Health Service Medical Supplies (Costs) Bill

Andrew Murrison Excerpts

Ping Pong: House of Commons
Wednesday 15th March 2017 Commons Chamber

[Mr Dunne]

I remind the House of the importance of this Bill. NHS spending on medicines is second only to staffing costs. The NHS in England spent more than £15 billion on medicines during 2015-16, a rise of nearly 20% since 2010-11. With advances in science and our ageing population, the costs will only continue to grow.

The UK has a lot to be proud of: we have a world-class science base and an excellent reputation for the quality and rigour of our clinical trials and the data they produce. The UK has one of the strongest life sciences industries in the world, generating turnover of more than £60 billion each year. Indeed, it is our most productive industry. The Government are deeply committed to supporting it to flourish and, in doing so, to provide jobs and transform the health of the nation.

In the 2016 autumn statement, an additional £4 billion of investment in research and development was announced, specifically targeted at industry-academia collaboration. We expect the life sciences industry to be a substantial beneficiary. That comes on top of measures such as the patent box and the R and D tax credits that the Government have introduced to encourage investment from innovative businesses.

That determined action is reaping rewards. The UK ranks top among the major European economies for foreign direct investment projects in life sciences. Last month, the Danish drugs company Novo Nordisk announced a new £115 million investment in a science research centre in Oxford. That comes on top of an additional investment of £275 million announced by GSK last June and AstraZeneca reaffirming its commitment to a £390 million investment to establish headquarters and a research centre in Cambridge—it is good to see the hon. Member for Cambridge (Daniel Zeichner) in his place. Looking ahead, Professor Sir John Bell, the regius professor of medicine at Oxford, has agreed to lead the development of a new life sciences strategy for the long-term success of UK.

At the same time, it is important that we secure better value for money for the NHS from its growing spend on medicines and other medical supplies. I remind the House that, overall, the Bill will do three things. First, it will enable us broadly to align our statutory scheme for the control of prices of branded medicines with our voluntary scheme, by introducing the possibility of a payment percentage for the statutory scheme. That could deliver £90 million of savings annually for the NHS. Secondly, the Bill will give us stronger powers to set the prices of unbranded generic medicines if companies charge unwarranted prices in the absence of competition.

Thirdly, the Bill will give us stronger powers to require companies in the supply chain for medicines, medical supplies and other related products to provide us with information. We will use that information to operate our pricing schemes, to reimburse community pharmacies for the products they dispense and to assure ourselves that the supply chain of specific products provides value for money for the NHS and the taxpayer.

During the Bill’s passage through the other place, the Government tabled 23 amendments, following debate and discussion in this House and with peers. I firmly believe that those amendments make it a better Bill. However, I will start with Lords amendment 3 and set out the reasons why it does not improve the Bill.

Lords amendment 3 would introduce a duty on the Government, in exercising their functions to control costs, to have “full regard” to the need to

“promote and support a growing life sciences sector”

and the need to ensure that patients have access to new medicines. The amendment would undermine one of the core purposes of the Bill by hindering the ability of the Government to put effective cost controls in place. Controlling the prices of medicines cannot, in itself, promote the interests of the life sciences sector and deliver growth. Having such a requirement in legislation could encourage companies to bring legal challenges where the cost controls have not, in themselves, promoted growth in the life sciences industry. That could significantly hinder the Government’s ability to exercise their powers to control costs effectively.

For example, if the Government were to take action to control the price of an unbranded generic medicine, because it was clear that the company was exploiting the NHS—several examples of that have been raised throughout the Bill’s passage through this House—it could be argued that that action did not promote the life sciences sector, because every generic drugs manufacturer could argue that it is a life sciences company. Nevertheless, that would, of course, be the right thing to do for the NHS, for patients and for taxpayers. Lords amendment 3 would enable companies to challenge any action by the Government to control costs by arguing that proper regard had not been paid to supporting a growing life sciences industry. The amendment would therefore make it more difficult to control costs, including where companies seek to exploit the NHS over and above the interests of patients, clinicians and taxpayers.

I say gently to those on the Labour Benches that it is ironic that they talk tough on the pharma companies, which they claim in other forums routinely seek to exploit the NHS, when today they are arguing the cause of the industry by supporting an amendment that would provide it with a legal stick with which to challenge the NHS when it seeks to control the costs of drugs, some of which, as they acknowledge, are exorbitantly priced. I therefore have to ask the hon. Member for Ellesmere Port and Neston (Justin Madders): whose side is Labour on?

The Government are seriously concerned that Lords amendment 3 has the potential to impact negatively on our ability to control costs. I do not expect that that was the aim of well-intentioned Members in the other place. I hope both Houses agree that it would be damaging to the NHS if, on every occasion that the Government deem it necessary to use their powers to control costs, the Government could be challenged for failing to give full regard to promoting the interests of life sciences companies.

The second part of Lords amendment 3 requires the Secretary of State to have full regard to the need for NHS patients to benefit from swift access to innovative medicines that have been recommended by the National Institute for Health and Care Excellence through its technology appraisals. However, NHS commissioners are already legally required to fund drugs and other treatments recommended in NICE technology appraisal guidance, normally within three months of final guidance. The Secretary of State’s power to control costs is a completely separate process. Therefore, this part of the amendment would not achieve anything.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

The Minister is of course absolutely right on the primacy of NICE in this matter, but today the NICE board will be imposing a budget threshold of £20 million a year, which would have the effect of at least delaying or possibly preventing the roll-out of new medicines. Does he share my concerns, particularly in relation to cancer drugs?

[Mr Dunne]

My hon. Friend is right to point out that NICE is considering today in its board meeting thresholds for the introduction of new medicines. What I would not do, however, is share his concern that it will necessarily lead to delay in their take-up. In essence, it will provide NHS England with greater commercial flexibility to negotiate with drugs companies that propose to introduce a drug that may cost more than £20 million in a full year. It will give NHS England more time to negotiate a lower price with the pharma company. That should not, in and of itself, lead to either delay or less take-up.

I am aware of the concerns, expressed by my hon. Friend, other Members and some charities in a national newspaper today, about the joint NICE and NHS England consultation on the proposed changes to the appraisal and adoption of new technologies. There have been suggestions by Opposition Members that this is rationing of NICE-approved medicines. I assure the House that that is not the case. Patients will continue to have the right to NICE-recommended drugs, as enshrined in the NHS constitution. The proposals are intended to ensure that patients benefit from even faster access to the most cost-effective treatments, while addressing issues of affordability as well as effectiveness.

Let me be very clear: Lords amendment 3 would not impact on the proposals; the NHS will continue to fund a product approved by NICE, in line with NICE recommendations. I also remind Members that NICE and NHS England are making the changes to address concerns about the affordability of high-cost new drugs and other technologies that were raised by the Public Accounts Committee, which is chaired by the hon. Member for Hackney South and Shoreditch (Meg Hillier).

I have read the suggestion by the Opposition that the NICE and NHS England proposals would be contrary to our intent to increase the uptake of new medicines. As I said to my hon. Friend the Member for South West Wiltshire (Dr Murrison), that is false. In reality, last year saw spend on medicines grow more quickly than in any of the past 10 years, as we seek to secure rapid access to new medicines for patients.

Access to medicines is primarily dependent on clinicians’ choices about what is best for their patients. Clinicians need to be aware of new medicines and persuaded that they may be a better option for their individual patients, taking into account other conditions each patient may have and other medicines they are taking. We need to change the culture and behaviour of those clinicians who may be reluctant to use innovative medicines, and legislation is not the right way to effect behaviour change in the NHS.

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[Justin Madders]

My hon. Friend is right to express that concern. We do not really know where this rebate has ended up, but all Members know from their personal experiences and our debates that across the board rationing is reaching unprecedented levels, particularly for new and innovative treatments. This is not just a manifestation of the financial straitjacket the health service currently operates in, nor is it just a disaster for individual patients, nor is it just an abrogation of the Minister’s responsibility to uphold the fundamental principles of the NHS; it is also a direct threat to the future prosperity of our life sciences industry. In answer to the Minister’s question about whether we are on the side of patients, I say we absolutely are. Proposed new clause 3(b) makes it very clear that we are on the side of patients, and in particular their ability to access new and innovative treatments.

