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.

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[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.

Regional Pay (NHS)

Andrew George Excerpts

Wednesday 7th November 2012 Commons Chamber

[Andy Burnham]

No, I will make some progress.

Breaking national pay is what the Government want to do, and that springs from an entirely different philosophy from the one that forged the NHS in the first place. The Government are rejecting the “one NHS” approach, whereby hospitals collaborate and the unpredictable pressures of any health service are balanced across the system. Instead, they have a vision of hospitals as stand-alone small businesses, on their own in the marketplace, with no bail-outs and free to earn up to 49% of their income from the treatment of private patients, but—as we are seeing in south-east London—finding little mercy in a private-sector-style administration process if the sums do not add up. That is a very different vision of the NHS, and it is not one to which the British people have ever given their consent in a general election.

[Andrew George (St Ives) (LD)]

I will join the right hon. Gentleman in the Lobbies on one reasonable condition: he acknowledges that the last Labour Government did not just introduce regional pay in the Courts Service, but introduced flexibilities for foundation trusts which, through employment law, could result in detriment to NHS employees. If he acknowledges that and apologises for his introductory remarks, I will certainly join him in the Lobbies.

[Andy Burnham]

I partly welcome what the hon. Gentleman has said. I have already acknowledged the flexibilities, and mentioned that only one trust in England ever sought to make use of them, because it wanted to add to the national floor that we had introduced. The flexibilities were there and I support them, but we left office with a national pay system in place. I look forward to his support later this afternoon.

We have a new Secretary of State, but those who expect a change of direction look set to be disappointed. In his first major interview, he described his mission thus:

“I would like to be the person who safeguards Andrew Lansley’s legacy”.

That must qualify as the shortest suicide note in political history. We have Lansley-lite—more of the same—but, in fact, it may be worse.

Looking at the Secretary of State’s past speeches, I could find nothing that conveyed any passion, belief or commitment to the NHS. On the contrary, I was worried when I read that he tried to remove Danny Boyle’s NHS tribute from the opening ceremony of the Olympic games. He is also one of the co-authors of a right-wing pamphlet entitled “Direct Democracy”. He may remember that pamphlet. It said:

“Our ambition should be to break down the barriers between private and public provision, in effect denationalising the provision of health care in Britain.”

Is that still the Secretary of State’s view? He has gone quiet now, has he not?

You will understand, Mr. Speaker, why NHS supporters get nervous about the intentions of this Secretary of State, but today he has a chance to calm those nerves. He can come to the Dispatch Box and send the clearest of messages to NHS trusts seeking to break from national pay. What he will learn about his job is that, if he says something with sufficient force, the NHS will respond.

The developing pay crisis in the NHS is the Secretary of State’s first real test, but so far he is failing it. As we reveal today, on his watch, the 20 NHS trusts that were threatening to break away in the south-west have become 32 NHS trusts across England. That is creating real worry for thousands of NHS staff and uncertainty for businesses, which have raised their concerns with the Chancellor. But what do we get from the Government today? A “do nothing” amendment expressing no view on the south-west issue, and inviting Government Members to sit on the fence and wait for the conclusions of the pay review body’s review. That will not do.

As the Government do nothing, national pay is being unpicked and the NHS is fragmenting before our eyes, but perhaps that is all part of the plan—it is nothing to do with them; it is all due to a local decision. The idea is to hide behind a review while national pay slowly and conveniently unravels, region by region, trust by trust. Staff facing the threat of a pay cut deserve some straight answers, but rather than getting a straight answer to the question “Does the Secretary of State support regional pay in the NHS or not?”, they are hearing contradictory statements from this shambolic Government. Not for the first time, the coalition is not speaking with one voice. I understand that the Liberal Democrat conference passed a motion opposing regional pay and that the Deputy Prime Minister was captured on film voting for it—although, as we know, being photographed making pledges does not make him more likely to keep them.

The Deputy Prime Minister has also made the following unambiguous statement:

“There is going to be no regional pay system. That is not going to happen.”

The trouble is that it is happening, under the Deputy Prime Minister’s nose and by the back door. Twenty NHS trusts in the south-west are openly defying the authority of the Deputy Prime Minister. Some 88,000 NHS staff are being affected by a unilateral drive to set a new going rate of NHS pay in the regions, which would be up to 15% lower than national “Agenda for Change” rates. The trusts are proposing to end overtime payments for night, weekend and bank holiday working, and to reduce holiday leave. They are also proposing to force staff to work longer shifts, and to cut sick pay rates drastically. That is no idle threat. The silence from Ministers is clearly emboldening them. Despite concerns raised here and elsewhere, they have built a fighting fund, set up a website, and appointed lawyers to make all this happen.

