NHS Commissioning (Pre-Exposure Prophylaxis)

Andrew Murrison Excerpts

Tuesday 7th June 2016 Commons Chamber

[Jane Ellison]

It is probably worth clarifying that we asked NICE to undertake an evidence review, not a technology assessment. What drugs are licensed for are matters for drug companies to address. The Government do not initiate the process on whether a drug is licensed— the drug company must initiate it. It also worth noting that when a drug is licensed for a new purpose, as would be the case for Truvada in PrEP, the company could apply for the patent to be extended to cover this new use. Again, that is something that the drug company would do.

On the hon. Lady’s first point, I agree that we need to consider the impact on women in the circumstances she described. That is one of the arguments for carefully planning this pilot programme and taking those sorts of factors into account.

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

The process that the Minister has outlined is correct, but does she recognise that the French Government have already approved Truvada for pre-exposure prophylaxis, and does she understand the urgency in this? The results of the UK PROUD study, funded by the MRC, are quite unequivocal, so we really need to get this going. Will she also reflect on the fact that the study showed no difference in the incidence of other sexually transmitted diseases, because Truvada does not protect against them, so the message has to go out that a condom is absolutely essential?

[Jane Ellison]

My hon. Friend is quite correct on his latter point about the impact of PrEP. Whether it was commissioned or not, and whoever it was commissioned by, we would still have the significant challenge that he describes around STIs. Drug-resistant gonorrhoea, for example, is a problem that we are increasingly aware of.

There are international comparisons that we can look at, as my hon. Friend mentions. I have looked at the matter in some detail, and the picture across the world is that many countries are in broadly the same position as the UK. They are trying to understand, leaving aside the question of clinical effectiveness, more about how PrEP can be used as part of an HIV prevention programme in broader cost-effectiveness terms, and how it compares in cost-effectiveness terms with other available interventions. My hon. Friend is right that there is work to do, and we are not resting easy on this. We are moving forward, and we are working on and planning these pilots now.

Comparative Healthcare Economics/NHS Finance

Andrew Murrison Excerpts

Tuesday 7th June 2016 Commons Chamber

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

I need to start by confessing an interest as a doctor. We are now 18 months into the five year forward view, and the big question really is: what next? “What next?” really means bringing English healthcare outcomes up to the standard enjoyed in peer group European nations, and I am afraid that means much more money. I hope that, in the next few minutes, I can suggest how we might go about achieving that.

The average age of Members of Parliament is 51. That means that most Members of this House have tipped, or are tipping, into the demographic twilight zone in which the incidence of common and chronic diseases begins to accelerate—it is sad but true. That focuses the mind on what a successful healthcare economy looks like and what it delivers for patients.

When those 51-year-olds enter the danger zone in a few years’ time, what will success look like? Success will mean accommodating the great advances in medicine that we believe we are on the cusp of achieving, and that we hope will add years to life and life to years, and I know that my hon. Friend the Minister is particularly exercised about those matters. Success will mean dealing with the healthcare needs of an ageing demographic, an expanding population, and more chronic diseases of lifestyle, which will amount to a 3% per annum uplift in demand, according to NHS England and the Nuffield Trust. Success will mean satisfying the legitimate demands of a less deferential, consumerist, better educated society that will not be content with second best. Success will mean closing the gap between healthcare outcomes here and in northern European countries with which we can reasonably be compared, and therein lies the “What next?”

In July 2010, the Government White Paper “Equity and excellence” exposed relatively poor health outcomes in the UK, compared with other countries. Our healthcare system was delivering poorer results in terms of mortality and morbidity. The most recent OECD statistics, published last year, have confirmed Britain’s relatively poor performance across pretty well the complete spectrum of common diseases—common cancers, ischaemic heart disease, cerebrovascular disease and the rest. Crucially, the number of unnecessary deaths—mortality amenable to healthcare—is substantially higher in the UK than in neighbouring countries.

However, healthcare is not just about reducing deaths. What about other measures of quality? Measures such as post-operative sepsis, pulmonary embolism, deep vein thrombosis, obstetric trauma and diabetic complications are worryingly unimpressive in the UK, compared with countries we would consider to be in our peer group. Although the teenage pregnancy rate has improved in recent years, the UK bumps along the bottom of the EU league table with recent accession states. The list goes on.

The Swedish-based and well-respected, if drug firm-funded, Health Consumer Powerhouse has been reporting on the performance of Europe’s healthcare economies since 2005. The UK’s position in its Euro Health Consumer Index has always been mediocre, but in January the UK was ranked 14th out of 35—just above Slovenia, Croatia and Estonia, and below European countries that most Britons would regard as peers.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on bringing this matter forward. This may seem a bit like politicking, but it none the less needs to be said. There is no doubt that the Transatlantic Trade and Investment Partnership has the potential to threaten the very nature of our NHS. What is even clearer is that we are sending millions of pounds every week to the EU that could be invested in our NHS, where that money is much needed. Does the hon. Gentleman agree that there is great potential to properly resource and liberate our great NHS, were we to vote to leave the EU?

[Dr Murrison]

I think the hon. Gentleman and I are on the same side of the Brexit debate, and I certainly would welcome the extra money that would be spent on the NHS in the event that we leave the European Union, so fingers crossed for 23 June.

The Health Consumer Powerhouse report highlights poor accessibility and an “autocratic top-down management culture” here, in contrast to top-performing Holland’s removal of what Health Consumer Powerhouse calls “healthcare amateurs”—that is to say, politicians and bureaucrats—from decision making. Unhappily, that sounds rather familiar. Earlier this year, Dame Julie Moore slated fellow senior NHS managers for “gross incompetence” and poor leadership.

The question is, what, apart from its management, accounts for the UK’s lacklustre ranking? Despite the UK’s innovative cancer drugs fund, Health Consumer Powerhouse found, for example, relatively poor availability of the latest oncology interventions and therapeutics, including radiotherapy. Sadly, that rings true, and we remember the high-profile case of Ashya King, the five-year-old with medulloblastoma, who was taken by his parents in 2014 from Southampton general hospital to Spain and then the Czech Republic for proton beam therapy, which was not available here.