It is impossible to look at the health of the pharmaceutical sector in this country without considering the central issue of access to treatments. The UK is home to about 4,800 life sciences companies and it continues to have the largest pipeline of new discoveries anywhere in Europe. We are all rightly proud of that. However, the fruits of this innovation are increasingly being enjoyed by patients in other parts of the world before NHS patients can benefit. For every 100 European patients who can access new medicines in the first year they are available, just 15 UK patients have the same access. How can anyone look at that and not say that something is going badly wrong?

As I set out in previous debates on the Bill, a recent report by Breast Cancer Now and Prostate Cancer UK showed that NHS cancer patients are missing out on innovative treatments that are available in any other comparable country to the UK. That should surely shame us all, and it looks as though the situation will get worse. A number of cancer charities estimate that the proposals by NICE to introduce a budget impact threshold could affect one in five new treatments. With one of the options available being a longer period for a phased introduction, the worry is that more patients will be denied access to those critical treatments. I thought that this Bill was meant to be the mechanism by which the cost of drugs would be controlled. Can the Minister explain the flaws in the proposed new pharmaceutical price regulation scheme that make this extra method of cost control necessary?

A debate in this place a few weeks ago drew attention to a number of breast cancer drugs, including Kadcyla, Palbociclib and Perjeta, that might no longer be funded due to changes to the cancer drugs fund. Those are but three examples. Media analysis by the King’s Fund found that there were 225 stories relating to rationing of services in 2016, compared with 144 in 2015 and 86 in 2011. There is clearly a trend developing and we need to reverse it.

We do not have much time today, so I shall draw my remarks to a close by reminding the House that this debate touches on many important issues that are all interlinked—three of them in particular. The first involves securing better value for the NHS; the second involves ensuring full and rapid access to treatments for NHS patients; and the third involves the need to support and promote our life sciences sector. The Government will not achieve any of those aims unless they adopt the right approach to all three. The Bill aims to put in place a system that will deal with the first of those aims, which we support. The amendment that we support today seeks to send a clear message to patients and to industry that the Government consider the other two elements equally important. That is why we are so disappointed that they are not prepared to listen to the overwhelming view expressed in the other place and support that amendment. I urge the Minister to reconsider.

[Dr Murrison]

I shall speak briefly to Lords amendment 3, but first I chastise the hon. Member for Ellesmere Port and Neston (Justin Madders), if I may, for his remarks about money. He is right to say that this is all about money, but I seem to remember that less than two years ago, he stood for election on a manifesto that would have had the effect of opposing the money that is currently going into the national health service, so we should not take any lessons from the Labour party on financing the NHS.

The Government are absolutely right to oppose this amendment. It looks a bit like a probing amendment, to be honest, and I am a bit surprised that it has got this far. It would subject this very good Bill to a whole shedload of judicial review. It would be a lawyers’ beanfeast. It bewilders me that people in this House who argue that the NHS needs more money, which it most certainly does, should support such a proposal when all the money would be going into the pockets of lawyers.

NHS England must fund any new drug found to be cost-effective by NICE within 90 days of that approval. This afternoon, the NICE board will approve this new measure, which will establish a budget impact threshold of £20 million. The hon. Member for Ellesmere Port and Neston is right to say that about one in five drugs will probably be within scope of the measure, and that is a cause for concern. Patients in the UK do not enjoy the full range of advanced medicines that are reckoned to be more or less routinely available in countries with which we can reasonably be compared—or if they do, they usually find that they are subject to unwarranted delays before they are treated. That is of course critical in the case of conditions such as cancer, and could well mean the difference between life and death; it will certainly mean a whole load of difference in quality of life. It is vital that we do nothing that would extend that process.

In response to my earlier intervention, the Minister gave me sufficient reassurance that the delay that the measure would introduce would be small, and that this would be an opportunity for NHS England to negotiate a lower price for these very expensive medicines. Indeed, that is the intention. Given that, I am more than happy to support the Government on this. However, any delay at all will send a signal to those in the life sciences sector; it is important that we make it clear that this will not introduce unwarranted delays in the introduction of new medicines, because frankly that would put them off. A lot of worthy work has been done recently, which has involved spending a lot of money, to support a vital part of our economy, and it would be a great pity if anything in the Bill reduced our life sciences sector’s ability to prosper in the years ahead.

Health and Social Care Budgets

Andrew Murrison Excerpts

Tuesday 14th March 2017 Westminster Hall

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I congratulate the hon. Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, on securing this debate. First, I would point out that a strong NHS requires a strong economy, and on that front the Budget brought good news.

In the short term, we need to think about how to deal with some of the problems we now face. To that extent, I very much welcome the £2 billion for social care, the £300 million to underpin sustainability and transformation plans and the £100 million for A&E. I also welcome the rumours of more medical school places, which, as my hon. Friend the Member for Totnes (Dr Wollaston), the Chairman of the Health Committee, said, are very important indeed.

We need to look at intergenerational fairness. Sadly, most healthcare cost is generated in our declining years. It is reasonable, after 2020, to look at instruments such as the triple lock to see whether those substantial sums of money should be handed to our national health service. Most elderly people I know would welcome such a thing.

We need to look fundamentally at what to do with healthcare funding going forward. It is very good to hear of the injection of money in the Budget, but it will not do in the long term, for reasons that have been explained. A Green Paper will not do either. Although that is welcome for social care, health care is much more complex.

A conversation with the public means looking fundamentally at what underpins our health service and trying to work out why outcomes in this country fall significantly short of those in countries such as Germany, which has been mentioned, France and Holland. That means examining Beveridge versus Bismarck, something in between or something completely different, which requires a commission or a convention—perhaps an Adair Turner-type commission. It needs to have that conversation with the public. On the NHS’s 70th birthday, that is appropriate, because we need to carry the public with us if what we are ultimately suggesting is quite substantial sums of money injected into healthcare to bring our healthcare outcomes to where they should be.

As an optimistic sort of person, I rather suspect that the reason why a Green Paper has not been suggested for healthcare—notwithstanding the “Five Year Forward View”, which is only halfway through its evolution—is that the Government are considering such a conversation as a proposition. I very much hope that the support I think the Prime Minister gave to the concept when a number of our colleagues met a short while ago is translated into concrete proposals in the near future, so that—on a cross-party basis—we can have the convention, commission or conversation that we need with the public to establish, in the NHS’s 70th year, a long-term funding arrangement for this national institution that we all hold so dear.

Rothbury Community Hospital

Andrew Murrison Excerpts

Thursday 9th March 2017 Commons Chamber

[Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)]

It is an honour to have finally been successful in the debate ballot and to bring the issue of the proposed closure of in-patient care beds at Rothbury community hospital to the House and to the Minister today.

Rothbury is a thriving small town at the heart of the Coquet valley community in my constituency, in Northumberland. The valley is a large, very rural and sparse community of over 5,000 people across hundreds of square miles, and it runs from the A697 at its eastern edge across to the Cheviot hills and the Scottish border to the west. Small villages and hamlets are dotted across traditional agricultural territory with mainly upland sheep farms, some of which are within the Northumberland national park and the Otterburn Ranges—the Army’s largest training base in England.

Families’ commitment to living in this idyllically beautiful but quite challenging day-to-day environment is vital to the land management necessary for our tourism, our farming and our military needs as a nation. Over 30% of those living in the valley are over the age of 65—a figure that will only grow, as Rothbury and the surrounding villages are wonderful places to retire to or for people to stay in long after their children have flown the nest. Therefore, we must plan for the right long-term, sustainable healthcare offer for this close-knit community of families and businesses and for the unique challenges they face.

The local community hospital has, until now, provided 12 in-patient beds, primarily for palliative, post-operative recovery and respite care. The clinical commissioning group reviewed activity data last year as it brought in a system-wide approach to discharging patients home, and average bed occupancy in Rothbury was 50% through 2015-16. The CCG declared that to be too low to be sustainable.

As a result of nursing workforce challenges across the Northumbria healthcare trust—albeit that we face fewer challenges than the rest of the UK, thanks to our excellent forward-thinking trust, doctors and managers—the reality is that we do not have the nursing capacity adequately to cover the 12 in-patient beds at Rothbury at present. A combination of those workforce challenges, and the under-occupancy concerns cited by the CCG, meant that the use of those in-patient beds was suspended temporarily in September 2016.