--- Later in debate ---

[Mr Geoffrey Cox (Torridge and West Devon) (Con)]

It is never pleasant not to be in complete concurrence and happy harmony with one’s own Front Bench, but I hope the Minister will not ignore the fact that, despite voicing concern about the Government’s position, I strongly deplore the Labour party’s behaviour in taking a position that can only be described as cynically opportunistic. It is simply untenable for the right hon. Member for Leigh (Andy Burnham) to contend that he can, like Pontius Pilot, take his hands off the situation and wash them clean of what is going on in the NHS in the south-west today.

It is precisely the implementation of the freedoms granted under the right hon. Gentleman’s stewardship that these consortia are operating. He is in exactly the same position as the householder who opens the door to the burglar, and then complains when he walks in and burgles the property. He opened the door with his changes. It was his policy that introduced flexibilities, and to suggest that he was blind to the probability that trusts would exploit it by introducing differentials in pay up and down the length of the country is not merely naive but wilful irresponsibility and will be judged by people listening to this debate. The people in the low-wage areas I have the honour and privilege to represent will not be fooled by the Labour party’s position.

On the other hand, it is perfectly fair to say that the introduction of regional pay in the NHS would be a retrograde and wrong step. The fact is that low-wage areas, such as those I represent, are already suffering: 26% of families and homes in Torridge are on the edge of poverty. Only two constituencies in Cornwall, an area that receives special help in the form of objective 1 money from the EU, are in a worse position than those in Torridge and West Devon.

[Andrew George]

I represent one of those constituencies. In view of the hon. and learned Gentleman’s comments about the right hon. Member for Leigh (Andy Burnham) and his criticism of regional pay—a stand I entirely agree with—would he acknowledge that the Conservatives voted in favour of the legislation that brought in foundation trusts and flexibilities, and does he regret that? I recognise, of course, that he was not in the House at the time.

[Mr Cox]

I do not believe that any party can take its hands off and claim to be not responsible for measures that allowed trusts to exploit the ability to drive down pay by forming such consortia. The Labour party cannot disavow responsibility, and neither, if it voted for it, can the Conservative party.

I want to say something about regional pay. I hope and I am sure that the Minister is listening. I have already written to my right hon. Friend the Secretary of State. In areas such as Torridge and West Devon—areas that depend on public sector pay to create the spending and buying power that puts at least some life into its economy—the concept that pay could be even lower than it is now is unconscionable and inconceivable to those of us who represent them. I hope that the Government will think again in this review. I am comforted by the Secretary of State’s words when he says that they are committed to national pay scales. I hope that those words can be counted on.

I, for one, could not support a measure that introduced regional pay as formal NHS policy, unless I was satisfied that there were sufficient safeguards for the low-wage areas I represent. People often associate rural areas such as Torridge and West Devon with prosperity, but that is a grossly inaccurate caricature. In Torridge, 26% of households are on the edge of poverty, wages are in the bottom 5% of all areas in the country, and West Devon is not far behind. It is simply inconceivable for me, as its representative, to agree to a proposition that would further depress incomes in those areas.

Having said that, it is clear that the NHS has to do something about the pay bill, which is 70% of its budget, and the only appropriate way of dealing with it is for the unions and all parties, including all political parties, to tackle it at a national level. I am disturbed that those national negotiations are apparently not taking place. I hope that the right hon. Member for Leigh will encourage the unions to take part in those discussions, because we all have to accept that there is a major national problem with the burden of the NHS pay bill.

--- Later in debate ---

[Andrew George (St Ives) (LD)]

It is a pleasure to follow the hon. Member for Worsley and Eccles South (Barbara Keeley), a fellow member of the Health Committee. I endorse her comments. She, like many others, has emphasised the reason it is so important that the House rejects the concept of regional pay and urges unions and employers to accelerate the process in order to reach a speedy conclusion on national pay bargaining. This is a serious issue, and it deserves a serious response from all parties in the House. It should not become a subject to be kicked around the playground of an Opposition Day debate in an opportunistic manner, as has so often happened—before the election as well as after it, to be fair. A matter as serious as this should not be debated in that way.

I intervened on the right hon. Member for Leigh (Andy Burnham) to ask whether he would acknowledge that we are where we are today because of the freedoms the previous Government created for the cartel in the south-west, or in any other part of the country. We are aware that other trusts are looking closely at what is happening with that cartel. The previous Government should be applauded for introducing the “Agenda for Change” and attempting to introduce a rigorous and effective method for agreeing pay and conditions at national level, but they also legislated to introduce foundation trusts and the new freedoms that went with them. The Liberal Democrats opposed that legislation at the time.