The much-vaunted Commonwealth Fund report that some use to claim that the NHS is super-efficient and effective actually contains just one element that deals directly with health outcomes—a composite of deaths amenable to medical care, of infant mortality and of life expectancy at 60, it puts the UK 10th out of 11, the US being bottom. Tenth out of 11 sophisticated healthcare economies is not where I want the UK to be, and not where the Minister wants the UK to be either. The British public would expect us to be doing rather better against a raft of healthcare outcomes where the UK is firmly in the wake of our immediate northern-European neighbours France, Germany, Holland, Belgium and Denmark.

Can we explain why UK healthcare outcomes are not as good as those of peer group nations through differences in the level of healthcare funding? We can expect an opinion from the House of Lords, which last week set up a Select Committee under Lord Patel to examine the sustainability of the NHS—that is, the “what next?” question. I would be very surprised if it did not conclude that the answer is to bring spend up to the level enjoyed in countries such as France, Germany and Holland. After all, closing the gap with the EU15 in health spending as a proportion of GDP was a goal explicitly set in 2000. However, Conservative Members tend to be somewhat wary of making spend a proxy for outcome. It is not enough just to write big cheques and consider the job done. Can we do better with what we have? There are apologists for our low spending on health who cite the supposed efficiency of the NHS, but simply asserting that the NHS is more efficient than health services in other countries does not make it true.

I do not know what is in the Minister’s speaking notes, but there is a very good chance that he will use the New York-based Commonwealth Fund analysis on comparative healthcare to support a contention that the NHS is very efficient and thus ameliorates the relatively low UK spend on healthcare. The report’s methodology rewards close examination. I am sure he will have read it thoroughly, but if not, I commend it to him. In my opinion, its methodology renders the sorts of deductions that have been made unsafe. The only reliable element of the analysis that is used to claim that the NHS is relatively efficient is the percentage of national expenditure spent on administration and insurance, meaning that the UK comes in at fifth out of 11. Given that the nature of our system means that insurance and transactional costs are very low, that is hardly something to crow about. Other markers of efficiency rely on patient and practitioner surveys and include items such as time spent filling out financial transaction forms. UK-relevant metrics, such as rehospitalisation rates, were found to be comparatively poor. I conclude that it would be unsafe to make claims about the relative efficiency of the NHS based on contestable reports like that of New York’s Commonwealth Fund.

Let us suppose for one moment that the NHS is fairly efficient—not very efficient, because Carter and others suggest that that would be unwise, but fairly efficient. Indeed, I have no reason to suppose that it is institutionally profligate. If it is fairly efficient, we will not be able to squeeze many more efficiencies from it beyond the Stevens assumptions, but we will still be left with relatively poor outcomes and still needing to know “what next?” Simon Stevens still believes that we can squeeze £22 billion in efficiencies from the NHS. Much of this, presumably, is predicated on productivity gains that are contingent on holding down salaries and wages—a challenge if incomes in the economy rise. This is what I think he means by “strong performance”—strong indeed, because the implied productivity gains of 2.4% are well in excess of anything that has been achieved by the NHS historically and well beyond expectations for the wider economy. It also depends on sustained spending on social services and public and preventive health. Both, in the event, have been impacted by cuts to local government funding—cuts that I supported and accept were entirely necessary to repair the public finances, but cuts nevertheless.

So “what next?” will inevitably mean a step change in input—in money—if not by the end of the five year forward view period, then without doubt during the next decade and beyond. Here again, it is instructive to look across the channel, where we find some good news for Ministers. The Office for National Statistics has just tweaked its approach to health accounting to comply more closely with that of the OECD, and obligingly, this increases the UK’s spend on public and private healthcare combined from 8.7% of GDP to 9.9%. Most of this is due to re-badging a slice of publicly funded social care as healthcare spend. Of course, none of this accountancy changes by one penny the amount spent on care, but it impacts on the international spending league table. It means that we overtake southern European countries such as Spain, Portugal, Italy and Greece. However, we still lag well behind Germany, France and the Netherlands—my chosen basket of similar European countries.

So what next? Data from the Kings Fund and the Institute for Fiscal Studies suggest that income tax must rise by at least 3p in the pound simply to offset the fall in NHS spending as a proportion of GDP predicted over the rest of the decade. But all that will do is arrest the UK’s relative downward trajectory towards being the sick man of Europe. To bring spend up to the EU15 average would now involve an 8p increase. That eye-watering sum may be toned down a little bit by the new Office for National Statistics method for calculating healthcare spend, but probably not greatly if the comparison we actually want to make is with our closest European neighbours France, Germany and the Netherlands.

So, if we accept that big fistfuls of money are needed, the question becomes, “How are we to get it?” The Labour party does not know. It has yet to say how much it thinks the NHS budget should be, despite every encouragement from me and others to do so. All we know is that the party opposed the Stevens uplift at the general election. Maybe the unaccustomed reticence about pledging money from the party of fiscal incontinence is an indication of the sheer scale of the spending challenge that even Labour has perceived in a rare lucid moment.

Although I have every confidence in my right hon. Friend the Chancellor, a precipitous growth in the economy seems unlikely, and further borrowing should not be an option. In fact, half the £350 million per week that we send to the EU—a figure, net of rebate and subsidy, that I personally rely on—would, by my reckoning, halve the difference. I fervently hope that it will be in play after 23 June, but it would still leave a gap. How will that gap be closed? It is said that if we want a social healthcare system, we must choose between Bismarck and Beveridge. For my part, I cannot see how the transaction costs implicit in insurance-based models or large-scale schemes of co-payment would improve productivity or efficiency in our NHS—this despite the fact that the UK healthcare economy is distinguished from others by the small scale of its private provision.

For me, the Bismarck versus Beveridge debate is pretty much settled. However, I would expect a commission to examine all possible funding streams, drawing on experience from other countries. I would expect it to look closer to home at incentives that can be given to encourage subscription to mutuals, such as the Benenden Healthcare Society, formed in 1905 by and for Post Office workers, whose headquarters in York I visited recently.