Where I part company from our hard-working CCG on this issue is that I believe that those beds have been empty not because of a lack of demand, but because decisions have been taken to send people home to receive community care, or to Alnwick infirmary to receive in-patient care. As a result, Alnwick infirmary has been running near to capacity for some time, and those in the north and east of my constituency who might otherwise have been sent there have been forced to remain in the urgent care beds at the UK’s first specialist emergency care hospital at Cramlington— our new specialist care hospital for the whole of Northumberland and north Tyneside—for longer, placing greater strain and expense on our healthcare system than necessary.

If this in-patient ward is permanently closed, that will have negative impacts on my Coquetdale community and greater financial implications for our NHS across Northumberland. In particular, the challenge is that we do not have anything like enough community nurses and carers adequately to support those older patients who are sent straight home with their transition back to independent living. It has always been a challenge for our community teams, working across rural Northumberland, to see anything like the number of patients in one day that they would see if they were based in a town or a city, because our CCG is not funded to commission enough community nurses to genuinely provide the amount of care to meet the extra challenges that this sparse and disparate community generates. If a community nurse needs to visit someone three times a day but her other patients are 30 miles away, she will make three or four visits a day rather than the 10 or so that an urban-based community nurse would be able to make. Many of our older people who have received medical interventions live alone or have elderly partners who are no longer able to be full-time carers themselves. The value of a step-down care transition provided by a few days of recuperation at Rothbury community hospital would have medical as well as psychological value for these communities.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I congratulate my hon. Friend on the powerful case she is making for her rural constituency. Has she been able to compare and contrast the cost of a community hospital bed with the cost of a bed in the district general hospital to which she referred? I suspect that she has done so and will have found that there is a yawning difference between the two—a very good argument for community hospital beds.

[Mrs Trevelyan]

I thank my hon. Friend for making that point. This issue is critical, and it has brought some confusion to the community, who felt that the financial model did not seem to make sense. Why keep someone in a very expensive acute bed for longer than necessary if there is the capacity to have a local relationship with nurses who know the community very well? This is part of the CCG’s work, obviously, but we need to be very clear about it to be sure that we are not making a bad financial decision in the longer term.

As a result of this consultation, residents across the Coquet valley who have needed admission to an acute ward may well now find themselves staying longer than necessary on that acute ward; being re-admitted to an acute ward for lack of adequate rehabilitation care at home; sent home with inadequate support from an over-stretched community nursing service; or, at best, sent to recuperate in a different community hospital much further from friends and family, placing extra pressure on alternative populations needing to use that provision.

When, back in September, the decision was taken to temporarily suspend admissions to Rothbury community hospital for a period of three months, I wrote to every household across the valley calling on them to share with me their own experiences and concerns about the proposed threatened closure of the in-patient beds. The message came back loud and clear that being near family and their own community while they recuperated, or ending their days with dignity and privacy in the valley they have lived and worked in rather than dying at home alone, is invaluable. I know that this Government want our world-class NHS to provide not only the best medical interventions but the respect and provision of dignity for every patient while they are under its care.

The Coquet valley is frequently cut off during winter months, making travel to Alnwick infirmary to see loved ones receiving care especially difficult and sometimes not possible at all. Even during the summer months, there is little public transport to connect the valley and Rothbury to Alnwick. The ability of loved ones to visit patients receiving care at Rothbury community hospital was cited time and again to me as one of the primary reasons the in-patient beds are so vital to my constituents. The value of our community hospitals is often overlooked and certainly cannot be quantified when, too often, consultants have not been made aware of their option to transfer patients to receive care in Rothbury.

My constituents have come together in an extraordinary show of unity to speak in one voice under the banner of the Save Rothbury Hospital Campaign—4,500 people have signed the petition calling for the reopening of the ward. Our CCG has worked closely with the campaign team, for which I thank them, particularly Dr Alistair Blair, who has so many pressures on him and his team at this challenging time, and has invited us to bring forward a proposal that would see the beds made available for step-down and end-of-life care. I am concerned, however, that the CCG is telling me that because it does not commission respite or palliative care services, these cannot be part of a sustainable solution, as the valley residents would hope.

Northumbria Healthcare NHS Foundation Trust is one of NHS England’s vanguard trusts with its sustainability and transformation plan, and it will be the first accountable care organisation in England in the coming months, so surely we should be able to ensure that integrated care can work in one of our most challenging geographical locations. The University of Leeds is currently conducting a study called, “Cost Structure and Efficiency in Community Hospitals in the NHS in England”. The Public Accounts Committee, of which I am a member, regularly challenges NHS England on how it spends taxpayers’ money to deliver the best integrated health and social care provision. I know that the Minister is working hard to drive this forward, and we encourage him to go further, but until the results from the University of Leeds are published, the Minister has little economic evidence of the value of the intermediate care provided by community hospitals with which to work on the sort of sustainable solution that I want to see for our community hospital in Rothbury.

[Dr Murrison]

My hon. Friend is being generous in taking interventions. I am interested in the study to which she refers. Does she agree that a likely outcome of the configuration of healthcare in the longer term will be increasing specialisation at really quite large district general hospitals? If that is the case, there will be an even greater need for community hospital beds—step-down, step-up care—otherwise people’s only access to in-patient care will be at one of the huge regional or sub-regional centres that I suspect our NHS will be developing in the years to come.

[Mrs Trevelyan]

I thank my hon. Friend for his comments. We are unwittingly seeing what he suggests already. In Northumberland, we have an extraordinary specialist A&E hospital, with which we have led the way in England. It has drawn much more attention and patient focus than perhaps any of us expected, because there in one place are all the specialisms, with the best maternity care. The result is that patient needs have migrated to it.

However, we now rely much more than we should on sending patients straight home, whereas we should be using community hospital beds to provide the best step-down care for our older people, in particular, who really need that support to get back home. Getting home, getting up and about, making their own cups of tea, moving around and avoiding the risk of muscle wastage caused by staying in a hospital bed are real issues for them. As medical science moves on and that becomes more and more clear, in-patient bed units in community hospitals should probably adapt to reflect that. Such units must help to preserve the mobility of people who are taking that step-down approach to going back home; the term “in-patient bed” should not mean that they are stuck in their beds. We understand that continued movement and redevelopment of muscle are important in rehabilitation, and we must absolutely make sure that patients are not left in the wrong part of the NHS when they are trying to get back home after extraordinary medical interventions. Those interventions are now developing very quickly and giving us the opportunity to live much longer.

I therefore call on the Minister to pause the CCG’s consultation and the plans to close permanently the in-patient beds until the results from the University of Leeds have been published. Northumbria Healthcare NHS Foundation Trust is leading the way in establishing an accountable care organisation—a model that many people buy into and understand the value of. We all instinctively assume that the NHS is one block, but of course it is not; it has always been made up of separate parts, which work better or less well depending on where they are. The accountable care organisation offers a real opportunity for streamlining and making the flows work much better. We will be the first to do that in Northumberland, so we should be the beacon for fully integrated community care—making the best use of our taxpayers’ money and ensuring that my constituents have the most appropriate and supportive care framework —rather than being a victim of the short-term workforce challenges with which the NHS is struggling.

Health and Social Care

Andrew Murrison Excerpts

Monday 27th February 2017 Commons Chamber

[Dr Wollaston]

I thank the hon. Gentleman for making that point, although I think we should use the term “delayed discharges” rather than “bed-blocking”, because the latter can make older people who are in that position feel as if somehow they might be to blame. Nevertheless, I take his point.

The estimates memorandum seeks a transfer from the capital departmental expenditure limit of £1.2 billion to prop up revenue. It also seeks a £23 million transfer from Her Majesty’s Treasury reserve, a £58.5 million transfer from other Government Departments, and a £6 million transfer to capital from other Departments. Again, we see an unsustainable position, as pointed out by the Comptroller and Auditor General.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I am following closely my hon. Friend’s remarks, which are, as ever, wise. Does she share my concern that if we are to transfer money from capital to revenue, the sustainability and transformation plans, most of which imply a certain level of capital investment in order to save revenue in the long term, will not be possible?

[Dr Wollaston]

I absolutely agree with my hon. Friend and will discuss that later.

