Social Care Funding

Caroline Dinenage Excerpts

Tuesday 1st October 2019 Westminster Hall

[The Minister for Care (Caroline Dinenage)]

It is a great pleasure to serve under your stewardship in this important debate, Sir Charles, and I share the sentiment of many Members across the House in congratulating the right hon. Member for Twickenham (Sir Vince Cable) on securing it. I also wish to highlight the incredibly constructive and collaborative nature of the way that he opened this debate. He was right to highlight from the outset that the only way to find a solution to this thorny issue, which is not unique to our country but a challenge faced by countries around the world, is by working in a co-operative, collaborative, and constructive way.

The right hon. Gentleman rightly pointed out that successive Governments have tried and failed to deal with this thorny issue, and despite everybody recognising the need for consensus, for too long it has been weaponised. We have heard expressions such as “dementia tax” or “death tax” used by all parties over the years. That has not been helpful, and it is one reason why different parties and Governments have placed this issue in the “too difficult” pile. He was also right to highlight the sense of urgency, because we no longer have the luxury of time to place the issue in that pile.

Over the past couple of years the Government have responded to huge short-term pressures, and funding for local government has gone up, as opposed to being cut, as outlined by Labour Members. However, we must set out our long-term plans, and consider how to solve the thorny issues of long-term funding for adult social care. At the moment, one in 10 people face what we might call catastrophic care costs in excess of £100,000, and potentially lose their home to pay for their long-term care.

I thank hon. Members across the House who have spoken with great passion and, in most cases, an enormous amount of collaboration and desire to work together to find solutions to these problems. I join them in recognising and paying tribute to the carers, nurses, social workers, and unpaid friends and families of those who require care. Every day, carers work tirelessly to ensure that people live dignified and fulfilling lives, regardless of how tough that challenge is. In doing this job and fulfilling this role, it has been my greatest privilege to meet those people on an almost daily basis and hear their stories. The hon. Member for Kingston upon Hull West and Hessle (Emma Hardy) said that carers must be accorded the status that they deserve, and given resources to drive the right amount of quality, and she was absolutely right. She was wrong, however, to say that we have lost caring from the caring system. People may be driven to that point in some respects, but they care and they do so in the most beautiful way.

[Jamie Stone]

May I associate myself with what the hon. Member for Plymouth, Sutton and Devonport (Luke Pollard) said about young carers who go home and look after parents who may have an alcohol or drug dependency problem? In my constituency an organisation called The Young Karers East Sutherland helps to support them. My mother died four years ago, but she was cared for at home very well. The younger carers—those who had left school and gone into the profession for the first time—were the most amazing. They embraced this profession, and one could see they had a vocation. I suggest that one way to sort out this problem is to encourage the recruitment of young people by giving them taster sessions and letting them come from school and see what it is like. Often, we might get converts who will stay in the profession for life.

[Caroline Dinenage]

That is an excellent intervention, and the hon. Gentleman is right to say that we must do more to recognise and support young carers. The hon. Member for Plymouth, Sutton and Devonport said that we must do more to help schools to identify young carers, and that was a key part of the carers action plan that was announced last summer. A young carers’ takeover day of Parliament is planned in the months ahead: every MP across the country will be encouraged to invite a young carer from their constituency, which will give us a real in-depth understanding of what an amazing job young carers do.

We all recognise the challenges that the social care system faces. As a population, we are getting older: by 2040, one in four people in the UK will be 65 or over, as the right hon. Member for Twickenham pointed out. It is also important to understand that social care is not just a service for older people; the number of people under 65 who have carers is growing and accounts for more than half of social care spending. That can have quite a disastrous impact on local authority budgets, as the hon. Member for Plymouth, Sutton and Devonport pointed out. I will certainly take forward the points that he made.

These long-standing trends put increasing financial pressure on local authorities. In response, we have taken steps to ensure that the social care system has the funding to meet urgent challenges in the short term. In 2017, we announced an additional £2 billion in grant funding for social care, which we supplemented with a further £650 million in the 2018 Budget. Councils have responded by increasing their spending on social care, which has risen in real terms in each of the past three years.

[Bambos Charalambous (Enfield, Southgate) (Lab)]

Will the Minister give way?

[Caroline Dinenage]

I will make some progress, if the hon. Gentleman does not mind.

As a result of our investment in social care, 65% of local authorities were able to increase home care provision in 2017-18. Local authorities have increased the average fee paid for older people’s home care by 4.7% in 2018-19, bringing some much-needed stability to the provider market. I am very pleased that the Care Quality Commission has rated 84.1% of social care settings as good or outstanding.

I am delighted to say that in our most recent spending round we announced further investment in adult social care. We will provide councils with access to an additional £1.5 billion for adult and children’s social care next year, including £1 billion in new grant funding over and above the £2.5 billion of existing social care grants. In the spending round, we confirmed that all the existing funding streams would be maintained next year—hard-wired into the Budget, if you like. The Government will also consult on a 2% adult social care precept that will enable councils to access a further £500 million. This increase in funding is part of the biggest increase since 2015 in overall core spending power for local government: it will increase by 4.3% in real terms next year.

The new funding from the spending round will support local authorities in meeting the rising demands that they face, while helping them to continue to stabilise the wider social care market. This additional funding is the first step towards putting adult social care on a fairer and more sustainable footing. We have already started preparing for the multi-year spending round due next year.

The challenges facing social care are not purely financial, as hon. Members across the parties, including my hon. Friends the Members for Central Suffolk and North Ipswich (Dr Poulter) and for Newton Abbot (Anne Marie Morris), have said. It is important to point that out, because stakeholders across the sector tell MPs: “Even if money were no object, we would not necessarily continue to provide this service in the current system.” The current system is not working in so many respects, and it is not working properly for some of our most vulnerable citizens, which is why we are continuing to support the system through a programme of sector-led improvements to help councils to make better use of funding to deliver high-quality personalised service, with more than £9.2 million committed by the Department in 2019-20.

We are also breaking down barriers to encourage much better integration of health and care, and we are looking at what more we can do to support the workforce and carers, as I have mentioned. In terms of integration, the better care fund has helped to enable much better co-operation between health and social care partners at a local level. It has also been instrumental in reducing delayed transfers of care, which has been mentioned: they have decreased by 2,147 since February 2017. We are looking at how we can use the fund to drive better integration.

My hon. Friend the Member for St Ives (Derek Thomas) spoke about bed vacancies and people stuck in hospitals. There is a lot more integration going on between care providers and health settings that are using those beds to provide the step-down care and discharge to assess that we want to see.