But affirming that the great bulk of healthcare in the UK should continue to be funded through general taxation does not just mean more of the same. A variable hypothecated tax would be an easier sell to the public than a general tax hike. Treasury officials, or course, hate hypothecation, but the Treasury has been softening its approach in recent years and we are now, of course, wedded to the far less economically literate practice of hypothecated spend as a proportion of GDP for selected areas of public expenditure. Despite the Treasury’s reluctance, if we are talking about several pence in the pound to bring UK health spending up to the average of neighbouring similar countries, we have to find a politically acceptable and publicly palatable way of doing so. Either way, gathering a consensus on this most sensitive and complex of public policy areas, using a vehicle on a spectrum from royal commission to non-departmental public body, surely makes sense. As a model, may I suggest the influential Pensions Commission, chaired by Adair Turner, during the last Labour Government?

If the NHS is the closest we have to a national religion, its critical friends are often seen as heretics. We saw that even at the height of the Mid Staffs scandal. How, then, are we to uphold this rallying point for national morality, decency and righteousness with the more prosaic imperatives to save and lengthen life, make sick people better, prevent ill health and match health outcomes in comparable countries? I hope that the Minister will agree that the proposal for a commission and associated national conversation—made by me and others in this House, in the other place and elsewhere—has merit. I warmly congratulate Ministers on successfully arguing the NHS’s corner at a time of austerity. However, I urge the Government to give serious thought to establishing a commission that will examine how we can properly and sustainably fund healthcare and close the widening gap that exists between us and our European neighbours.

[Jo Churchill (Bury St Edmunds) (Con)]

I do not think that a commission is the right way to go, but does my hon. Friend agree that we sit on a new horizon, with molecular diagnostics, personalised medicine and so on, and that it is really important that we take a broader look at what our healthcare needs will be in future and how we can embrace more self-responsibility and new techniques for ensuring good patient outcomes? I said in this place in 2010 that we were lagging behind; sadly, we still are.

[Dr Murrison]

My hon. Friend is absolutely right: we are lagging behind. I hope that in the course of my remarks I have made it very clear that we are lagging behind countries with which we can reasonably be compared, particularly Germany, France and the Netherlands. The challenge is to bring our spend up to that level and to anticipate new developments and technologies. We should welcome that, because it will extend our lives and it will make us healthier for longer, but we do have to decide where the money will come from. Since the sums, I fear, will be so great, I believe that a commission would be a reasonable way to approach this matter and to have the conversation with the public about how the money will be raised.

The sands are fast running through the five year forward view hourglass. I believe it is time for Ministers to consider, “what next?”

Defending Public Services

Andrew Murrison Excerpts

Monday 23rd May 2016 Commons Chamber

[Heidi Alexander]

We were very clear at the last election that we would have had an emergency Budget to put every penny that the NHS needs into its funding.

I was talking about the reduction of NHS spending as a proportion of GDP. In terms of real funding, the House of Commons Library has shown that, if spending as a percentage of GDP had been maintained at Labour levels, by 2020, £20 billion more would be being spent on the NHS each year. That demonstrates the scale of underfunding that we have already seen and just how tough the coming years are going to be. That is not to mention the deep cuts to adult social care, which have piled the pressure on to hospitals, and the £22 billion-worth of so-called efficiency savings that this Government have signed up to. I have yet to meet anyone who works in the NHS who thinks that efficiencies on this scale are possible without harming patient care.

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

I do not disagree with the hon. Lady that there are big pressures on the horizon, but can she say how much, beyond Simon Stevens’ predicted costs, her party is now pledged to spend on the national health service, because so far all we have heard is prevarication?

[Heidi Alexander]

I am not going to be drawn into giving figures here at the Dispatch Box today. Yesterday the Life Sciences Minister was tweeting that we need a big public debate about funding of the NHS.

Three days ago, the scale of this crisis was laid bare. NHS Improvement, the body responsible for overseeing hospitals, published figures showing that NHS trusts ended 2015-16 with a record £2.45 billion deficit—I repeat, £2.45 billion. To give hon. Members some context, that is treble the deficit from last year. What is the key cause? It is the spiralling agency spend because of staff shortages. When this Government talk about more money going in, let us remember that, before that money gets to the frontline, the bulk of it will be spent on paying off the bills from last year.

--- Later in debate ---

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

It is always a pleasure to follow the hon. Member for Oldham East and Saddleworth (Debbie Abrahams). It is a privilege to be able to speak in today’s debate.

I start by echoing the comments by my hon. Friends the Members for Harrow East (Bob Blackman) and for High Peak (Andrew Bingham), in particular, and other hon. Members, about the digital economy Bill. I am delighted that the Minister for that business area, my hon. Friend the Minister for Culture and the Digital Economy, has just walked into the Chamber. This Government have done a splendid job in trying to roll out broadband. It is very difficult to make inroads into the last 5%, but the universal service obligation and the commitment to 10 megabits is absolutely right. I look forward, in particular, to my rural constituents and their small businesses being able to access 21st-century technology in the very near future. On behalf of those constituents, I thank the Minister for all his hard work.

I am a doctor, as you know, Mr Deputy Speaker, and I have to declare that interest since most of my contribution will be about healthcare. The Gracious Speech rightly began with the economy, however, and we found out why that might be over the weekend when Simon Stevens, the head of the NHS in England, made it very clear that without a sound economy one cannot have an effective healthcare system. That is absolutely fundamental to the delivery of public services in general, and particularly to the national health service. It is perhaps ironic that Simon Stevens was once a Labour councillor. I wonder what he would make of the financial illiteracy displayed this afternoon by Labour Front Benchers, who must answer the fundamental question about what they would want to spend on our national health service beyond Simon Stevens’ five year forward view. On a number of occasions they have been pressed on this matter and failed to come up with an adequate answer. I say ever so gently that Labour Front Benchers must answer the point being made by me and other hon. Members about precisely what figure they would be prepared to commit to our health service, since at the last general election they opposed the Government’s spending plans, and had they been in government now, enacting their proposals made only a few months ago, our national health service would have little chance of seeing the £30 billion overall extra spend to the end of this decade that it so desperately requires.