The point about the raids on capital budgets over the years—this is the third year in which we have seen transfers from capital to revenue budgets—is that we are talking about the money required to keep facilities up-to-date, and for essential repairs and the roll-out of new technologies. Putting off such repairs and investments means they cost more down the line, so it is a false economy. It is simply an unsustainable ongoing mechanism. The Department of Health has indicated that it would like to see an end to the practice by 2020, but both the Public Accounts Committee and the Health Committee have called for it to be stopped immediately because we feel it is, as I say, a false economy. As my hon. Friend the Member for South West Wiltshire (Dr Murrison) pointed out, it is about raids not only on capital budgets, but on the sustainability and transformation fund. It is increasingly becoming all about propping up the sustainability part rather than putting in place the essential transformation.

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[Anne Marie Morris]

I thank my hon. Friend for that helpful example. She is absolutely right.

If we look at the whole measurement system—this was acknowledged in one of our Public Accounts Committee sessions by the Department of Health—we see that there is limited measurement, and that there probably should be more. When I challenged the individual concerned on whether the Government would be looking at that, he stood from one foot to the other and could not give us much of an answer. These estimates have to be based on proper measurement of need, on what is operationally put into practice, and on the outcome for patients, but that simply is not the case.

We need to look at the differences between the NHS and social care as regards how the money is allocated. In the NHS, we have some ring-fencing, while in social care we do not, but because the two are inextricably linked, unless we look at the way in which each of those pots is managed, never mind how much is in them, we give rise to problems for the future. Social care is not ring-fenced. I am sure we are all grateful for the additional moneys that have been provided, but frankly they do not go far enough. The first chunk of money might cover the living wage, and the ability of local authorities to increase the precept by 3% is welcome, but as the Chair of the Public Accounts Committee said, that is taxpayers’ money.

[Dr Murrison]

My hon. Friend is making a very good speech. Does she share my concern about the 3% precept, as shifting the cost of health and social care away from general taxation on to a property-based tax has obvious problems—not least, that it will disadvantage communities that are less well off?

[Anne Marie Morris]

My hon. Friend makes a fair point. I have one of those constituencies where communities are not very well off. Many of the facilities that are there to provide social care are failing because we do not have the more affluent individuals who can ensure that some of our care homes, particularly nursing care homes, are alive and well. I am now down to just three for a very large constituency, and that is completely inadequate.

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[Mr Clive Betts (Sheffield South East) (Lab)]

The Communities and Local Government Committee is currently undertaking an inquiry into the funding of social care. We have not produced our reports yet, so anything I say should be taken not as the Committee’s considered view but as some of my own reflections on the evidence we have heard so far. I hope it will not be too long before we can provide a report for Members to look at on the immediate issues of social care, and then, in due course, we will go on to look at the longer-term issues as well. We have taken evidence from a variety of different organisations, including councils, care providers, directors of social care, the Nuffield Trust, and the King’s Fund. Carers and care providers, as individuals, have related their personal experiences to the Committee.

As a constituency MP, it is not terribly surprising to have heard what I have heard today. Unfortunately, as an MP, like everyone else here, I am sure, I see only the tip of the iceberg of problems. Cases about the nature, and number, of social care failings have undoubtedly been increasing in my surgery, my postbag and my emails in the past two or three years. Some of the cases are quite horrific. A council that has to cut its budget on social care does so by going out to the private sector, or agencies, and substituting their services for the service that the council used to provide through directly employed staff. The way in which those services are delivered—often the simple failure of people to turn up and provide the care when it is promised—causes real and increasing problems that I am certainly seeing as a constituency MP.

This is not surprising. The Chair of the Health Committee referred to the fact that we have had a 7% cut in real terms in spending on social care since 2010. Local authorities’ grants from central Government have been reduced by 37%. Councils have tried to prioritise social care—the evidence for that is absolutely clear—but they have not been able to protect it completely from the cuts. That is the reality. On top of that, not only has the money been going down but the number of elderly people requiring care is going up. We heard evidence that although the Care Act was great legislation in principle, all was not delivered in practice. The extra measures are welcome in trying to reward staff properly for the excellent work that many of them do in social care, but the increase in the minimum wage places additional costs on the system.

Amyas Morse, who wrote a very good article and made a good speech the other day about the relationship between health and social care, said that for a long time local authorities had been very successful in doing more for less, but have now got to the point of doing less for less, which is impacting on the people who received the services.

We should not blame local councils for failing to provide a certain standard of service. Simon Stevens told the Communities and Local Government Committee that even if every council did as well as the best, there would still be problems in the system. I challenged the Under-Secretary of State for Health, the hon. Member for Warrington South (David Mowat), to say whether there was a crisis in social care. He did not want to use the word “crisis”, but he did say that the system was “under stress”. Although we cannot agree about the word “crisis”, I think we can at least agree that the stress is obvious for all to see. An estimated 1.2 million people do not receive the care they need. That figure is 40% higher than it was in 2010.

We took evidence from people who were not getting the same amount of care as they had received in the past and others whose needs were increasing but whose care was not. We talked to care providers who were handing contracts back or pulling out of the service altogether, and to local authorities that are sacking care providers because the contracts were not being delivered properly. We also heard that people who pay for their care in care homes are subsidising local authorities because they cannot afford to keep increasing their fees. There is a cross-subsidy in the system, which does not seem fair to many people. At the same time, the turnover rate for care staff is 27%, so they do not have long-term experience and are not being trained regularly over time to deliver care. Those are all problems that we learned about from the compelling evidence that our inquiry received. The Committee will reflect on its conclusion, and I am sure that eventually we will, as always, come to an unanimous view in our report.

In the short term, of course the Government have done things, including the introduction of the council tax precept. I welcome the fact that, by and large, local authorities have taken that up, because the situation is so serious. There are problems, of course, with the fact that the council tax precept raises much more money for some local authorities than for others, and the better care fund, which is meant to stabilise the situation and help authorities that raise less, is back-end loaded. The new homes bonus cut and the additional grant are welcome for social care, but that causes real problems for some small district councils that are not social care providers and suddenly find that their budget position is fundamentally altered.

In his article, Amyas Morse described how the Government simply were not thinking through what would happen in the long term. They moved money—it is often a lack of money—around between social care and health without giving any real thought to the end result. Government officials, and sometimes Ministers, took decisions without any real understanding of what happened to the money at the end of the line, when local authorities faced with very difficult choices had to make decisions about the cuts that were being passed on to them. Those are just some of the issues on which we will reflect in our report.

Clearly, the link between health and social care is very important. We ought to join them up better and it will be interesting to see what comes out of the Manchester example, given that both services have been devolved. There is a clear link between the two, and not just with regard to delayed discharging; there is now virtually no money in the system for preventive social care. The only social care funding available is that for people with the highest need. If people do not get it in the early stages, that means that they are more likely to end up in hospital and cost the whole system much more. That is another thing that we learned.

I was pleased to sign, along with the Chairs of the Health Committee and of the Public Accounts Committee, the letter to the Prime Minister saying that we need longer-term arrangements. It is right, however, that the Government should respond to the here and now, because that is important. To put it bluntly, if we do not deal with the here and now, some people will not be around to see the long-term arrangements being put in place.

When the Communities and Local Government Committee went to Germany, we learned that it solved this problem 20 years ago. Those involved sat down on a cross-party basis and agreed a long-term solution. It might not be the right solution for this country—it is based on social insurance, because that is what the German health system, as well as its pensions system, is based on—but that is what they decided to do. It is interesting that it has stood the test of time for 20 years. They have recently decided, with cross-party agreement, to increase social insurance and there has been virtually no public opposition, because the system is seen to be reasonable and fair. The German system is not purely funded by the taxpayer—there are private contributions as well—but it is an example. For heaven’s sake, let us sit down on a cross-party basis, as the Chair of the Health Committee has said, and work out a solution that stands the test of time, whichever Government comes to power in the future.

[Dr Murrison]

There is much in the hon. Gentleman’s speech with which I agree. Does he agree that the fundamental issue is that countries such as Germany, France and Holland, to which people here would reasonably compare this country, spend a great deal more money through either the Bismarckian system that he describes or others—this country’s system is based on Beveridge—and that somehow or another we are going to have to close that gap, as it is highly likely that the difference in mortality, morbidity and outcomes generally in this country compared with those aforementioned countries is causally related to the amount of money that we put into healthcare?