[Dr Poulter]

The better care fund and how it is applied on the ground locally varies across the country. Overall, the impact has been disappointing in terms of the ambition for that fund. I urge my hon. Friend to look at why there are two different commissioning systems for the NHS and social care. Unless we get that right, we are not going to drive improved integration or more personalised care.

[Caroline Dinenage]

My hon. Friend is right to say there were teething problems, but in the most recent reporting cycle, 93% of local areas agreed that joint working had improved as a result of the better care fund. We want to use it to drive much better integration and to look at how we undertake more joint commissioning in future.

We are committed to working alongside all partners in adult social care to attract and support a growing workforce with the right skills and the right values to deliver quality and compassionate care. Earlier this year, we launched the “Every Day Is Different” national adult social care recruitment campaign to raise the profile of the sector. We have secured a further £3.8 million for the next wave of that campaign, which will start later this month. We fund Skills for Care to support the sector in recruitment and retention.

[Rachael Maskell]

Will the Minister give way?

[Caroline Dinenage]

I do not have time. We also fund the workforce development fund, and social care employers can bid for this funding to pay for their staff to gain training qualifications at all levels.

There were lots of questions raised across the Chamber, and I want to deal with them all. The hon. Member for Totnes spoke about the impact of Brexit. As the Prime Minister has said, he wants our immigration system to help to attract the brightest and best talent from across the world. This includes delivering an Australian-style points-based immigration system as a first step. The Home Secretary has commissioned an independent migration advisory committee to review this and the appropriate salary threshold. Clearly, we want to attract people to work in adult social care.

We are aware that the system is already under pressure and recognise that EU exit could add to this. We have been working on this for a long time alongside partners, including ADASS, the Local Government Association and local authorities, to ensure robust contingency plans are in place. [Interruption.] I am going to have to make progress as I will have to sit down in a second.

There is still much more to do. The funding announced in the spending round is a down payment on much more fundamental reforms to social care that we need to introduce. As the Prime Minister said on the steps of Downing Street, the Government will set out plans to fix the crisis in social care once and for all, to give every older person the dignity and security they deserve. We want to ensure that nobody has to sell their home to pay for care. The Government will not shy away from the long-term challenges that face social care. Our proactive approach to funding and reform means that we will ensure that our social care system can respond to the challenges that lie ahead with confidence that the most vulnerable in our society will be able to live with dignity and respect and receive the care they deserve.

Variant Creutzfeldt-Jakob Disease (vCJD) Risk Reduction Measures: Revised Advice

Caroline Dinenage Excerpts

Monday 9th September 2019 Written Statements

[The Minister for Care (Caroline Dinenage)]

I would like to inform the House that the Government, along with the Scottish Government and the Welsh Government, will be updating some specific variant Creutzfeldt-Jakob disease (vCJD) precautionary measures in England, Scotland and Wales.

In 2004, the Government were advised to establish precautionary vCJD risk reduction measures in the UK, acknowledging the unknown risks of vCJD to recipients of UK plasma and platelets. A number of measures were introduced, such as the introduction of leucodepletion of all blood components and the deferral of previously transfused donors. These specific risk reduction measures are highly effective and will remain in place to maintain the safety of the UK blood supply.

An additional risk reduction measure adopted involved the treatment of patients born on or after 1 January 1996 with imported plasma and/or apheresis platelets. This was to reduce the risk of exposure to components that were thought to have potentially increased their risk of developing vCJD.

Over the last 15 years, accrued scientific evidence has indicated that the risk of vCJD through the transfusion of UK plasma or platelets is much lower than initially thought; there have been no known transfusion transmissions of vCJD from any blood components since the leucodepletion process was introduced. In March 2019, the independent advisory committee for the safety of blood, tissues and organs (SaBTO) reviewed the scientific evidence and operational practices, engaged with stakeholders, and recommended that some specific risk reduction measures, requiring the use of imported plasma and apheresis platelets for individuals born on or after 1 January 1996 and/or with TTP, be withdrawn.

SaBTO’s final advice has been published on the gov.uk website, providing a comprehensive analysis of the risk attributed with updating these vCJD risk reduction measures. This advice is available online at: https://www. gov.uk/government/collections/sabto-reports-and-guidance-documents.

Upon receiving this expert advice, the Minister for Care has approved the use of domestic plasma and pooled platelets for patients born on or after 1 January 1996 or with TTP. Other risk reduction measures will remain in place, including leucodepletion, deferral of previously transfused donors and a ban on the manufacture of plasma derived medicinal products from plasma sourced in the UK.

NHS Blood and Transplant already sources 94% of plasma from UK donors and increasing domestic plasma use will provide further benefits relating to equitable provision of blood components, reduced operational complexity for hospitals and increased accessibility at the point of use. Clinicians who wish to prescribe and source commercial imported plasma products for patients, based on patient need and clinical preference, will continue to be able to do so in accordance with local and national guidelines.

The Minister for Care has now directed NHS Blood and Transplant (BT) to begin increasing domestic plasma acquisition in England through a managed, incremental transition. The Scottish Government and the Welsh Government have also asked their respective blood services to begin implementing SaBTO’s recommendation. In Northern Ireland, any decision on SaBTO’s recommendation to update vCJD risk reduction measures will be deferred until a Minister is in post.

[HCWS1821]

Lower Limb Wound Care

Caroline Dinenage Excerpts

Tuesday 23rd July 2019 Commons Chamber

[The Minister for Care (Caroline Dinenage)]

It has sometimes been said that MPs in this House speak about things they do not know about, and sometimes MPs speak about things about which they have only a little experience, but I do not think I have ever had the honour of responding to a debate where a Member has spoken with so much current, relevant experience. I must congratulate the right hon. Member for Cynon Valley (Ann Clwyd)—

[Ann Clwyd]

It is pronounced “Cun-on”

--- Later in debate ---

[Caroline Dinenage]

I do apologise—I went to university in Wales, so I should get that right.

I must congratulate the right hon. Lady, first, on securing the debate, and, secondly, on making such mammoth, gargantuan efforts to be here. She did that with some help from her friends on the 12th floor of St Thomas’s, the experts in the Gallery—I am going to have to be careful what I say. She is nothing short of an inspiration to all of us, both as a long-standing Member of Parliament who is greatly respected in this place and as a human being. We are so grateful for the fact that she has made it here today, and we wish her a very speedy recovery. We look forward to her being back here to monitor every development that the Department can bring about in the context of wound care and how we look after people in hospital more generally. She is a great inspiration to all of us, and I thank her so much for raising this issue in the House.