I very much welcome the commitment to the so-called seven-day NHS. As it happens, I was visiting a constituent in a busy hospital ward this weekend, and from the activity that I saw, it seemed that the NHS was working at full tilt. However, in some important respects, our health service is different at the weekends from how it is midweek. It is absolutely right that the Government should be attempting to roll out Sir Bruce Keogh’s 10 clinical standards, particularly the four he has identified as most important in this matter. The seven-day working week is essential to being able to do that in a comprehensive fashion. I commend the Government for the efforts that they have put into this for the past several months.

I also welcome the commitment to dealing with sugar. We heard earlier about the perils of obesity and the time bomb, as it were, that this presents to the younger generation. If we are going to be true to our mission on public health and preventive health, it is absolutely right that we should send out the right message to those who sell fizzy drinks—sugary drinks—and ensure that we try to reduce consumption of those things.

The Secretary of State has a very tough job, in my opinion. He has to improve outcomes—which are not good in this country compared with countries with which we can reasonably be compared—and deal with increased public expectations, demographic change, and economic stringency. I am very pleased that I do not have his job. If I may say so, the strain is showing—on the national health service, I hasten to add, not on the Secretary of State—since we know from last week’s data that there is a £2.5 billion deficit that involves two thirds of trusts being in the red. That is set to endure, since we have a real issue in reconciling the money going into the national health service, welcome though it is, with the extra demands being put on the health service all the time through the demographic changes that I mentioned.

We are now 18 months into the five year forward view, and the £22 billion in savings looks challenging, to put it mildly. Those savings are predicated on a number of assumptions—in particular, a continuing input into public health—and yet, necessarily, the local government grant has been squeezed this year. According to the Health Foundation, we also have a £6 billion social care cost funding gap. All this impacts on health generically. Simon Stevens made his prognostications based on continuing spend on public health and on social services, both of which have been squeezed. I make no criticism of the Government on that, since it is absolutely necessary to deal with the economy, as I said in my opening remarks. It has happened, nevertheless, and therefore, I am afraid, undermines much of what Simon Stevens had to say. We need to bear that in mind when we assess how realistic is the £22 billion figure, which, by his own admission at the time, required what he described as a “strong performance” by the national health service.

“Five Year Forward View” talked of a “radical upgrade” of public health and prevention, stating that public health was its first priority. Many of us can remember the Wanless report by the late Derek Wanless, which said that improvements in public health and prevention were absolutely essential if his “fully engaged” scenario was to be enacted. The recent Carter review showed a considerable unwanted variation across our national health service. In this, there is some hope for squaring the budget, since if there is such a wide variation across the national health service, there must surely be capacity to improve practice across the service and thus generate efficiencies. However, it appears that Carter has stalled, and we need to have a proper plan for the future on how the differences may be dealt with and, we hope, erased. Beyond some useful sharing data, it is not clear that Carter has been progressed in the way that we might want. I fear that if we do not give it a bit of oomph, there is a risk that it will go the same way as Wanless, which would be a great pity.

I very much support the seven-day-a-week national health service. As I have said in the past, I am not terribly convinced by the mortality data that underpin it. I am much more persuaded that we need to look at items of clinical service to underpin the argument for a seven-day NHS. I am thinking particularly of things like palliative care services. I am thinking about the fact that there are no routine endoscopy lists on a Saturday and a Sunday. That has huge implications for people who have had an upper gastro-intestinal bleed on a Friday, for example. The upper gastro-intestinal endoscopy example is a good one, since it touches on Bruce Keogh’s standards 5 and 6, which recommended endoscopy within 24 hours of a bleed. That is not happening in many of our acute hospitals. A lot of the remedy has to do with considering how to network hospitals, and perhaps reconfigure our national health service estate, in order to ensure that when people are acutely unwell they go to a unit that is capable of managing their healthcare needs in the most efficient and effective manner and ensuring that they have the very best chances of leaving hospital in good order.

We are faced with the reality of a healthcare system that is working at full tilt, and of which we are enormously proud, but delivers healthcare outcomes that could be better by international standards. Part of the reason is that we do not spend enough on healthcare. The reason I do not envy the Secretary of State for Health is that he is going to have to grip the reality that in this country we spend very much less than countries with which we can reasonably be compared—8.5% of our GDP compared with 11% in the Netherlands, Germany and France. I have no easy solution for that, but I do suggest, ever so gently, that we need to look a little more broadly at potential solutions. We could think, perhaps, of having a non-partisan commission that may grapple with this extraordinarily difficult and complex matter, because one thing is for sure—the institution that is held most closely in the public affection is our national health service, and we must fund it properly.

[Several hon. Members rose—]

--- Later in debate ---

[Huw Merriman (Bexhill and Battle) (Con)]

It is a pleasure to follow the hon. Member for Sheffield Central (Paul Blomfield) in this debate on the Queen’s Speech. In the time afforded to me, I want to focus on the defence of three key public services—the NHS, schools and the BBC.

On the first, 28% of my constituents in Bexhill and Battle are over the age of 65, versus a national average of 17%. There are forecasts that the national average will reach 25% by 2050, which is a cause for great celebration. However, as a result of an ageing population, my constituency has the highest rate of dementia in mainland Britain. East Sussex has the highest percentage of over-90s in the UK, and is predicted to be able to make the same claim for the over-75s and the over-85s in the years to come. Accordingly, the state of the NHS is of particular importance to my constituents—not just those who rely on it in their older age, but those who need to access it across the age spectrum.

I have ruptured, and this week re-ruptured, my Achilles tendon, so I have been something of a drain on NHS resources. It has, however, given me the opportunity to witness, at first hand, the NHS and the first-class people who work in it. I want to say a huge thank you to every clinician and employee for what they do for my constituents. Their clinical expertise, dedication and care make me incredibly proud to be British and equally determined that we should listen to their ideas for and concerns about the NHS.