[Andy Burnham]

rose—

[Andrew George]

I was going to go on to talk about employment law, but I am happy to give way to the right hon. Gentleman.

[Andy Burnham]

This subject has featured a lot in today’s debate. I would encourage the hon. Gentleman to go back to the speeches made by Ministers when that legislation was being introduced. They were clearly saying that there could be occasions when flexibility would be needed at the margins to deal with a particular short-term pressure or problem. Such an arrangement was used once, in respect of Southend, to put pay up. It is important to understand that there was no suggestion that pay could be reduced across the board in a co-ordinated, orchestrated move to undercut the national pay system that was being brought in at the same time. That argument has been put today, but it simply does not hold water.

[Andrew George]

That might have been the stated intention, but the effect is being seen through the cartel’s actions. What is happening is not the result of any coalition Government legislation; it is the result of an opportunity having been made available under employment law. This is not within the parameters of “Agenda for Change”. It is a result of the freedom given to foundation trusts to step outside those agreements and to use employment law to seize the opportunity of certain flexibilities, to the detriment of the employees in their pay. That might not have been the intention behind the legislation, but it has been the effect of it, whether the previous Government appreciated that or not.

If the right hon. Gentleman is really so concerned about this, and given the fact that he can now see the effects of his legislation being played out by the cartel in the south-west, perhaps the shadow Minister, the hon. Member for Copeland (Mr Reed), will acknowledge, in summing up the debate, that that was not the intention behind the legislation. Will he, having noted what is now going on as a result of that legislation, commit to rescinding that element of it if Labour were to come to power, to put right the weaknesses of it? If so, we would know that Labour Members were genuine and sincere in their intent, and that they acknowledged that weakness, which they had not anticipated at the time but which is now being exploited.

I strongly support my hon. Friend the Member for Southport (John Pugh) and congratulate him on his characteristic breathtakingly brilliant contribution to the debate. He was most entertaining, and there was disappointment across the whole House when he resumed his seat without having used all the time available to him. He made many insightful comments about the situation we are in today, and the weaknesses of it.

I also thank my hon. Friend the Member for North Cornwall (Dan Rogerson) for pointing out the significant weaknesses in the legislation and the impact they are likely to have on NHS staff. I am pleased to see my hon. Friend the Member for St Austell and Newquay (Stephen Gilbert) in the Chamber today. We are all aware that the Royal Cornwall Hospitals Trust’s involvement in the cartel is creating deep concern across Cornwall. The hon. Member for Truro and Falmouth (Sarah Newton) made a telling intervention earlier when she said that Cornwall has some of the highest costs of living in the country, while perpetually being at the bottom of the earnings league table, pretty much since records began.

One of the drivers behind the problem is the cherry-picking in the NHS. The private sector is already offering the easiest procedures. A private provider in Cornwall carries out the easiest procedures for the fittest patients with low anaesthetic risk and those who are the least likely to suffer complications following orthopaedic procedures. It is now extending its services into areas such as cardiology, hernias, haemorrhoids and endoscopy. If any complications occur, it will simply pass the patient across to the Royal Cornwall Hospitals Trust to deal with any difficulties or emergencies. It therefore has no need to invest in all the facilities necessary to provide the kind of wrap-around service that we want the NHS to provide. The fact that such private sector companies are able to vary wages, terms and conditions for their staff is undermining the NHS. The foundation trusts are having to compete with those companies, and that is one of the pressures that is driving their agenda. All parties need to recognise that fact, and Ministers need to acknowledge that this continued cherry-picking by the private sector is fundamentally undermining the capacity and ability of the NHS to respond adequately.

We must also ask why we are in this situation in the south-west. In regard to resource allocation, only two years ago Cornwall was getting £56 million a year less than the Government said that it needed to provide the necessary services. If there is a significant gap between the funding actually provided for the local health community and the amount that the Government say is the target funding, it is no wonder that local trusts find themselves having to make extremely challenging decisions.

I urge the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), when he winds up the debate, to acknowledge that resource allocation still needs to be addressed. Members of Parliament from across the south-west and I have arranged to hold a meeting with him on this matter, and I hope that it will take place soon so that we can have an opportunity properly to address the issues.

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[Andrew George]

If the hon. Gentleman really believes that, and the motion does say that the Government should intervene, is he aware that his Government gave foundation trusts such freedoms that in fact the Government cannot intervene?

[Mr Bradshaw]

Of course they can.