I think we all recognise the importance of ensuring that patients have access to high-quality lower limb wound care. As a Government, we are absolutely committed to ensuring that people receive the right care in the right place at the right time, whether through acute services, a local GP or services based in the local community. As the right hon. Lady knows, wound care treatment is a vital service which, during the initial period, is predominantly provided by a community nurse. That crucial provision offers relief to those with leg ulcerations or diabetic foot ulcerations and pressure ulcers.

As Members will know, venous disease is the most common type of leg ulceration, and can cause great distress and suffering to patients and their families. The right hon. Lady spoke powerfully of the pain that she has suffered, and that others suffer, as a result of the condition. I think it is important to keep that in mind because of the side effects that having to live with enduring pain for long periods can have on a person’s emotional and mental health and wellbeing.

Our priority is for leg ulcers of this type to be treated early and in the community when that is possible, without the need for further hospital admissions or GP appointments. I think that that preventative approach is right for patients and for the system. It is key for wound care to be delivered effectively and efficiently. Good wound care not only saves patients from distress and suffering, but gives nurses more time to deliver other important services, and alleviates pressure on acute services. That is why NHS England and NHS Improvement have commissioned the Academic Health Science Network to develop and deliver a national wound care strategy programme for England, which aims to improve the quality of wound care provision. It is a comprehensive programme, which covers improving prevention of pressure ulcers, wound care of the lower leg, and management of surgical wounds.

The programme’s work will be informed by the following priorities. First, it will improve patient experience and outcomes by developing national clinical standards of care and a more data-driven approach. I know that the right hon. Lady is very keen on that. Secondly, it will work with industry to ensure that the right wound care products are reaching patients at the right time through the development of a much more robust supply, delivery and distribution model. Thirdly, it will aim to improve the current patchy provision of wound care training—of which I know the right hon. Lady is well aware—and the inconsistencies in the availability and quality of educational resources. As well as improving the care provided by healthcare professionals, that will allow patients to become more capable in self-care.

The right hon. Lady raised several issues that I should like to follow up. Let me first pay tribute to the work done by the Lindsay Leg Club Foundation in relation to community-based leg ulcer care. I am pleased that the committee of the lower limb clinical workstream of the national wound care strategy programme includes members of the foundation. As the right hon. Lady said, leg clubs are organised by the local community rather than health providers, but leg club nursing teams are employed by NHS local provider services, clinical commissioning groups and GPs. That is why it is so important for everyone to work together to support people as much as they can in the community. I can imagine that when this condition starts it is so painful that people can feel extremely alone and isolated, and the provision of leg clubs and other support mechanisms in the community, to offer the information, advice and support that they need, can help them to stop feeling that isolation and fear.

I also join the right hon. Lady in welcoming the all-party parliamentary group on vascular and venous disease. It is important for us to have all-party parliamentary groups which really recognise conditions of this kind, and which are doing their best to push the Government, and us in the Department of Health and Social Care, to do everything we can to support people who suffer from them.

The programme that I was talking about started its work in late 2018, and since then has brought together a range of experts. It has recruited over 500 stakeholders from a very broad range of private and public sector organisations to its stakeholder forum, and it is important that we have people with real experience from across the country taking part in this and influencing the decisionmaking. They aim to deliver their recommendations by the end of the 2019-20 financial year. We look forward to receiving them and the positive impact that they will have on patients’ lives. This is just for England, but NHS England is in communication with wound care leads in the three other devolved nations to ensure that they are sharing this learning across the piece.

The research in this area is also very important. The Department funds research into all aspects of human health through the National Institute for Health Research at the level of about £1 billion a year, and the NIHR has funded a number of studies focusing on lower limb wound care, including venous leg ulcers and vascular problems. A five-year funded programme on complex wounds comprised 11 new and updated reviews of the existing literature, a survey and interviews with people with complex wounds, their carers and health care professionals. There has also been a series of venous leg ulcer studies using randomised control trials to investigate the clinical and cost effectiveness of new versus traditional venous leg ulcer treatments from types of compression bandage through to compression hosiery to larval therapy.

The right hon. Lady also spoke about the importance of having the right staff, expertise and medically trained people to be able to deliver the care, and it is no secret that community nurses are a fundamental part of our health system; they provide vital services that ensure patients are treated where they are most comfortable, which often is in their own home, and that they are supported to manage their conditions and to live independently. To help deliver our vision for community services, we are investing an extra £4.5 billion a year to spend on primary medical and community health services by 2023-24. The key to delivering the long-term plans and vision is ensuring that we have the right nursing numbers, particularly in the community, and that is why the interim NHS people plan is prioritising taking urgent accelerated action to tackle some of the community nursing vacancies. That will be done in a range of different ways, including increasing supply through under- graduate nursing degrees, clearer pathways into the profession through the nursing associate qualification and apprenticeships, and tackling some of the misconceptions about the role of community nurses, which sometimes deter people from entering the profession. In addition, in May 2018 we announced £10 million for incentives to postgraduate students to go on to work in some of the areas that we care very passionately about and where we want to recruit the best people, such as mental health, learning disability and district community nursing roles.

[Jim Shannon]

I am pleased to hear this very positive response from the Minister. In Northern Ireland we have a very good community nursing programme that is delivered through the social care services. It cares for those who need care and a change of dressing for their wounds every day. The Minister referred to contact with the regions and devolved Administrations; will she contact the Northern Ireland Assembly and the permanent secretary of the Department of Health, Richard Pengelly, so they can give some idea of what we do there?

[Caroline Dinenage]

The hon. Gentleman is always full of brilliant ideas and we will only move forward as a nation if we share best practice and the expertise gained from different parts of our country. So I would be very keen to speak to his colleagues at the Northern Ireland Assembly and see if we can gain any learning from that.

[Jamie Stone]

I could not possibly let the occasion pass without commenting. Can I take it that that promise will be extended to the Scottish Parliament and the Scottish Government? The issue we have heard about today is no less a problem in Scotland.

[Caroline Dinenage]

Yes. We do not discriminate. We are keen to talk to everyone to get the best possible learning so that patients up and down the country can benefit from all the expertise that is available.

In thanking the right hon. Member for Cynon Valley for making the supreme effort to be here today, I reassure her that both the Government and the NHS recognise the importance of ensuring that patients have access to high-quality lower limb wound care and will continue to support the work of the national wound care strategy programme for England on improving the quality of wound care, including lower limb wound care, in the country. I thank her once again for being here to make her case so incredibly powerfully. I wish her a speedy recovery and send her all our love from this House.