The decision by our junior doctors to call the first ever all-out strike was a deeply depressing outcome of the breakdown of the contract negotiation. On the day of the strike, I went to the picket line to meet the junior doctors who had looked after me following my first Achilles tendon rupture. I spent an hour listening to the concerns of those junior doctors. Some concerns were linked to their personal circumstances and their feeling that it was unfair, in their position, to have only the same rights as a fixed-term employee when it came to the unilateral imposition of contract terms. Other concerns were about their workplace and their ability to do their best in the face of increased demand from patients.

On that day, I was asked whether I would write to the leader of the BMA and the Secretary of State for Health and pass on those junior doctors’ desire for talks to resume and a negotiated settlement to be reached. I duly did so and was delighted when talks were subsequently held and a resolution was reached. I hope that the junior doctors will consider the settlement negotiated by the BMA a fair compromise that is worthy of acceptance, and I thank the Secretary of State for going the extra mile.

It is clear to me that, once the contract is finally negotiated, we should have a grown-up debate about the future of the NHS. Can we expect it to meet the needs of an ageing population, carry on purchasing ever more expensive drugs, deliver innovative treatment and cope with an increasingly obese population when we as a nation only put 8% of GDP towards health? In the French and German model, it is 11% of GDP. Inflationary patient demands on the NHS equate to a 4% increase per annum, yet the increase in spending, welcome as it is, is running at 2%. This Conservative Government have spent record amounts on the NHS, but does the current situation make it reasonable that those who fail to take individual responsibility, or who waste the time of our doctors or nurses or disrespect them, should pay towards their care or be denied it? I welcome the Government’s decisions to introduce a new Bill to tax sugar content and to strengthen existing rules to ensure that all health tourists from abroad pay for their treatment. However, we could also look closer to home in expecting patient responsibility in return for treatment.

I am intrigued by the requirement for the NHS to deliver £22 billion of savings at the same time as introducing a seven-day NHS. If we are to have a fully functioning NHS on a Sunday, it means absorbing all the costs of running and supporting such a service. I ask myself whether I want to have my physiotherapy on a Sunday, and the answer is that I do not.

[Dr Murrison]

I share my hon. Friend’s confusion, but in fairness, it is only right to point out that weekend working means meeting the four key clinical standards that Sir Bruce Keogh outlined. I fear that my hon. Friend will probably not be getting his physiotherapy at the weekend.

[Huw Merriman]

I thank my hon. Friend for that clarification—it turns out that I will be satisfied, then. However, the point is that when we talk about a truly seven-day NHS, we need to be absolutely clear what services there will be on a Sunday. Those who work in the profession want the flexibility and freedom to work hours that allow them to experience an enriched life and to raise a family. They want to succeed in the workplace and to make a contribution in their field. If they cannot, they will decide to work in another profession. I hope that that will be taken into account when changes are made to Sunday operating practices.

From discussing the pressures on the modern-day NHS with Government, clinicians and managers, it appears to me that there are many shared views on patient safety and individual patient responsibility. Like most of my constituents, I yearn for the day when politicians and clinicians join together and recommend the difficult decisions that both parties know are required. Our NHS would be stronger for it, and our patients would be better served.

I turn to our schools. I was particularly pleased by the introduction of the new White Paper on education. The day after it was announced that schools would be forced to become academies, I spoke in this place about the need to allow good and outstanding schools to make their own choice. I am delighted that the Government have made that alteration, although rightly not for schools for which local education authorities are not fit for purpose or those that are no longer of a viable size.

That is not to say that becoming an academy is not a good idea for a school that wants to. I have just spoken of junior doctors’ desire to take control of their career and their destiny, and it strikes me that we now have a generation of headteachers who are no longer willing to be told what to do by their LEA but want to make their own decisions about how to run their school and whether to expand. It comes down to choice, which drives up standards. I hope that my local schools will consider making their own determination on expansion.

Junior Doctors Contract

Andrew Murrison Excerpts

Thursday 19th May 2016 Commons Chamber

[Mr Hunt]

The hon. Gentleman is right. A seven-day NHS is not just, or not even mainly, about junior doctors, although they are a very important part of the equation. We will need a new contract for consultants and we are having constructive negotiations with them. Many other people working in the NHS are already on seven-day contracts, so there will not necessarily be a contractual change, but the hon. Gentleman is right to say that we will need, for example, diagnostic services operating across seven days so that the junior doctor who works at the weekend will be able to get the result of a test back at the weekend. Those are all part of the changes that we will introduce to make the NHS safer for patients.

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

I warmly congratulate both sides on reaching this agreement. Our NHS is different at weekends, and my right hon. Friend is right to inculcate Sir Bruce Keogh’s four key clinical standards on a Sunday and a Saturday. Does he agree that it is important not simply to rely on mortality data, which are often difficult to interpret, to underpin the case for a seven-day NHS? Will he look closely at other metrics based on clinical standards for things like routine lists for upper gastrointestinal endoscopy on a Saturday and Sunday? Will he also look at palliative care, which of course does not feature in any hospital mortality data?

[Mr Hunt]

My hon. Friend speaks, as ever, very wisely on medical matters. I particularly agree when he talks about palliative care; it has got better, but there is a long way to go. We have recent evidence that it is particularly in need of improvement where we are not able to offer seven-day palliative support.

Oral Answers to Questions

Andrew Murrison Excerpts

Tuesday 10th May 2016 Commons Chamber

[George Freeman]

I am not against people taking whatever they feel helps, but my hon. Friend will understand that in this field, in allocating every pound, we need to be guided by the very best science and evidence. Internationally, we are applauded for the quality of our assessment, and I intend to do everything to make sure that that continues.

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

Outcomes in cancer are not just about survival. Does the Minister agree that nowhere is the case for a seven-day NHS stronger than in palliative medicine, and will he say what can be done, in rolling out the 7/7 NHS, to address the scandal whereby only one in five hospitals has specialist palliative care cover on a Saturday and Sunday?

[George Freeman]

My hon. Friend makes a really important and specific point. He is absolutely right, and that is one reason why we are committed to our seven-day NHS. It is improving—I can share the data with him—but he makes a good point, and that is one reason why we need to continue.

NHS Bursaries

Andrew Murrison Excerpts

Wednesday 4th May 2016 Commons Chamber

[Heidi Alexander]

Thank you, Mr Speaker. I will leave my comments on that matter there.