[Mr Betts]

We heard quite a lot of evidence that, as a percentage of our national income, we do not spend as much as several others on health and social care combined. The Communities and Local Government Committee will reflect on that. Of course, it is not simply a question of asking for more public funding; I would not come to that conclusion, although I might personally believe it. There is, however, an issue with where we get the private funding from, because nobody has argued to us so far that the whole of social care can be publicly funded. There will be private contributions, so how do we raise that private money? Should it come from individuals who simply need care at that point in time, or should we ask people to pay more into an insurance system? How do we put in more money from the public sector? Indeed, can we rely on local authority funding alone, particularly if it comes largely from business rates, which will not grow at the same rate as the number of people who want social care?

[Kevin Hollinrake (Thirsk and Malton) (Con)]

rose—

[Dr Murrison]

rose—

[Mr Betts]

I give way to my Select Committee colleague, the hon. Member for Thirsk and Malton (Kevin Hollinrake).

--- Later in debate ---

[Andrew Selous (South West Bedfordshire) (Con)]

It is a pleasure to follow the Chair of the Communities and Local Government Committee, the hon. Member for Sheffield South East (Mr Betts).

Notwithstanding the issues that have already been brought to the House’s attention, it is worth putting on the record the increase in the money—the extra £10 billion by 2020—that the Government are committing, with the 11,400 more doctors and 11,200 more nurses in the system, as well as the near eradication of mixed-sex wards and the huge reduction in hospital infections. I also note that health spending in England is nearly 1% higher than the OECD average.

[Dr Murrison]

I am sorry to intervene on my hon. Friend so early in his speech. Does he agree with me that the OECD average is probably a specious comparator? It covers countries—such as Mexico and Turkey, and former eastern bloc countries—whose health economies, laudable though they may be, are not ones with which most people in this country would wish ours to be compared.

[Andrew Selous]

My hon. Friend makes a fair point. I will outline some areas in which I think more spending is necessary.

I want to start by focusing on an individual case—it is not from my constituency—which highlights many of the issues that have been raised so far. It concerns a 98-year-old lady who was admitted to a hospital in one of our major cities on 22 January. Unfortunately, she died in that hospital on 31 January. It was made clear to the hospital on 25 January that the nursing home she had come from—she had been in its residential part—had nursing facilities, and it would have been able to take her back and deal with the deterioration in her health. Despite that, no action was taken to remove her back to the nursing home, which resulted in an extra six days’ stay in hospital.

The relatives who drew this true case to my attention asked me to raise two points. First, they thought it was not really good enough that the hospital concerned did not have a good knowledge of the fact that in addition to the residential facilities, the nursing home had facilities that would have been able to care for the elderly lady and thus free up a hospital bed. Secondly, they were disappointed that because her period in hospital spanned a weekend, they were told by several of the nursing staff that no doctor was available to make a decision about moving her back to the nursing floor of the home she had come from and where she had always wanted to end her days. That story illustrates some of the issues—I know Health Ministers are aware of them—of making sure that there is knowledge of what residential and nursing facilities are available in the community for elderly or frail people who go into hospital, and of making sure that there is weekend cover so that appropriate decisions can be taken and beds are not unnecessarily taken up in hospitals.

A couple of weeks ago, I sat down with a number of social care providers covering both residential and domiciliary care in Bedfordshire, and I asked them what they thought they needed to attract enough people into care provision. As the Chair of the Select Committee has just told us, there is a 27% turnover rate, and I learned that the providers cannot always attract people of the calibre they would like. For domiciliary care, I was told very clearly that the ability to offer a salary—perhaps of £16,000 to £18,000 a year—rather than paying people on an hourly basis when they provide care, would go a very long way to attracting the right sort of people into this profession.

That domiciliary care provider, which is one of the better ones in my area, pays 30p a mile for travel costs. All of us, as Members of Parliament, get paid 45p a mile when we travel in our constituencies. Frankly, I find it an affront that there is a division between rates for travel within the public sector. Social care staff do an incredibly important job and, frankly, it is not right that they are lucky to be offered 30p a mile, when Members of Parliament get 45p a mile. I am not just asking local authorities to put up what they pay to such a level straightaway. We must be realistic, and I fully recognise that that would come with a price tag that would have to be provided through taxation. However, having a salary of £16,000 to £18,000 a year, rather than hourly rates of pay that do not include travel time, and having travel properly paid for—it is currently paid for at a very miserly rate compared with what other people in the public sector get—would go a long way.

One of the issues that has not been highlighted so far in the estimates is the revaluation of the NHS litigation costs. There has been an increase of some £8 billion, which is a fairly large figure. It is worth focusing on that because litigation costs mean a couple of things. First, they mean that patients have not got the right quality of care first time around, and secondly, they mean that money is going out the door of the NHS, often to lawyers, that could be better used doing the job correctly the first time.

In that regard, I make no apologies for again drawing the House’s attention to the Getting it Right First Time initiative, which seeks to embed quality in clinical care across the NHS. I often find that we do not focus sufficiently on that in this House. Variability in the rates of infection and of the revision surgery that is required are significant across the NHS. If we could raise the quality of clinical care to the level of the best across the NHS, we could get the amount for litigation down substantially.

I was pleased to join a meeting that the Chair of the Public Accounts Committee, the hon. Member for Hackney South and Shoreditch (Meg Hillier), held a couple of weeks ago on the “Manifesto for a healthy and health-creating society”. It was led by Lord Crisp, the former permanent secretary of the Department of Health, with colleagues in the House of Lords and others. Although that may seem a long-term approach to the acute problems we face today—the Chair of the Communities and Local Government Committee is right to say that we need action now to get the preventive issues right, because not everyone will be around in the longer term—it is incredibly important, none the less, that we take a lot of the ideas in the report seriously to try to reduce the strains on the NHS and to create a healthier population in the years to come.

There are already some very good examples of such ideas. The St Paul’s Way transformation project in Poplar in the east end is doing sterling work. The Well North initiative, which is supported by Public Health England, is focusing on 10 cities in the north of England that have poor health outcomes and bad levels of health inequality. It is all about creating what it calls vibrant and well-connected communities to deal with issues such as debt, jobs, training, missed educational opportunities, poor housing and loneliness. Our late lamented colleague Jo Cox focused on the issue of loneliness, and many of us in the House are determined to carry on her work in that important area. Such long-term preventive work to increase the resilience and health of society is absolutely fundamental to all the issues we are talking about tonight.

On the sustainability and transformation plans, I have spent time with both GPs and hospital staff during the past couple of weeks, and I observed that clinicians in hospitals often point to the work that they thought should have been done but had not been done by GPs, while GPs pointed out that they do quite a lot of work that in the past they would have expected hospitals to undertake. As we move forward with the sustainability and transformation plans, there would be some merit in making sure that those in time turn into accountable care organisations, so that we get a proper join-up between the different parts of the system and such finger pointing between different parts of the health system becomes a thing of the past.

Finally and briefly on the issue of beds, I totally understand the Government’s correct focus on shifting more care to the community, but we have 8,000 fewer beds than we had five years ago, while the occupancy rate has increased from 84% to 87%. At times, operating theatres stand idle because of delayed discharges for care. I should like Ministers to reflect on that.

NHS Shared Business Services

Andrew Murrison Excerpts

Monday 27th February 2017 Commons Chamber

[Mr Hunt]

The Minister responsible is the Under-Secretary, my hon. Friend the Member for Oxford West and Abingdon. This case happened before she was in post, so I took personal responsibility given it was such an important issue. I will write to the hon. Gentleman with more details about how the east midlands has been affected.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

Does the Secretary of State agree that it is vital that we move towards a fully paperless national health service, but that it will be very difficult to do so as long as national health service trusts cannot talk to each other electronically? Radiological images, for example, are often not available when consultants see patients, who therefore have to have the test again, which is contrary to all the precepts of good practice in the Ionising Radiations Regulations 1999.

[Mr Hunt]

My hon. Friend is absolutely right. This is a very big part of our transformation plans for the NHS. Where the NHS does well internationally is in out-of-hospital records; our GP records are among the best of any country’s. GPs have done a fantastic job over the past 15 years in keeping all their records electronically, and they provide a lifetime snapshot of a patient’s history. Where we are less good is in our hospital records, where one can still find paper records in widespread use. That is not just very, very expensive but—he is quite right—unsafe at times.