[Madam Deputy Speaker (Dame Rosie Winterton)]

I echo the Minister’s warm comments about the right hon. Member for Cynon Valley (Ann Clwyd). We are all deeply impressed to see that she has come from her hospital bed on the 12th floor of St Thomas’s to raise this important issue in the House. I have known and been a friend of the right hon. Lady for more than 30 years and I know her courage and resilience so it is not a great surprise that she has done so, but nevertheless we are hugely impressed. Like the Minister, on behalf of the whole House, I wish her a speedy recovery and look forward to having her back full time in September.



Question put and agreed to.

Oral Answers to Questions

Caroline Dinenage Excerpts

Tuesday 23rd July 2019 Commons Chamber

[Eleanor Smith (Wolverhampton South West) (Lab)]

11. What recent estimate he has made of the number of people unable to access social care services.

[The Minister for Care (Caroline Dinenage)]

All councils have a statutory duty to look after people’s care and support needs in their areas. In total, between 2016 and 2017, and in 2019-20, the Government have given councils access to £10 billion more social care funding.

[Afzal Khan]

Given that the Government have promised a spending increase for the NHS in the regions, is the Minister aware that at the current funding levels, Greater Manchester Health and Social Care Partnership will be operating on a predicted deficit of £2 billion by 2021? Will she advise on what work has been done in partnership with the GMHSCP to avoid this huge deficit?

[Caroline Dinenage]

There is no doubt that the system is under pressure, but that is why the Government have been putting an enormous amount of money in and giving councils access to additional funding to be able to address the growing need—up to £10 billion over the past three years. We know that people are living longer and living with much more complex conditions. This situation is only going to get worse, so we do need to find a more sustainable way to deal with it in the long term. The hon. Gentleman will be interested to know that Manchester will receive an additional £42.9 million for adult social care funding in 2019-20.

[Eleanor Smith]

Figures from the Care and Support Alliance and Age UK show that at least 1.4 million older people in England are not receiving the care and support they need. We know that this figure will be much, much higher owing to the number of working-age disabled people who are being denied the care and support they need to lead better lives. Speaking as co-chair of the all-party parliamentary group on adult social care, how much longer do we need to wait until the Government publish the long-awaited Green Paper on social care and finally start to show some much needed leadership in this vitally important area of public policy?

[Caroline Dinenage]

First, I pay tribute to the hon. Lady for her work in the APPG on adult social care. It is really important that we have an APPG that represents this really important issue. As I said, the fact that we have an ageing population is a growing issue that we have to face as a nation, and, in fact, as a world. Her area of Wolverhampton will receive an additional £22.1 million for adult social care in 2019, but we know that that is not a long-term solution and we will be publishing a Green Paper at the earliest opportunity.

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

The Government’s utter chaos over Brexit has already impacted on recruitment in the social care sector. Scottish Care told the Scottish Affairs Committee that providers have lost 67% of their intake from the European economic area. The fact is that this Government’s actions are putting the health of the sick and elderly at risk. Will the Government make an assessment of how the staffing crisis in social care is impacting on the rate of hospital admissions?

[Caroline Dinenage]

The hon. Gentleman is right: we do have a number of vacancies—a large number of vacancies—in adult social care. That is why, earlier in the year, the Government announced a recruitment campaign, “Every day is different”. It ran for a few months, with enormous success. There have been 14% more apply clicks on the relevant Government jobs site as a result, so we have just announced that we are going to expand and extend that recruitment campaign, with an additional £4 million of funding.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

Among those most affected by lack of access to social care are the 2,300 autistic people and people with learning disabilities stuck in inappropriate in-patient units because of a lack of funding for community placements. Labour, my party, has pledged to spend £350 million per year to support moving as many of those people as possible into community placements. I note that the Health and Social Care Secretary actually pledged extra funding for social care if he became Prime Minister, so will the Care Minister tell us if he now promises to match Labour’s pledge and ensure that autistic people and people with learning disabilities can live in homes, not hospitals?

[Caroline Dinenage]

The hon. Lady is absolutely right. One of the biggest issues we have had with people with learning disabilities and autism ending up in in-patient settings is a lack of community provision. That is why the NHS long-term plan commits to an extra £4.5 billion a year for primary and community health services, and local areas will be expected to use this investment to develop the sort of specialist services and community crisis care that will help divert people away from in-patient care settings.

[John Howell (Henley) (Con)]

8. What steps his Department is taking to help prevent mental health illness among young people.

--- Later in debate ---

[Kerry McCarthy (Bristol East) (Lab)]

15. What additional funding he plans to allocate to the NHS to reduce the number of people with autism and learning disabilities held in in-patient settings.

[The Minister for Care (Caroline Dinenage)]

The NHS long-term plan commits to an extra £4.5 billion a year for primary and community health services by 2023-24. Local areas will be expected to use part of this investment to develop specialist services and community crisis care to reduce avoidable admissions and lengths of stay for autistic people and those with learning disabilities.

[Kerry McCarthy]

I do not know whether the Minister has seen the report from the Children’s Commissioner, but it says that the number of children with autism or learning difficulties in mental health hospitals has doubled in recent years. Many are very far from home. Their parents are not consulted properly on their care, and they are in for much longer than they need to be. What proportion of the money that she mentions will go towards trying to ensure that children can have support in their home, so that they are not in this situation?

[Caroline Dinenage]

The hon. Lady has hit on a really important point. The truth is that a lot of children who end up in an in-patient setting are not diagnosed with autism or a learning disability until they are there; they normally come in on a mental health diagnosis. There are a few points to make here. One is on making sure that early intervention is there as early as when a child is in school. That is why the Government have made a commitment to having mental health support available from a very early age, in schools. This is also about making sure that families do not get to crisis point, and that the investment is there in the community, so that children get the support that they need at every possible step.

[Gordon Henderson (Sittingbourne and Sheppey) (Con)]

16. What steps he is taking to reduce the number of missed GP appointments.

--- Later in debate ---

[The Minister for Care (Caroline Dinenage)]

I thank the hon. Gentleman for raising that, because one of the things that I have learned in this role is that working in care should never be described as unskilled. It is probably one of the most skilled professions, and it requires people with exactly the right principles and values to deliver it. We are clear that people should be paid a fair and decent wage, and I am more than happy to meet the hon. Gentleman to discuss it further.

[Helen Goodman (Bishop Auckland) (Lab)]

The Minister with responsibility for mental health is a very sympathetic person. Unfortunately, that does not seem to translate into action. Our clinical commissioning group has stopped funding the voluntary sector to provide counselling, and now it is taking counselling services out of GP surgeries as well. Will she look into that?