[Andrew George]

They cannot.

[Mr Anderson]

Clearly, there are issues about foundation trusts, but the Government can do what they want—or they can as long as the Liberal Democrats help them. Tonight, however, the Liberal Democrats have a chance of stopping the Government doing what they want, by doing what their party wants, and what the people they represent want—by throwing out the proposal, and voting on the clear principle that national pay bargaining should happen in the national health service, and nothing should be done to undermine it, including supporting the amendment.

Regional Pay (NHS)

Andrew George Excerpts

Wednesday 7th November 2012 Westminster Hall

[Mr Bradshaw]

The tariff is a separate issue, but that was an interesting intervention, because, for the first time, we had a Conservative MP actually speaking out in favour of regional pay in the NHS. That is not Government policy, and in all the correspondence that I have had from Ministers, they have denied that it is. At least the hon. Gentleman is one of the few MPs in the south-west who has the courage to be honest and to say that he supports it. He is almost alone; I have not spoken to a single other Conservative or Liberal Democrat Member of Parliament who supports this policy. I hope, as I said earlier, that those who do not support it will have the courage of their convictions, stand up for the west country for once and vote for the Labour motion in the main Chamber later.

As I was saying, there will be an exodus of staff to other regions and to hospitals in our region that are not part of the cartel. Between May 2010 and 2012, the south-west suffered the biggest reduction—3.54%—in qualified nurses of any region in England, and the situation is set to get worse. However, the impact will be felt not just on the health service. The south-west of England already has the biggest gap of any region in England between housing costs and wages. A reduction in public sector pay in our region of just 1%—of course, the reductions that we are talking about are much bigger—would suck £140 million out of the south-west economy, at a time when we need more, not less, demand in our economy.

I acknowledge, as do the unions and staff organisations, that there may be a case for changes to Agenda for Change. The NHS—this is partly a response to the point made by the hon. Member for Plymouth, Sutton and Devonport (Oliver Colvile)—is, after all, having to cope with the huge costs of the Government’s disastrous reorganisation of the health service, combined with its tightest-ever funding. However, the answer is to deal with these issues in national talks, in the usual way, and not to allow these parallel plans to proceed, threatening to derail national discussions and making a sensible agreement at national level less likely.

[Andrew George (St Ives) (LD)]

I would be grateful if the right hon. Gentleman clarified whether he supported the previous Government’s introduction of regional pay in the Courts Service or the freedoms that they gave foundation trusts, which enabled this very cartel to be established?

[Mr Bradshaw]

I am afraid the hon. Gentleman is wrong: the FT legislation allows FTs to pay wages that are as good as, or better than, those under Agenda for Change, so the claim often made by Liberal Democrats, who feel very uncomfortable being part of a Government who support regional pay in the NHS, is wrong. The FT legislation is quite clear: FT hospitals must pay rates as good as or higher than those under Agenda for Change. The hon. Gentleman’s point is completely irrelevant to our discussion.

In their answers to me so far, the current Health Secretary and his predecessor have tried to hide behind the very flexibility argument that the hon. Gentleman has just made—that flexibilities already exist in Agenda for Change—and they have declined to intervene. Yes, there are flexibilities in Agenda for Change to allow for local market conditions, but that is not what we are talking about. What we have here is an explicit—those involved have made it explicit—walking away from Agenda for Change, with the wholesale adoption of a regional and regionally negotiated pay structure, which, incidentally, takes no account of the different market conditions in, say, Cornwall and Wiltshire.

I know, as a former health Minister, that all it would take is a simple word from the Minister here today, and this madness could be stopped. Will she undertake to Members to intervene and make it clear to the 20 trusts involved that the Government do not support regional pay and that they should rejoin the national pay negotiation process under Agenda for Change? If she will not do that, she needs to explain why—and, please, no flannel about the NHS trusts being autonomous. She has been a Parliamentary Private Secretary and then a Minister for long enough to know that all she needs to do is speak to Sir David Nicholson, the chief executive of the NHS, or to the estimable chief executive of the southern region, Sir Ian Carruthers, and they would stop what is happening. If she will not intervene, she also needs to explain why she is prepared to continue to inflict damage on south-west NHS staff morale and destabilise the national pay negotiations.

If what is happening was thought up in the Department as a clever ruse to get the national talks kick-started, or to try to wring more concessions out of the staff side, it has backfired disastrously. There is a sensible way through, which the Minister has the power to achieve: to agree changes to Agenda for Change at the national level. The alternative is continuing uncertainty, long-term damage to staff morale and a wholly irresponsible risk to patient safety and the quality of care in the south-west of England.