Oral Answers to Questions

Andrew Murrison Excerpts

Tuesday 7th February 2017 Commons Chamber

[David Mowat]

As I said earlier, we will have 5,000 further doctors working in general practice by 2020. A chunk of those will be available for every part of the country, and Enfield is included in that. I do accept that the GP system is under stress and that we need more GPs, and the points that the right hon. Lady makes are right.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

Employing more GPs is, of course, important, but the Minister is right to say that so is collaboration. How far have we got with spending the £1 billion earmarked by the Chancellor in 2014 for improving GP surgeries? Does the Minister share Ara Darzi’s vision of more polyclinics, which will enable GPs to work more closely together?

[David Mowat]

The vision set out in the GP five year forward view is of substantially more spend in the community and of an increase, as a proportion, in the amount of money in the NHS going to people in primary care. Part of that will be in polyclinics and the estate generally. As I say, one of the most innovative things we have found in the GP vanguards is that when they start to put together groups of 30,000, 40,000 and 50,000 patients in a GP hub, the quality of care increases dramatically. We are going to accelerate that.

Public Administration and Constitutional Affairs Committee

Andrew Murrison Excerpts

Thursday 2nd February 2017 Commons Chamber

[Mr Bernard Jenkin (Harwich and North Essex) (Con)]

I am grateful for the opportunity to present to the House the seventh report of PACAC this Session, “Will the NHS Never Learn?”, a follow-up to the Parliamentary and Health Service Ombudsman report on the NHS in England, “Learning from Mistakes”.

Over the past decade, written complaints regarding NHS services have doubled, from just over 95,000 in 2005-06 to more than 198,000 in 2015-16. Investigations into such complaints have frequently failed to identify the root causes of any mistakes that occurred. Even more frustrating is that they have failed to prevent the same mistakes from being repeated over and over again, despite multiple reports highlighting that as a critical issue from both the Parliamentary and Health Service Ombudsman and the Public Administration and Constitutional Affairs Committee, which I chair.

In its report “Learning from Mistakes”, which was published last year, the PHSO highlighted the fear of blame that is pervasive throughout the NHS. That fear drives defensive responses and inhibits open investigations, which in turn prevents NHS organisations from understanding what went wrong and why. That also undermines public trust and confidence, because the public can see that NHS organisations are failing to learn from mistakes—if they did, that would drive improvement. A combination of a reluctance on the part of citizens to express their concerns or to make complaints, and a defensiveness on the part of services to hear and address concerns, has been described by the PHSO herself, Dame Julie Mellor, as a “toxic cocktail” that is poisoning efforts to deliver excellent public services.

To further understand the issues and what more needs to be done to tackle them, PACAC recently undertook its inquiry, which followed up on the PHSO’s “Learning from Mistakes” report. In PACAC’s report, which was published earlier this week, we conclude that if the Department of Health is to achieve its policy of turning the NHS into a learning organisation, it must integrate its various initiatives to tackle the issue and come up with a long-term and co-ordinated strategy. That strategy must include a clear plan for building up local investigative capability, as the vast majority of investigations take place locally. We will hold the Secretary of State for Health accountable for delivering the plan.

PACAC’s report also considered the potential impact of the new healthcare safety investigation branch, which is in the process of being set up. The creation of HSIB, as it is known, originates from our recommendations as the Public Administration Committee in 2015. The Government accepted our recommendation, and HSIB is due to be launched in April. It will conduct investigations into the most serious clinical incidents, and is intended to offer a safe space to allow those involved in such incidents to speak openly and frankly about what happened. In so doing, it is hoped that HSIB will play a crucial role in transforming the expectation and culture in the NHS from one that is focused on blame to one that emphasises learning. It should be a key part, albeit only a part, of the wider strategy that we want the Government to adopt.

Unfortunately, there is still a long way to go if the Department of Health’s aim of turning the NHS into a learning organisation is to be achieved. Most importantly, HSIB is being asked to begin operations without the legislation necessary to secure its independence and ensure that the safe space for its investigations is indeed safe. That undermines the whole purpose of HSIB. It is essential that the Government introduce the necessary legislation as soon as possible.

To ensure that the learning produced from HSIB’s investigations leads to an improvement in standards, PACAC also reiterates its previous recommendations, made in our 2016 report, “PHSO review: Quality of NHS complaints investigations”, that the Government should stipulate in the HSIB legislation: first, that HSIB has the responsibility to set the national standards by which all clinical investigations are conducted; secondly, that local NHS providers are responsible for implementing those standards according to the serious incident framework; and, thirdly, that the Care Quality Commission should continue to be responsible, as the regulator, for assessing the quality of clinical investigations at local level according to those standards.

The purpose of complaints is not just the redress of grievances—which I must say is extremely unsatisfactory in the NHS anyway—although that is clearly important; complaints are a tool by which public services can learn and improve. When medical professionals are forced primarily to be concerned with avoiding liability and responsibility and are trapped in a culture of blame, there can be no learning. There is an acute need for the Government to follow through on their commitment to promote a culture in which staff feel able to speak out and in which the emphasis is placed on learning, not blame. I very much hope that they will implement PACAC’s recommendations as a step towards achieving that as soon as possible.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I congratulate my hon. Friend for his work, and that of his Committee, on producing the report. He is absolutely right about HSIB and the need to underpin it properly. The Government have said that they would cap litigation costs at £100,000. I think my hon. Friend would accept that there will always be litigation, even if we get a more satisfactory means of redressing grievance, in the way he has suggested. Does he think that that cap would be appropriate, particularly since motor costs, for example, are capped at that level? Would that mean that people with grievances would be properly compensated while, sadly, their lawyers would not be?

[Mr Jenkin]

I confess I am not sighted on the proposal to cap litigation costs, but people resort to litigation only because they feel that their complaints are not being heard and that the problems they have identified in the service are not being addressed. People resort to litigation because they do not feel they are being told the truth. We know from our surgeries that most people who complain come in and say, “I only want to make sure this doesn’t happen to somebody else. I don’t want compensation.” Nevertheless, because that public-spirited attitude to complaining is so often rebuffed in the health service, people resort to litigation because they feel there is a cover-up.

In other fields, such as aviation and marine investigations, where this kind of investigative process is already established and is designed to find the causes of accidents without blame, there is far less resort to litigation at the outset. That does not preclude litigation in the final analysis, but discovering the truth without blame is the first step towards reconciliation.

NHS and Social Care Funding

Andrew Murrison Excerpts

Wednesday 11th January 2017 Commons Chamber

[Dr Whitford]

Money is not the only problem. I accept that part of it is about how things are done. The Secretary of State talks about variations and many hospitals performing well, but, as I said, only one trust is meeting the target and only nine are at over 90%, so it is not that the majority are doing well and a few are failing.

The ability to look at how we deliver the NHS is crucial, but change costs money. We must therefore invest in our alternatives so that our community services and primary care services can step up and step down to take the pressure off. One of the concerns about the STPs is that because people do not have enough money, a lot of them start by thinking that they will shut an A&E, shut a couple of wards, or shut community beds—even though those are what we need more of—to fund change in primary and social care. Then the system will fall over. We need to have double running and develop our alternatives and then we will gradually be able to send the patients there.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I always enjoy listening to the hon. Lady’s well-informed remarks. I agree that most people do not want to go to A&E if they can avoid it. Does she agree that part of the problem is that when people phone general practices, they tend not to be offered an appointment that they regard as being within a reasonable timeframe, or they cannot get to see the doctor with whom they are closely associated, which particularly applies to people with chronic and long-term conditions? As today’s National Audit Office report makes clear, we need to address that as a matter of urgency. Paradoxically, seven-day-a-week general practice may militate against being able to provide people with such continuity of care during core hours.

[Dr Whitford]

Many doctors in general practice would accept the argument for having access to a GP on Saturday morning, particularly for people who are otherwise at work. However, someone who cannot see their favourite doctor is very unlikely to go to A&E and wait eight hours to see a doctor they have never seen before in their life. This is not about that; this is about the fact that people feel they cannot find an alternative. If it takes three or four weeks to get any appointment with their GP and they do not yet have a community pharmacy offering such a service, they will eventually end up at A&E. It is therefore the service of last resort for people who go there and just stay there. We have to develop alternatives first, but as the hon. Gentleman says, no one in their right mind would choose to go and wait four hours in A&E if they could be seen in half an hour in a community pharmacy.