--- Later in debate ---

[Thelma Walker (Colne Valley) (Lab)]

Can the Secretary of State confirm that the Care Quality Commission has recently inspected Calderdale and Huddersfield NHS Foundation Trust, and that patient safety was raised as an issue during that inspection? If that is the case, what action is he taking?

[Caroline Dinenage]

Clearly, patient safety is a massive priority for the Government. I do not know the exact details of the site that the hon. Lady is talking about, but if she would like to drop me a line, I will definitely find out and get back to her.

Batten Disease: Access to Drugs

Caroline Dinenage Excerpts

Tuesday 16th July 2019 Commons Chamber

[The Minister for Care (Caroline Dinenage)]

I congratulate my hon. Friend the Member for North East Somerset (Mr Rees-Mogg) on securing this important debate on what is a heartbreaking issue, as I am sure you will agree, Mr Speaker. He and other Members have spoken up movingly and with great passion about and on behalf of their constituents, and I am grateful to them for doing so. I understand how vital it is for patients and their families to be able to access new medicines as quickly as possible. This is one of the hardest types of debates that one has to respond to as a Minister, when we can put ourselves in the position of the families up and down the country who are facing such a desperate situation.

I will endeavour to respond as fully as I can to the issues that my hon. Friend and other Members raised, but I should begin by saying, sadly, that I am unfortunately unable to comment on matters relating to the availability of Brineura, a drug used to treat Batten disease, as this is currently subject to an active judicial review procedure.

As we have heard from hon. Members, Batten disease is a terrible condition that progresses rapidly, leading to loss of speech, mobility and vision, progressive dementia and early death. It is a rare genetic disease, and it is estimated that around three to six children in the UK are diagnosed each year, with around 30 to 50 children living with the condition. Current treatment options are limited to symptomatic relief and supportive care. I fully understand how vital any new treatment option could be to the families of children with this rare and devastating condition.

The Government want patients, including those with rare diseases such as Batten disease, to be able to benefit from effective new treatments. It is in the interests of all NHS patients that we have a system in place for making evidence-based—

[Andrew Griffiths]

On a point of order, Mr Speaker. This important debate is about whether this drug is going to be available for these young children, and you will share my concern that we are not going to get the answers we want because it is supposedly prevented by a judicial review. Can you rule on whether we should be able to have the information we seek in this debate for the parents who are watching?

[Mr Speaker]

I am extremely grateful to the hon. Gentleman for his point of order. He anticipates me, because his discernment is such that he will have observed me in conversation with the Clerk at the Table. Let me say, for the avoidance of doubt, that the content of the Minister’s reply is, of course, a matter for her, and it is not something with which I would seek to interfere. That is not for me.

However, for the purposes of clarification, I want to make this point. I am not aware that this matter is sub judice, as I have not received prior notification that it is. I am not aware that it is, I have not been informed that it is, and the Clerks have not been informed that it is. If it is not sub judice, nothing whatsoever precludes the Minister from commenting on this case. If it is sub judice, as colleagues will know, it is within the competence —I use that term in the technical sense—of the Chair to waive the sub judice rule, which it would most certainly be my instinct to do.

What the Minister says is a matter for the Minister, but it would not be right, as far as I can tell, to say that it is not possible, in a legal sense, for the Minister to comment on this matter. The Minister is the Minister, and the Minister’s answer on the specifics is sought. If the Minister wishes to proffer that answer, she can do so.

[Caroline Dinenage]

Thank you, Mr Speaker. You have made my position even more difficult. I am very grateful for your advice.

The advice I have been given by the legal team within the Department of Health and Social Care is that anything I say could potentially influence the outcome of judicial proceedings that may be ongoing.

[Mr Speaker]

The Minister is nothing but solicitous and courteous. I have found her unfailingly courteous in her dealings with me over many years, and I certainly do not seek to make life difficult for her, but my concern is with the rights of Members of this House and of the people they are here to represent.

Frankly, if lawyers within the Department of Health and Social Care are of that view, it would have been courteous to consult the officials of the House. As far as I am aware, the officials of the House have not been consulted, and I have not been consulted about this matter. I am simply saying that if the Minister wishes to respond to the specifics, which manifestly the hon. Member for North East Somerset (Mr Rees-Mogg) was going to raise—that is the rationale for the debate—it is perfectly open to her to do so.

If the hon. Member for North East Somerset is not able to secure satisfaction on this occasion—the Minister must judge what she wants to say in response—and if he wishes to pursue the matter further in another Adjournment debate, during the course of waiting for which further time will unfortunately have been lost, that debate will be available to him. I am determined that this matter will be effectively raised in the Chamber of the House of Commons by the hon. Gentleman and by other Members.

[Caroline Dinenage]

Thank you for clarifying that, Mr Speaker. I very much share the passion that I detect my hon. Friend the Member for North East Somerset feels about this issue, which I know is shared by Members on both sides of the House.

[Mr Jim Cunningham (Coventry South) (Lab)]

On the basis of what Mr Speaker has said, surely if those who are taking this issue to the courts withdrew their challenge, or if the Minister gave them a satisfactory answer to help the hon. Member for North East Somerset (Mr Rees-Mogg), it would not be sub judice. The Minister has the power to do that.

[Caroline Dinenage]

I am very tempted to do so, but I would like to try to make progress on some of the things I can say, and then we can maybe move on to a more satisfactory conclusion.

[Andrew Griffiths]

On a point of order, Mr Speaker.

--- Later in debate ---

[Mr Speaker]

It is certainly open to the Minister to do so, and I think that it would, without question, be to the advantage of the House if such an oral statement were proffered before the House goes into recess. What I should say to the hon. Gentleman and to other colleagues is that, to my knowledge—forgive me, but I am dealing with this matter literally on my feet—the case has not been set down; it is not listed for court consideration. There are no current proceedings dated. Therefore, as we understand it—my advisers and I—it cannot be said to be sub judice. Sometimes a judgment might be made about the possibility of prejudicing a case—that is a wider consideration–but the real issue is: is it sub judice? Our answer, on the best information available, is that it is not, and so I think a statement would be helpful. Alternatively, if Members wish to exercise their ingenuity in raising important and of course legitimate points of order, and the Minister wishes in the meantime to consult her officials so that a full and detailed response on the specifics can be provided, that is open to her. I recognise that that might be challenging at such short notice and she may not wish to do that, but it would certainly be helpful to have a substantive response, preferably this evening, and a full oral statement before we go into recess. I would say to the House that I am giving the ruling that I am giving both on the basis of a decade’s experience as the occupant of the Chair and on the strength of top-quality procedural advice.