In the past few months, Ministers and I have had a number of exchanges across the Dispatch Box about the unnecessary and dangerous fight the Government are picking with junior doctors. You might think that having totally alienated one section of the NHS workforce, Ministers would think twice about doing it again, but you would be wrong. Not content with junior doctors, the Government are now targeting the next generation of nurses, midwives and other allied health professionals: podiatrists, physiotherapists, radiographers and many more. Instead of investing in healthcare students, and instead of valuing them and protecting their bursaries, which help with living costs and cover all their tuition fees, the Government are asking them to pay for the privilege of training to work in the NHS: scrap the bursary, ask tomorrow’s NHS workforce to rack up enormous debts, and claim that this is the answer to current staff shortages.

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

The hon. Lady is making a spending commitment. Why then, only a few months ago, did she stand on a manifesto that opposed the Government’s £10 billion investment in the NHS?

[Heidi Alexander]

The Labour party has always made it clear that it would have given the NHS every penny it needs.

Given the approach to healthcare students I have outlined, most people would think the Government had taken leave of their senses. They would be right.

--- Later in debate ---

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

May I start by declaring my interest as a member of a healthcare profession allied to nursing?

Two thirds of those who apply for nursing school places are rejected and have to look at other trades or professions—that is tens of thousands of people every year. Despite the comments of some hon. Members, those are good, high-quality applicants. I took the trouble of looking at the entry requirements of the three universities that accept adult candidates on to general nursing degree courses in the south-west—Bournemouth University, the University of the West of England and Plymouth University. The typical offer is 300 UCAS points—three Bs at A-level—so there is not a shortage of applicants who are academically well-qualified and, indeed, qualified in every way. Lots of young men and women who wish to study nursing and to be nurses are being turned away.

That is a double tragedy because we have a gross shortage of nurses in this country, and nothing I have heard from the Opposition gives me any confidence that they have any plan as to how we are to satisfy the two imperatives of allowing those who want to study nursing to do so and of plugging the shortage in our national health service. At the moment, I am afraid, we are able to deal with that issue only because nurses from overseas are prepared to come here—nurses, very often, from countries that can scarcely do without them.

Historically, student nurses have been an intrinsic part of the NHS workforce. My hon. Friend the Member for Totnes (Dr Wollaston) will remember, as do I, that they were essential to the working of hospital wards, and one or two of the good points made by Opposition Members revolve around that issue. The question is whether, in this day and age, we are still heavily reliant on that workforce for the proper functioning of hospital wards. If we are, there is a good case to be made for allowing for that in the bursary arrangements for student nurses, because it is simply not right to expect those people to do service work and not be compensated in some way for it. I hope very much that that strand of thought will be taken up as part of the consultation.

However, the fact remains that as part of Project 2000 in the 1990s, the nursing profession decided to move away from a hospital-based training structure to a structure based around universities—that was driven by the profession itself. The debate we are having today is part of that process—the process by which nurses become graduates, in exactly the same way as anyone else, including those who are preparing, for example, to teach in schools.

When we design the finances for student nurses, it is of course important that we understand the difference between a nursing degree course and a normal degree course, as it were. We must also accept that this is a graduate profession, and that it is not right to try—as I think the hon. Member for Lewisham East (Heidi Alexander), who speaks for the Opposition, did—to distinguish between graduates and to say that one graduate is more worthy than another. She may have in mind a view of a typical graduate, but those graduates are also potential teachers, engineers, biomedical scientists, and all the rest. We start down a very difficult path if we try to hold up one graduate as being superior morally, or in some other sense, to others. That is a very difficult thing to sustain.

I very much support the notion of a nursing associate. I am old enough to remember state-enrolled nurses. These were nurses who would not satisfy the entry criteria for a course leading to state registration but wanted to be members of a caring occupation. Naturally enough, nursing associates will not be SENs revisited, because we now live in a very different age, but there is surely a place within healthcare and our national health service for a group of people who may not want the academic rigour that goes with a nursing degree—or indeed be fitted for it, at their stage of life—but who nevertheless want to nurse, and to enter an intrinsically hands-on, caring occupation. The important difference, though—this is where SENs, I am afraid, suffered so badly all those years ago—is that there must be a sufficiently pervious system to allow nursing associates, if they want to and have the necessary skill sets, to enter a professional nursing stream. It was a tragedy that so many well-qualified SENs were unable to develop their careers in that way. I hope that as we design the future for nursing, we keep that very much in mind.

A few hon. Members have commented on workforce planning. Historically, the NHS has been absolutely abysmal in this regard, and we need to do much better in future. We need to avoid unintended consequences of the changes that we are making. We need to ensure that the £21,000 threshold that would apply for nursing graduates does not mean that people are inclined to avoid it by working part time where they might otherwise work more full-time hours. That would be a great disservice to the overall workforce.

The 10,000 new places created must not be denuded by our offering them to applicants from overseas, because that would not be in the interests of our national health service. We need to understand that nursing graduates may be tempted to migrate as a result of the introduction of these fees. I ask the Minister, in his consultation, to think of all the unintended consequences that may develop, given our general historical tradition in this country of doing health workforce planning so abysmally.

Junior Doctors Contracts

Andrew Murrison Excerpts

Monday 25th April 2016 Commons Chamber

[Mr Hunt]

I will tell the hon. Lady what is unsafe for patients. It is not standing up to the BMA when it behaves in a totally unreasonable way with a Government who are determined to make NHS care safer. With the greatest respect to her, because she is new to the House, she should appreciate that previous Labour Governments did not stand up to the BMA, and that is why we are left with many of the problems that we face today.

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

The Health Secretary is doing the right thing for patients, and I welcome his statement. However, does he accept that there is more to be done in contractual terms for the NHS workforce if Sir Bruce Keogh’s 10 clinical standards are to be implemented? Although he may not wish to reflect on it at this particular point in time, what does he think can be done to improve contracts for non-training grades and consultants in the NHS?

