcome that we want is for more patients to live longer and more healthily than ever before. The right thing for me to specify in the mandate is that we want the NHS to deliver improved patient outcomes. Sometimes that will involve using the independent sector and the voluntary sector, but in the vast majority of cases it will mean working within the traditional NHS. If we deliver those improved outcomes, we will be doing the right thing by patients throughout the country.