[Caroline Dinenage]

Thank you, Mr Speaker. I am very grateful—

[Mr Rees-Mogg]

On a point of order, Mr Speaker. My point of order follows on from what you said and I hope it may be helpful to the Minister in giving her a moment to reflect on what you have just said. I would express a broader concern on this sub judice question, because, as you rightly said, it is always the prerogative of this House to discuss what it wishes to discuss, regardless of what is going on in any court. The sub judice rule has only ever been a self-denying ordinance of this House, to feel that it should not trample on things that were immediately before another court, rather than something that can be enforced upon us. In that respect, we are different from any other place in the country—other than of course their lordships’ House—which would be subject to sub judice as a matter of law. We are subject to it only in so far as we feel that it is wise to be cautious and prudent, and not to interrupt another of the separated powers within our judicial system. Therefore, it seems to me that whenever Ministries decide to cite sub judice rules, it would be wise to have consulted Mr Speaker or one of the Clerks in advance, in order to have some clarity before the debate begins.

[Mr Speaker]

Yes, it is a matter of prudence on the part of the House of Commons; it is not a cloak behind which the Executive branch should seek to hide. I know that the Minister would not attempt to do so, but any advice that might be thought to be intended to allow that to happen would be ill viewed by right hon. and hon. Members, and most certainly by their constituents.

[Caroline Dinenage]

I take on board all the comments that you have made, Mr Speaker, and indeed that hon. Members have made. I need to go away and reflect on this. I would like to make some progress with what I feel confident to be able to talk about today, and then, if inspiration does not approach me from anywhere else in this Chamber in the next few moments, I will commit to coming back with a fuller response if that is possible before we break for recess, if that would be acceptable to you, Mr Speaker.

[Catherine McKinnell]

I thank you for your guidance on this issue, Mr Speaker. I wonder whether the Minister would accept that the legal action that is being discussed would be unnecessary if NHS England, the National Institute for Health and Care Excellence and BioMarin got around the table and resolved this issue. On the broader point, on 21 May I and a number of colleagues, including the hon. Member for North East Somerset, met the Secretary of State to discuss this issue. He has since written to me to say that he is

“doing all he can within the legal constraints to resolve this”

situation. I was therefore hoping that the Minister could clarify what exactly that means, and what progress is being made as a result of that meeting and the representations we have made today.

[Caroline Dinenage]

I know that the Secretary of State met the hon. Lady and other Members recently, and this is something that he cares about passionately. We are doing everything we can in the Department of Health and Social Care to try to move the position forward. The hon. Lady is right to say that had this issue been satisfactorily resolved, we would not be having this discussion at all, we would not be talking about legal proceedings and the situation would hopefully be a lot easier to resolve.

I have only a short amount of time left to be able to give some sort of response to my hon. Friend the Member for North East Somerset.

[Mr Rees-Mogg]

We have 40 minutes left, Mr Speaker, so we are not short of time.

[Mr Speaker]

No, we have plenty of time. We can continue until 7.30. [Interruption.] Oh yes, we have plenty of time. And of course, there will be an opportunity for either a ministerial statement or an urgent question between now and Thursday, so we have, if I may say so, bucket-loads of time to deliberate on this important matter. I know that that message will be extremely well received by the Minister.

[Caroline Dinenage]

Thank you, Mr Speaker.

The legal position, as I understand it, is that NHS England and NHS Improvement have been in discussions with the manufacturer BioMarin for some time to try to seek a deal that would enable NICE to recommend the drug for use on the NHS, but so far an agreement has unfortunately not been possible. As hon. Members know, and as I said at the beginning of my speech, NICE’s assessment is currently subject to an ongoing legal procedure. NICE has published its draft recommendation and was unfortunately unable to recommend the use of the drug, despite its meeting the criteria for consideration under the highest cost-effectiveness threshold. NICE has not yet re-published its final word on this issue, and that may provide more clarity. In the meantime, it is of course open to the company to enter into an agreement with NHS England that would make the drug cost-effective and would make the legal procedure unnecessary.

[Mr Jim Cunningham]

If NHS England got a satisfactory agreement with the drug manufacturer, would that have any bearing on the decision of the Secretary of State or on NICE?

[Caroline Dinenage]

I do not think it would contravene any legal recommendations if I were to say that if the manufacturer, NHS England and NICE were to get around a table and agree a satisfactory price, there would be no need for the legal challenge. In actual fact, the desperately poorly children we have heard about today would therefore be able to get the treatments that they desperately need.

[Catherine McKinnell]

Does the Minister share my concern that one reason why NICE turned down Brineura is that there is not enough long-term evidence about the drug’s effectiveness? That does prompt the question, which I am sure people at home would wonder about: how can we secure that long-term evidence when the treatment is so new—yet so effective, in my view—but is not even available on the NHS in this country? How do we ever find enough evidence to match the criteria that NICE is looking for?

[Caroline Dinenage]

That is a really good question, and I think that is one reason why NICE is looking again at its systems. It must be possible, because around 80% of new drugs are recommended for NICE approval and approved by NICE. It is clearly possible for new drugs to make it through even when they have not been around for a long enough period to see the very long-term consequences of their impact. It is really important in cases such as this, in which the opportunity—

[Andrew Griffiths]

On a point of order, Mr Speaker. I seek your advice, because we have a precedent for a situation that can arise on numerous occasions. In the nine years I have been in the House, I have heard of many debates in which right hon. and hon. Members have brought forward demands for treatments for rare diseases. We call the Minister to the Dispatch Box to answer—to be accountable. If we have a situation, going forward, where the Minister can claim sub judice, on advice from officials—it is not the Minister; she is taking advice from her Department—and be allowed to hide behind that cloak of anonymity and prevent the House from doing its job, which is to establish the facts and find out the truth behind the matter, that clearly prevents the House from being able to do its job.

You would share my concern, Mr Speaker, that that would prevent Members in this House from serving their constituents in a way that they would be expected to do. Therefore, can you ensure that you will go away today and look at this situation and make sure that, if this procedure has gone wrong, Departments are told very clearly that they cannot hide behind sub judice and that they must be candid with this House, regardless of the advice they have been given by officials.

[Mr Speaker]

That is a most helpful point of order from the hon. Gentleman, to which, essentially, the answer is a simple yes. I will happily go away and reflect on how Departments might usefully be advised to proceed in these matters. Beyond that, there are two points. First, as I have been advised, the matter is not sub judice. It has been suggested to me by a very constructive member of the Treasury Bench that advice to the effect that the case might be sub judice was proffered, though not to the particular Clerk whom I have been consulting, but that advice was not judged to be correct. Put simply, as far as we can see, the matter is not sub judice.