[Dr Murrison]

The hon. Lady is being very generous in giving way. I have to disagree with her, because winter pressures and the pressures we are seeing at the moment tend to involve not people with short-term, self-limiting conditions, but the chronically sick. Those people in particular, and with good reason, want to have a relationship with a particular practitioner who understands their needs and their family context. That is surely the essence of general practice.

[Dr Whitford]

I totally agree, but in fact the chance that their doctor will be on duty would actually be lower on a Saturday morning or a Sunday afternoon. One of the things we have done in Scotland with SPARRA—Scottish patients at risk of readmission and admission—data is to identify that 40% of admissions involve 5% of the patients. Those patients are all automatically flagged and will get a double appointment no matter what they ring up about, because it will not just be a case of a chest infection or a urine infection, but of having to look at all their other comorbidities.

That is the challenge we face; it is not a catastrophe of people living longer. All of us in the House with a medical background will remember that that was definitely the point of why we went into medicine, and it is the point of the NHS. However, we are not ageing very well. From about 40 or 50 onwards, people start to accumulate conditions that they may not have survived in the past, so that by the time they are 70 they have four or five comorbidities that make it a challenge to treat even something quite simple. My colleagues and friends who are still working on the frontline say that it is a question not just of numbers, but of complexity. Someone may come in with what sounds like an easy issue, but given their diabetes, renal failure and previous heart attack, it is in fact a complex issue.

That is part of the problem we face, and we need to look forward to prepare for it. We need to think about designing STPs around older people, not around young people who can come in and have an operation as a day case and then go away, because that is not what we are facing. Older people need longer in hospital, even medically, before they reach the point of being able to go home. It takes them a couple of days longer to be strong enough to do so. They probably live alone and do not have family near them, so they will need a degree of convalescent support and they may need social care. That is really where the nub of the problem lies. Social care funding has gone down, and therefore more people are stuck in hospital or more people end up in hospital who did not actually need to be there in the first place.

--- Later in debate ---

[Dame Rosie Winterton (Doncaster Central) (Lab)]

The debate so far has shown the huge level of concern from the public and NHS staff about the crisis in the NHS and social care. The hon. Member for Totnes (Dr Wollaston) reflected some of the views of the Select Committee, but I ask all Government Members to take those concerns seriously and not to dismiss them. All hon. Members must surely be receiving representations from staff and patients about what is happening locally.

I want to pay tribute to all the health and social care staff in Doncaster, in particular those at Doncaster royal infirmary whose work I have seen at first hand. I know how dedicated and committed they are to caring for patients in these most difficult of circumstances. At the end of December, they had managed to achieve 90% against the 95% target and had good ambulance handover times, as well as good support from the council and community partners, but they are facing real pressures and they are fearful about the pressures still to come, especially if, as predicted, there is a cold spell. That is why the mixed messages from the Secretary of State have been extremely damaging.

I was a Health Minister for four years and had responsibility for emergency care. I know how important it is to work with NHS staff to help to implement targets, and not to give the impression that the NHS is somehow giving up on those targets. The lead from the top is incredibly important. There has always been controversy about targets, but as a Health Minister I visited many, many A&E departments. There is absolutely no doubt in my mind that the A&E target led to improved care for patients and that it reduced waiting times dramatically. The evidence is clear: it shows that that is what happened. One striking thing about those visits was seeing how consultants, nurses, ambulance teams and all members of the healthcare team worked together. For example, they would work out protocols so that emergency nurse practitioners could take over some of the work previously done by consultants, to ease the burden and share the work among the team. Triaging—seeing who needed urgent treatment by a consultant and who could be seen by a nurse practitioner—became the norm.

I would ask staff, “Is the target getting in the way, or is it helping?”, and invariably the answer would come back, “It helps us to work together more effectively.” I vividly remember a nurse practitioner saying, “Please don’t abandon the target, because it is making the consultants sit down with us and look at the whole team.” For patients, the difference was crucial, as it was for practitioners’ working lives, because they were not having to see patients who had been sitting around for hours and were feeling thoroughly depressed and demoralised. That made a difference to the healthcare team as well, because it improved their working life as well as patient care.

[Dr Murrison]

Does the right hon. Lady agree that it is not so much meeting the target that is important as getting patients seen expeditiously and well? There is not an A&E department in this country that does not want to improve its position in the league table of response times. The difference that now applies, and which perhaps did not apply quite so much when she was a Minister, is that the level of informatics and comparison is much improved. I suggest to her, ever so gently, that while the four-hour target was important when she was a Minister, its importance has degraded over time, because everybody is trying to see patients more quickly.

[Dame Rosie Winterton]

I do not agree with the hon. Gentleman. The four-hour target led to much better diagnoses and much improved provision of the type of treatment that people needed, as well as better interaction with communities. And I want to come on to that point because the Secretary of State has been trying—perhaps the hon. Gentleman is guilty of this as well—to separate the target for A&E departments from what happens outside, whereas I see the importance of putting the two together. Providing alternative treatment, which is perhaps part of what the hon. Gentleman was getting at, means having proper support in the community. It was bringing those two things together that made it possible to achieve the target, so it was a driver.

--- Later in debate ---

[Sir Simon Burns]

The hon. Lady is absolutely right. There was a wage freeze for those who were earning more than £20,000 a year, but that was in keeping with the policy throughout the public sector, which included Ministers and other Members of Parliament.

The important point is that it was possible to achieve that saving by a variety of means. One of them was a pay freeze, but others were improving the delivery of service, cutting out inefficiencies and ineffective ways of operating and getting rid of nearly 20,000 surplus managers, so that the NHS could concentrate on enabling clinicians, nurses, ancillary workers and everyone else to work on patient care. That is the right way forward, and we cannot give up on it. We must continue to think about where we can make savings.

[Dr Murrison]

Will my right hon. Friend give way?

[Sir Simon Burns]

I am afraid not, because I am about to finish.

Much has been said about the STP programme. We have an STP in Mid and South Essex, and I strongly support it, because it is completely focused on improving and enhancing the quality of accident and emergency care. What annoys me is that people wish to politicise it for grubby political reasons. [Interruption.] Funnily enough, I am not talking about Opposition Members.

Our STP involves three hospitals with three A&E departments. Not one of those departments is to be closed under the proposals, yet as soon as they were published, and on the assumption—correct, I suspect—that most people had not read them, word went out that my local A&E department was to be closed down by the Department of Health because of this nasty Government’s proposals to save money. The exact opposite was the case. If one read the document, one could see that all three A&Es are remaining open.

What will happen is building on what happens now. If someone has a heart attack, they are immediately taken to Basildon hospital, because that is the specialist for cardiothoracic treatment. If someone needs treatment for burns or plastic surgery, they come to Broomfield hospital in Chelmsford, because it has one of the finest units in the whole of Europe. If someone has a head injury, they will go down to Romford in the east of London, because that is the specialist area for people with head injuries. If I had any of those conditions, I would want—and I would want for my constituents—the best possible treatment from the best experts available. That is what is happening and that is going to be built on, enhanced and improved. That is an improvement. That is not a cut; that is not taking away services from local communities. Those people who have an agenda and want to play politics will tell people anything in the hope that they believe it, or to frighten them by trying to discredit the work of the NHS.

I am pleased we have had the opportunity to discuss this matter. It is very tricky, and there is no simple answer—what is happening is not unique; we frequently have winter crises, particularly because of the ageing population and the increasing demands on health services in recent years—but we must not lose sight of the fact that we have an NHS and a Government who are determined to improve further and enhance the quality of care and the safety and standards of care for all our constituents, aided and abetted by a first-class workforce who are often working under very difficult circumstances.

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[Mr Harper]

The whole point of the STP process is to ensure that we have capacity across the health sector. One important thing that the Secretary of State talked about is the other changes to the health and social care system—indeed, that is mentioned in the Prime Minister’s amendment, which is why I will support it. In that I agree completely with the Chair of the Select Committee. We have to look at the two things together.