[Mr Hunt]

My hon. Friend speaks very wisely and also from experience on these issues. He is right. I have tried to make the point in my statement that a seven-day NHS is not just about junior doctors—it is about the whole range of services; it is about consultants, diagnostic services, general practice. As we seek to move towards a seven-day NHS, we will also be expanding the NHS workforce to ensure that the current workforce does not bear all the strain by itself. This is an opportunity. We have had lots of comments today about morale. I simply say this: the way to improve morale for doctors is to enable them to give the safest possible care to patients. At the moment, much of the frustration from doctors is that they do not feel able to give the safe care they would want to. We want to change that and to work with the BMA to make that possible.

Junior Doctors Contracts

Andrew Murrison Excerpts

Monday 18th April 2016 Commons Chamber

[Mr Hunt]

With respect, that precisely encapsulates the problem. The hon. Gentleman has interpreted the fact that I want to do something about excess mortality rates, which mean that a person admitted at the weekend has an 11% to 15% higher chance of death than if they were admitted in the week—that is proven in a very comprehensive study—as an attack on the medical profession. Nothing could be further from the truth. It was actually the medical profession—the royal colleges and Professor Sir Bruce Keogh—that first pointed out this problem of the weekend effect. We are simply doing something about it.

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

The Health Secretary rightly mentioned the excellent Salford Royal, which the BMA has used to suggest that the new contract is not necessary, because of the progress that it has made on seven-day working and on Sir Bruce Keogh’s clinical standards. However, is it not the case that what might be right in a large hospital in a densely urban centre might not be applicable right across our national health service? Is that not why the very radical changes to working practices that he is rightly prosecuting are necessary?

[Mr Hunt]

Yes, there are some hospitals that have managed to eliminate the difference between weekend and weekday mortality under the current contracts, but there are only a few. Having talked more widely with the medical profession, it is clear that we need a sustained national effort—contract reform is part of that effort—if we are to promise uniformly across the NHS that we will provide every patient with the same high-quality care, every day of the week. Part of that is having a modern contract for junior doctors that deals with the anomalies that they themselves recognise in the current contract; that is why this is the moment for wider reforms.

Upper Gastrointestinal Haemorrhage

Andrew Murrison Excerpts

Monday 11th April 2016 Commons Chamber

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

I am sure we are all very relieved to be having the Adjournment debate at this hour, rather than at two o’clock in the morning, as was previously rumoured.

I must first declare my interest as a doctor. I am grateful for the opportunity to bring forward this extremely important debate—it is certainly important for our constituents—about the management of acute upper gastrointestinal bleeding. I am grateful to the British Society of Gastroenterology, and particularly to its president, Dr Ian Forgacs, for helping me with research in preparing for the debate. The BSG has done a great deal of work over many years to highlight this issue.

Between 50,000 and 70,000 people every year are admitted with acute upper gastrointestinal bleeding, and 10% will, sadly, die. That presents a significant challenge to our national health service.

For the avoidance of doubt, let me say that upper gastrointestinal bleeding is what was so vividly portrayed by Hugh Bonneville, as Lord Grantham, in Julian Fellowes’s “Downton Abbey”. As the New York Post said, the Downton ulcer his lordship had been moaning about for weeks finally erupted all over the dinner table and all over Lady Cora. That is at the extreme end of the spectrum, but when it happens it needs to be dealt with very quickly and proficiently.

I want to start with a little bit of good news. Lord Grantham was lucky to survive in the 1920s, but mortality from upper gastrointestinal bleeding has been falling in the UK, with modest improvements in recent years as new treatments and innovative therapies have emerged, despite an ageing demographic. That is a tribute to our NHS and to some great pioneering work in therapeutics and interventions, much of which has been trialled and researched in the UK.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for giving way; I asked him beforehand for permission to intervene. Northern Ireland has seen some improvements by allowing relatively experimental procedures, provided they are regulated, such as nitrogen treatment systems, to name just one. Does the hon. Gentleman agree that all trusts across the UK need to share such information on any and all new developments, to advance treatments nationwide so that we all gain across the whole of the United Kingdom of Great Britain and Northern Ireland?

[Dr Murrison]

I am grateful to the hon. Gentleman, who takes an interest in these matters. He is right to say that we need to do more networking, to ensure that good practice is understood and inculcated. I will deal with some of that in my remarks.

Two major studies—one by NHS England and the British Society of Gastroenterology in 2013, and the other by the National Confidential Enquiry into Patient Outcome and Death in 2015—highlighted significant shortcomings in provision, confirming earlier studies.

The foreword to the NCEPOD report is starkly entitled “A Bleeding Shame”. NCEPOD found that the clinical care of 45% of acute GI bleed patients was sub-optimal, with a similar number receiving care judged to be good overall. Alarmingly, a quarter of all hospitals treating upper gastrointestinal bleeding were found not to be accredited by the joint advisory group set up 20 years ago to set standards for endoscopy. More hospitals told NCEPOD that they could deliver open surgery of the sort Lord Grantham had in the 1920s than interventional radiology for this particular range of conditions.

Some would say that that is down to inadequate resources. That is the mantra we often hear, particularly from the Labour party, but the situation is far more complicated than that. Alarmingly, NCEPOD reported that organisational issues led to less than satisfactory care in 18% of cases. “Organisational issues” is a polite way of saying poor management, such as failure to organise rotas—the “Bleeding Rota”, as NCEPOD graphically puts it—and I will come back shortly to how that can be addressed with minimal resource implications.

I support the concept of the seven-day NHS, or at least my interpretation of what a seven-day NHS actually means. The management of this range of conditions provides an excellent case study of why seven-day working is important and why Ministers are right to pursue it.

Overall, the evidence does not support the proposition that relatively poor weekend healthcare outcomes for conditions across the board are attributable to a lack of seven-day working. As Professor Matt Sutton’s work, reported by the Office of Health Economics last year, has shown, the quality-adjusted life-year evidence just does not support the cost of translating midweek working to the weekend. Data on increased mortality for those admitted at the weekends are alone insufficient to justify organisational change. The much cited Freemantle paper on weekend deaths does not say that excess weekend deaths are avoidable. Unfortunately, it has been quoted incorrectly by some who have confused association and causation.