Secondly, however, and this is an extremely important point in the context of the specific debate that the hon. Member for North East Somerset has secured, the issue is that of ministerial intervention, and therefore whether or not the case is sub judice—I repeat that I am advised that it is not—the matter of ministerial intervention is manifestly one for Ministers, and it is therefore a matter upon which a Minister from the Bench can comment and would widely be expected to do so. Frankly, this question of the legal status is not germane to the capacity of a Minister to respond to the specifics of the debate. That is the situation.

[Caroline Dinenage]

Thank you, Mr Speaker. I do apologise for the further confusion that is here today. We are trying to seek further guidance on this—

[Mr Rees-Mogg]

Will my hon. Friend allow me?

[Caroline Dinenage]

In a moment.

The advice that I have been given is that I have to be very careful on the legal procedure because of the fact that it is not a legal procedure between individuals and the Department, but between individuals and NICE. I do not want anything that we say potentially to negatively impact on a family’s opportunity to get these very important drugs for their children.

[Mr Speaker]

Very important decisions are subcontracted to NICE, but policy responsibility, as the hon. Member for North East Somerset has pointed out, is that of the Government. We do not have Government by NICE; we have Government in the case of health policy through the Department of Health and Social Care.

[Caroline Dinenage]

I give way.

[Mr Rees-Mogg]

I am grateful to the Minister for giving way. I understand that discussions have been rapidly going on while we have had points of order and various other things happening in this Chamber. I am not sure whether this is orderly, Mr Speaker, but I happened to notice that there has been a return to the officials’ box of advisers. I wonder whether inspiration might now be forthcoming and heading in the direction of the Minister and whether I am now giving time for such advice to be passed through, or whether the telephone calls that I heard were taking place have not been as fruitful as I might have hoped.

[Mr Speaker]

I am not in a position to know that immediately for the simple reason that the Speaker does not possess eyes in the back of his head, and I have been focusing on the hon. Gentleman, the Minister and other colleagues, rather than on the occupants of the officials’ box. I have seen a note that has been circulating and a Minister is attempting to assist one of my advisers. I assume the Minister is attempting to do so on the basis of information provided. Whether there is something that is so valuable that the Minister in question is about to furnish the answering Minister with it, I do not know, but I am allowing a suitable opportunity for that missive to be passed to the Minister for Care, who is, of course, entitled to digest and reflect upon its contents and to decide in the light thereof how she wishes to continue, but I repeat that there is no shortage of time. I am very grateful to the Minister for her characteristic courtesy.

[Caroline Dinenage]

We are in a difficult position because the advice that has been forthcoming from the Department of Health and Social Care is not the same as the advice being given by the brilliant Clerks here. That puts me in a very difficult position, which is why I would like to commit to returning to the House with a statement once I have been able to pursue this matter a little bit further.

The Government want patients, including patients with rare diseases such as Batten disease, to be able to benefit from effective new treatments. It is in the interests of all NHS patients that we have a system in place for making evidence-based decisions on whether new medicines should be made routinely available to patients. That is why we have NICE, which makes independent, evidence-based recommendations for the NHS.

--- Later in debate ---

Motion made, and Question proposed, That this House do now adjourn.—(Jackie Doyle-Price.)

[Caroline Dinenage]

NICE now operates two separate programmes for the assessment of new medicines: first, a technology appraisal programme through which NICE assesses the vast majority of new medicines; and secondly, a highly specialised technologies programme that is reserved for the evaluation of very high cost drugs for the treatment of very small numbers of patients suffering from very rare diseases in England who are treated in a handful of centres in the NHS.

Where NICE recommends a treatment for use on the NHS, NHS commissioners are legally required to make funding available so that it can be prescribed to patients. This is reflected in the NHS constitution as a right to NICE-approved treatments. The intention of NICE is to have a system that means that the public can have confidence that the price paid by the NHS is consistent with the improvement in health outcomes that the medicine brings, ensuring fairness and the best possible use of funding for patients and the NHS.

As I said to the hon. Member for Newcastle upon Tyne North (Catherine McKinnell), NICE has recommended around 80% of products it has assessed. Through its important work, many thousands of patients, including patients with rare diseases, have benefited from access to effective new treatments.

It is right that NICE’s processes continue to evolve with developments in science, healthcare and the life sciences sector. That is why it keeps its methods and processes updated through periodic review that includes extensive engagement with stakeholders, including patient representatives, drug manufacturers and clinicians. In this spirit of continuous development, through the 2019 voluntary scheme for branded medicines pricing and access, which was published in December, the Government announced that NICE would be undertaking a review of its methods and processes in 2019-20 for both its technology appraisal and the highly specialised technologies programme.

[Andrew Griffiths]

I thank the Minister for the honourable way in which she has played a straight bat in what is a very sticky wicket; I am grateful to her for that. She mentioned that she was prepared to come back and make a statement to the House, for which I think we are all grateful. Would she just confirm whether she intends to make that statement before the House rises for the summer recess?

[Caroline Dinenage]

Yes, I will come back and make that statement before the House rises for the summer recess, with the correct legal recommendations.

The NICE review of its methods and processes has now begun. That will be quite helpful for some hon. Members who are questioning whether those processes are as they should be. Although I do not think it would not be appropriate for me to pre-empt the review by commenting in detail on its scope, I can assure hon. Members that it will be wide-ranging and will be carried out with full consultation with stakeholders.

My hon. Friend the Member for North East Somerset spoke about access to the new drug Brineura for his constituent Max. NICE is currently developing recommendations for the NHS on the use of Brineura through its highly specialised technologies programme for the evaluation of drugs for the treatment of patients with very rare diseases. It has not yet published that final guidance. I understand that NHS England and NHS Improvement have been in discussions with the manufacturer of Brineura, BioMarin, for some time to seek a deal that would enable NICE to recommend the drug for use on the NHS, but an agreement has unfortunately not been possible so far. As I said at the beginning, NICE’s assessment of Brineura is potentially going to be subject to legal proceedings.

Let me move on to individual funding requests. Where a treatment is not routinely available on the NHS, including where NICE has not yet made a recommendation on its use, NHS clinicians are able to apply for funding through an individual funding request. This can be done when a clinician believes that their patient is clearly different from other patients with the same condition, or where their patient might benefit from the treatment in a different way from other patients.