Unlike what the hon. Member for Central Ayrshire (Dr Whitford) said, in Gloucestershire we are lucky to have a single CCG and a single county council, which work well together with lots of joint working, and they increasingly want to bring health and social care together. That is exactly what the Chair of the Select Committee said, it is the right thing to do and it is what the hon. Member for Central Ayrshire said is being done in Scotland to help deliver a better service.

My hon. Friend the Member for Cheltenham (Alex Chalk) is right that, the more we can improve capacity in the system to ensure that people can access primary care where they need it and can access social care where they need it, we will take pressure off the accident and emergency system. Indeed, when I visited the A&E department, it had a good triage system in place, with general practitioners based in the department to ensure that people with conditions that can be treated by general practice are signposted and treated in an appropriate setting, rather than damaging the service’s ability properly to deliver acute care to those who really need it. We need to consider such steps, going forward.

[Dr Murrison]

Would those people fall within the four-hour target? That lies at the heart of the debate. Should the four-hour target cover both urgent and more elective problems that people present to casualty departments?

[Mr Harper]

I do not know the detail of how the statistics are measured, but the important thing is to ensure that people who walk through the front door of an A&E department but who do not need urgent care receive care in the appropriate setting and are properly signposted, whether to community pharmacies, general practice or the information services that the NHS provides online or on the telephone. It is about making sure that people go to the right setting. The Government acknowledge that that is not perfect at the moment, and they are doing a lot of work to improve it in the future.

Finally, the Government’s moves to devolve spending power and decision making to local areas, particularly given what will happen in Greater Manchester, to bring health and social care together is the way forward, and I have certainly encouraged my local authority, as it leads the formulation of our devolution proposals, to make an ambitious ask of the Government on health. I hope the Government will look at that very seriously in the months ahead.

--- Later in debate ---

[Dr Andrew Murrison (South West Wiltshire) (Con)]

This has been an absolutely first-rate debate, with a number of extremely fine contributions. I was particularly taken, as ever, by the remarks of my hon. Friend the Member for Totnes (Dr Wollaston), the Chairman of the Select Committee. She rightly pointed out that we are all living longer, which is a great thing, but that unfortunately our healthy lives are not expanding. This causes real problems for A&E, which has to deal with that. Although we talk about large numbers of people passing through A&E departments—they are dealing with more people all the time—the truth of the matter is that it is those with chronic long-term and complicated conditions who tend to assume the lion’s share of A&E resources and those of the rest of the secondary care system. As we get older, there will be more and more of such cases. We need to prepare for them.

We also need to militate against those cases. One thing that has not been discussed very much this afternoon is prevention and public health: our need to ensure that we deal with things that are avoidable. The Prime Minister, in her excellent speech on Monday on the shared society, rightly said:

“We live in a country where if you’re born poor, you will die on average 9 years earlier than others.”

That is absolutely appalling and we should all be ashamed. Half that health inequality is due to tobacco consumption. Someone in a manual occupation is far more likely to be a smoker or to smoke more than a professional or managerial person. We have to be serious about controlling the scourge of tobacco. I encourage Ministers to produce the tobacco control plan, which is now overdue, as soon as possible, as we need to deal with this issue. I hope that the plan will contain some helpful remarks on the tobacco duty escalator and the licensing of retailers and involve serious conversations with supermarkets. The aim must be to reduce the availability of tobacco, reduce consumption and therefore reduce the burden of diseases that are affecting our NHS and having appalling consequences for citizens.

I very much support the Government’s amendment to the motion. I was not present when the hon. Member for Central Ayrshire (Dr Whitford), who speaks for the SNP, was speaking about community hospitals. I am sorry about that, because community hospitals are particularly important to me and I would have liked to respond to some of her remarks. I have community hospitals in my area. In particular, there is one serving my constituency at Shaftesbury that is threatened with bed closures under the STP. We need to be very careful about short-term funding cuts that might appear expedient, when we have not properly costed the service. Providing that the case mix is right—and traditionally case mixes have been pretty appalling in the NHS—community hospital beds can provide a cost-effective means of treating people, particularly the elderly, in a setting close to their homes rather than in large acute hospitals, which are the wrong places for elderly sick people. Community hospitals can deal quite effectively with some of the delayed discharge problems currently afflicting our system. As Members of Parliament, we are all sometimes faced with the political choice of whether to oppose, for our own expediency, the closure or reorganisation of services. I have faced that in my constituency. I was pleased to hear my right hon. Friend the Member for Chelmsford (Sir Simon Burns) say that sometimes we need to be brave when approaching such matters.

If we want to drive up standards and outcomes in our NHS, we will have to look increasingly at specialist centres, which will inevitably mean service reconfiguration and probably some closures. That will be disagreeable to many colleagues, but specialist centres certainly improve standards and outcomes for things such as cancer, strokes and heart attacks, and that implies regional and sub-regional services. I would not be one to oppose a closure, reorganisation or reconfiguration for its own sake. We have always to understand that resources are finite and that we need to get the best service and outcomes for the money available.

I say gently to the Minister that we need to look at funding. He will be aware of the campaign by the right hon. Member for North Norfolk (Norman Lamb), which I support, in relation to a commission or convention. It seems a non-partisan way of trying to approach the very difficult conundrum of how we will fund the NHS going forward. I commend it to the Minister. I was pleased to hear the Prime Minister say at lunchtime that she was prepared to meet colleagues concerned about the issue to see whether this proposal could be a productive and helpful way forward. We do not spend as much on the NHS as we need to. That is the bottom line. It is no good people saying we spend 1% above the OECD average. That is not good enough, given that the OECD includes countries with which most people in this country would not wish to be compared. As the Government of the day made clear several years ago now, we need to close the gap with the EU 15, particularly with countries such as Germany, France and the Netherlands, whose outcomes are much better than ours. It is no coincidence that they spend much more on healthcare.

Today, the chief executive of the NHS is being examined by the Public Accounts Committee. I hope he will be examined on the £22 billion efficiency measures that he felt might be achievable in the five year forward view. Two years in and it is clear that those savings will not be met—they never were going to be met. We need to determine how we are going to make up the delta—the difference—between the efficiency measures that the NHS can reasonably achieve and those projected two years ago.

I want to finish by congratulating the Minister and the Government on achieving what they have. We have heard how things have improved in recent years, particularly in relation to such things as activity and hospital infections, but there is much more to do. In particular, I hope he will look closely at the funding issue.

Mental Health and NHS Performance

Andrew Murrison Excerpts

Monday 9th January 2017 Commons Chamber

[Mr Hunt]

I was in touch with what was happening in the NHS every single day throughout the Christmas recess. As someone who has worked in a hospital, the hon. Lady might question whether it is particularly helpful for NHS hospitals to have visits by high-profile politicians right at their busiest periods. I have been very closely in touch. She talks about the problem at London ambulance service. That was a problem staff have been trained to deal with. The staff of her own hospital worked extremely well, but they do not welcome attempts—she is making one this afternoon—to politicise the problems the NHS faces.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

On the changes to the four-hour standard that the Secretary of State heralded, what can be done to incentivise and upskill GPs who may wish to take a closer interest in minor and moderate illnesses, including the use of nurse-led minor injury units?

[Mr Hunt]

They have a very important role. Some of the most successful and best-performing trusts, such as Luton and Dunstable, have a very good streaming process at the A&E front door, with good alternatives when it is not appropriate for people to go to an A&E department. We need to learn from that. Nurse-led units can be very important. GP-led units can make a big difference, too. It will not be the same everywhere, for reasons of space if nothing else, but there is a solution that everywhere can adopt.

Oral Answers to Questions

Andrew Murrison Excerpts

Tuesday 20th December 2016 Commons Chamber

[Mr Hunt]

The best thing we can do to narrow the gap is make sure that we continue to invest properly in the NHS and social care system, and make good progress on public health, which often has the biggest effect on health inequalities. That is why it is good news that we have record low smoking rates.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

With acute hospital bed blocking at a record high, do Ministers agree that it is a great pity that so very few of the 40 sustainability and transformation plans now in the public domain deal directly with step-down care and, in particular, with community hospitals?

[Mr Dunne]

As my hon. Friend has confirmed, 44 areas are working on their STPs, all of which are charged with looking at improving integration between hospitals and social care in order to improve discharge. In order for STPs to be taken forward, they have to address that issue.