Sir Bruce Keogh is right to say, however, that general hospitals are under-resourced at weekends, and the Academy of Medical Royal Colleges is right to point out that junior doctors are, to a certain extent, “winging it” out of hours, because consultants do not tend to be around to the same extent and many support functions are not, either. I remember it very well indeed. Sir Bruce was also right, in his 2013 review of 14 trusts with persistently high mortality rates, to commission Professors Nick Black and Ara Darzi to try to bottom out the relationship between excess mortality rates and avoidable deaths. Sadly, the report published last year did not seem to take us much further forward, other than to call into question the basis of the selection of trusts for the original Keogh review.

In my view, there is a firm argument for a seven-day-a-week NHS, but we need a common understanding of what that actually means beyond the soundbite. Upper GI bleeding is a good case in point, which the Government could perfectly reasonably use to support their proposals for seven-day working without resorting to selective quoting from, for example, the Freemantle paper. Most people are really not bothered about the inability to get an outpatient appointment in dermatology on a Saturday afternoon. That is a luxury bordering on an indulgence. However, if their Downton ulcer erupted on a Friday night, they would not really want to wait until a chaotic Monday morning list before getting endoscoped. They would need to be scoped on a routinely scheduled endoscopy list the following day, and they should not be subjected to delay in investigative and interventional radiology if that is necessary to manage their case optimally.

As far back as 2004, a large study by Sanders published in the European Journal of Gastroenterology and Hepatology showed that dedicated GI bleed units are associated with reduced mortality. NCEPOD asserts that patients with upper gastrointestinal bleeding should only be admitted to units with on-site endoscopy, on-site or networked interventional radiography, on-site surgery and on-site critical care. It promotes the model of comprehensive, dedicated GI bleed units in hospitals on acute medical take. We are far from achieving that.

That highlights some broader issues around right-sizing the NHS estate for optimal acute and critical care outcomes, which is a subject that I have raised before. Because critical care requires multi-specialties, because of the need for increased sub-specialisation and all that implies for populating staff rosters, and because of the better outcomes in large specialist units, not to mention the cost pressures, optimal management of this range of conditions underscores neatly the need for the model hospital concept outlined in February by Lord Carter of Coles. Why are we not moving faster towards having secondary and tertiary care in regional and sub-regional centres, where critical mass, and therefore quality of outcome, can be more readily assured?

I am proud to support a Government who are spending more on the NHS than ever before—spending, let it be remembered, that was opposed by the Labour party at the general election. However, outcomes in the UK routinely compare unfavourably with those in similar countries, with which we can reasonably be compared. I have no specific comparative data for acute upper GI bleeding, but I have no reason to suppose that they run counter to that general trend. The unavoidable truth is that our neighbours spend significantly more on healthcare than we do. The right hon. Member for North Norfolk (Norman Lamb) and I, with colleagues across the House, have called for a commission to achieve consensus on long-term funding. That is despite Simon Stevens’s five-year forward view, which does not come close to addressing what is needed to make progress, given the assumptions on which it is based, which we know we cannot rely on.

It is not just about money, however. The impression given by the studies that I have relied on is that the management of acute upper GI bleeding is a hit-and-miss affair. The BSG blames a

“lack of engagement from senior managers”

for that patchiness. That ties in with the remarks made last week by Dame Julie Moore, who said that there was a “culture of indecision” in the NHS, and that there was “gross incompetence” and a “failure of leadership”. That is pretty hard hitting from a very senior NHS manager, and I wonder how individuals can justify salaries well in excess of the Prime Minister’s if they are failing to get a grip on the sort of shortfalls described as “A Bleeding Shame” by NCEPOD. Dame Julie is right to ask why incredibly expensive senior NHS managers who are managing failure on this scale are still in post.

Last year’s NCEPOD report on acute upper GI bleeding is a wake-up call. Its first and prime recommendation —that patients with any acute GI bleed should be admitted only to hospitals with 24/7 access to on-site endoscopy, on-site or formally networked interventional radiology, on-site GI bleed surgery and on-site critical care—must be implemented without further delay. The answer is dedicated GI bleeding units that are seven-day NHS-compliant, and, with very few exceptions, no unit that cannot match the BSG’s guidelines should take patients with acute upper GI bleeding.

I look forward to hearing how the Minister will make this so. I invite him to return to the House after 12 months, if I am fortunate enough to secure another Adjournment debate of this sort, to tell us how the position has improved.

Oral Answers to Questions

Andrew Murrison Excerpts

Tuesday 22nd March 2016 Commons Chamber

[Jane Ellison]

My hon. Friend is right to draw the House’s attention to the fact that PrEP is only one part of prevention, although obviously we understand its importance. He is also right to mention the innovation fund, which, of course, he championed. We have invested up to £500,000 in new and innovative ways to tackle HIV. Some excellent organisations have come forward with some very innovative approaches, and we have also established the first national HIV home sampling service.

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

T1. If he will make a statement on his departmental responsibilities.

[The Secretary of State for Health (Mr Jeremy Hunt)]

The latest performance figures show the challenges that the NHS faces in coping with extraordinary levels of demand. Despite these pressures, however, the Government are making good progress in our ambition that NHS care should be the safest and highest quality in the world. Figures from the Health Foundation show that the proportion of patients being harmed has fallen by more than a third in the past three years, that MRSA infections have nearly halved since 2010, and that C. diff infections fell by more than a third over the same period.

[Dr Murrison]

The “Five Year Forward View” said that the NHS would need between £8 billion and £21 billion extra from the Treasury by 2021. It got a commitment of £8 billion, which was opposed by the party opposite. Can the Secretary of State say when the Stevens plan will be formally reviewed, and where in the range between £8 billion and £21 billion he expects the real requirement will be found to lie?

[Mr Hunt]

We are actually putting in £10 billion of additional public money to support the NHS over the next few years. That means that we need to find between £20 billion and £22 billion of efficiency savings. We will be reviewing the progress of the plan as we go through it, but I want to reassure my hon. Friend that I meet the chief executive of NHS England to view the progress of the plan every week and that we are absolutely determined to ensure that we roll it out as quickly as possible.