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[Andrew George]

It is my understanding that the cartel is not entirely engaging with the unions in the way that the unions believe it should. What powers do the Government have to intervene in the activities of the cartel, within the powers and guidance that were conveyed to them by the previous Government in the regulations?

[Anna Soubry]

I hope to answer those points in my speech, in the time available to me. If I do not, I will of course write to the hon. Gentleman and answer those questions in full.

I want to talk about the financial situation in the national health service. We have already guaranteed the NHS preferential funding for the current spending review, ensuring real-terms growth every year and additional cash of more than £12 billion per annum by 2014, going into 2015. We are driving up £20 billion of quality, innovation, productivity and prevention savings, stripping out bureaucracy, cutting management costs by up to one third and shifting resources to front-line services. To be blunt, we cannot spend more on public expenditure without putting our national financial reputation at risk. We must demonstrate that we have the commitment to ensure that our economy is sustainable.

The south-west consortium faces a stern choice. It can either continue to ignore the problem, and hope that it will go away, or it can face the challenge, share it with its staff and their representatives, and work in partnership to achieve the best outcome for everyone concerned, especially patients. I used to be a shop steward and a member of the National Union of Journalists. I understand and value the role of good partnership working with staff and trade unions. I believe that the south-west consortium is taking a mature approach. It published two discussion documents in August, setting out the scale of the financial and service challenge that it faces. It has not made any decisions. It has produced a paper, setting out a wide range of options for changes to terms and conditions, and how they might help. It has included options affecting all staff, including doctors, so that every opportunity is considered, no stone is left unturned, and there are no sacred cows. I believe that that is a responsible approach.

The consortium reaffirmed its commitment to national terms and conditions and agreed not to put any proposal to its boards until December, allowing reasonable time for the conclusion of national negotiations on a possible agreement to make Agenda for Change changes sustainable. I believe that that, too, is responsible.

--- Later in debate ---

[Anna Soubry]

I agree with my hon. Friend. Monolithic structures would not be welcome. What is welcome is when trusts take a responsible view to ensure that they act in the best interests of their employees and that they have a financially sustainable system. That is in the interests of everyone—staff and patients.

[Andrew George]

Following my intervention on the right hon. Member for Exeter, he responded that the only flexibility is to exceed existing pay and conditions, not to go below them. Is that also the Minister’s understanding?

[Anna Soubry]

My understanding is that foundation trusts—the hospitals—have powers and a great deal of autonomy. That was the system set up and backed throughout by the previous Government, and it continues today. NHS employers are better placed to decide how best to reward and motivate their staff for the benefit of patients. They are better placed to assess whether national terms are fit for purpose or sustainable in the light of local competition, and to assess the options and risks of any recruitment or retention problems that might follow from introducing local pay. Such decisions should not be, in my view, made by Ministers.

Some Members have expressed concern that it is not fair to pay different rates for the same job in different areas, as it could undermine recruitment or morale. I understand and appreciate the arguments advanced by many people and the concerns raised by those on both sides of the House. However, if that was the case, one might have thought that the Labour Government should not have included high-cost area supplements or recruitment and retention premiums when they introduced Agenda for Change in 2004, and that they should not have abolished the right of the Secretary of State to direct foundation trusts in 2003. The Labour party gave those powers to employers, and I make it quite clear that they were right to do so. We now have to trust employers to exercise their judgment wisely and to use the skills and expertise of their non-executive directors to consider what is in the best interests of their patients. We have to recognise that they know what rates of pay are fair and necessary in their local communities.

The Opposition need to allow the system that they created to work, without the political interference and micro-management that typified their term in office. If they want to do something useful, they should encourage the trade unions—those that fund many of their Members of Parliament—to ensure a swift and successful conclusion to national negotiations. That will secure the Agenda for Change as a sustainable option for employers and staff alike. Above all, it will put patients first and foremost.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 23rd October 2012 Commons Chamber

[Mr Jeremy Hunt]

It will be a totally impartial and very thorough review. This is an extremely important decision, and that is why I asked the Independent Reconfiguration Panel to take the time that it needs to do the review properly; that is the least that the hon. Gentleman’s constituents would want.

[Andrew George (St Ives) (LD)]

In order to get the Health and Social Care Act 2012 through this House, the Government gave explicit assurances that private companies could not cherry-pick the easiest procedures and patients, yet a recent letter from David Flory, the deputy chief executive of the NHS, back-pedals on the Government’s position, and shows that the Government are dependent purely on guidance. What can the Government do to put a bit of backbone back into that important policy?