In the absence of NICE’s final recommendations on Brineura, I am aware that NHS England and NHS Improvement have recently considered an individual funding request for my hon. Friend’s constituent Max that it has unfortunately been unable to support, because he would not be regarded as an exceptional case to existing policy. I understand how devastating that decision will be for Max, his parents and all those involved. However, if my hon. Friend’s constituents and their clinicians think that the process has not been followed correctly, they can ask for a review of the decision within 28 days. If a patient’s situation changes or more clinical evidence becomes available about the effectiveness of a treatment, they may also submit additional information to be considered and discussed.

[Catherine McKinnell]

Does the Minister understand how deeply hurtful the situation is to those families who are receiving this treatment on compassionate grounds from the drug company and how difficult it must be for them to listen to this debate? Not only are the Government seeking to hide behind sub judice rules when in fact they should be giving the answers that those families deserve; they are also sending families round and round, suggesting that they make applications based on individual circumstances and that they appeal decisions, when they just want to care for their very sick children. Is there nothing more that the Minister can offer those families who are listening to this debate?

[Caroline Dinenage]

I completely understand what the hon. Lady says, and I completely agree with her. I would love to be able to solve this problem straightaway and give these children the lifeline they need. Unfortunately, that is not the case today. I have committed to make a statement before the House finishes for recess at the end of next week, so I will come back shortly with all the information I am allowed to give. I really do not want her to think that this in any way suggests that I do not understand how the families must be feeling. I can only begin to imagine how desperate it must be to have such a poorly child.

[Mr Jim Cunningham]

I do not want to be difficult for the Minister, because she is doing a very difficult job, but could she clarify something? I got the impression from something she said a minute or two back that if NICE and NHS England concluded negotiations and agreed a price with the drug manufacturer, that would be acceptable to the Government.

[Caroline Dinenage]

My understanding is that if the manufacturer of this vital drug gets around the table with NICE and suggests a price within a reasonable scale, NICE would be very open to listening. That is my understanding. Certainly, I understand calls from Members across the House for NHS England, NICE and the manufacturer to get around the table to try to find a solution. That seems to me to be the most sensible way forward.

[Andrew Griffiths]

I thank the Minister for giving way again. The language she is using is the same as that we hear in a lot of these debates. She has said that many of these families and young children are receiving the drug on compassionate grounds from the drug company. For a parent whose child is not getting that drug to be told that somebody else’s son or daughter is getting compassion but theirs is not—the Minister is a mother herself, so she will understand this—is like a dagger through the heart. Will she do all she can to ensure that that compassion is extended to all those mums and dads who are looking on tonight?

[Caroline Dinenage]

Of course I will commit to doing everything I can to making sure that all the very valid and easy-to-understand sentiments that have been expressed by Members across the House are sent to all the parties involved in this discussion. I completely share Members’ desire to find a resolution to this and ensure that families get the answers they need. In the meantime, I thank all Members for the part they have played in today’s debate, the questions they have asked and the great interest they have shown in this issue. As I say, I will come back to the House shortly with fuller answers to some of those questions.

[Mr Speaker]

Ordinarily, the proceedings would now conclude, and they will do so shortly. However, I think it important that our proceedings should be intelligible not only to right hon. and hon. Members but others who are interested in our proceedings but are not Members of this House. To try to achieve that objective, I want to add, by way of conclusion, the following.

I am advised by my officials that the Department of Health and Social Care claims that this matter—the subject of the debate—is sub judice because an application for a judicial review has been made. In the light of that, let me explain. Under the sub judice resolution of this House,

“Civil proceedings are active when arrangements for the hearing, such as setting down a case for trial, have been made”.

The Department has not supplied evidence that this test is met. Therefore, I stand by what I said earlier on advice.

By way of conclusion, I say to the Minister—echoing, I think, the sentiments of colleagues—that her commitment made in the circumstances, at very short notice, to return to the House before the summer recess to make an oral statement is appreciated, and we look forward to that statement taking place either tomorrow or on Thursday. Policy is a matter for the Government and not the Chair, but the hon. Member for North East Somerset and other colleagues who are similarly interested may rest assured that, for so long as this matter is not resolved to their satisfaction and they wish to bring it to the House for questioning, interrogation and debate again, as far as the occupant of the Chair is concerned, there will be multiple opportunities for them to do so. The matter will not go away.

I thank the Minister once again for her courtesy and consideration in difficult circumstances, and I thank all Members who have contributed to the debate not on their own accounts but in the interests of their constituents, very anxious parents and families, and sympathetic people right across the country.

Question put and agreed to.

Children’s Palliative Care

Caroline Dinenage Excerpts

Monday 1st July 2019 Commons Chamber

[The Minister for Care (Caroline Dinenage)]

I congratulate my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson) on securing a debate on this important matter. I particularly thank her for the fantastic work she does both as a medical professional—a paediatrician—and in her role as co-chair of the all-party parliamentary group for children who need palliative care, on which she has been a tenacious, passionate and very effective campaigner.

The APPG produced a report last year on children’s palliative care, to which the Government responded in full, and today we have an opportunity to pay tribute to the incredible work offered by children’s palliative care providers, many of which are hospices, in supporting some of our most poorly children and their families.

Children’s Hospice Week took place last month, and this year’s theme was “moments that matter.” As MPs, we are all very aware of the crucial role played by hospices in supporting and caring for our communities at a time of great need. I first became aware of that many years ago, when my mum was involved in fundraising to build the Naomi House children’s hospice near Winchester. In fact, she embroiled my whole family in a series of embarrassing fundraising activities to further her ends.

Since then, I have been privileged to visit Naomi House and, later, Jacksplace, a facility for young adults collocated on the site, to see for myself the incredible care and support they offer to very poorly children and their parents, both on site and more broadly in the community.

In my role as Minister for Care, I see how crucial palliative and end of life care services are for families in need. We know that many areas across the country are delivering excellent support and palliative care for children, but there is no room for any kind of geographical inconsistency, which is why it is crucial that more is done to challenge and support areas that are not providing it. That is why we have made children’s palliative and end of life care a priority in the NHS long-term plan, particularly in supporting children’s hospices.

NHS England’s hospices programme currently provides £12 million a year for children’s hospices, helping to provide care and support to children with life-limiting conditions and their families. I am delighted to announce, and my hon. Friend and other members of the all-party parliamentary group will be very pleased to hear, that NHS England has committed to increase the funding to £25 million by 2023-24. That will guarantee the additional £13 million for the children’s hospice grant. Clinical commissioning groups had been asked to provide match funding, but NHS England has now taken the decision to guarantee the investment after concerns were raised. As my hon. Friend said, match funding would not necessarily achieve the full investment anticipated.

I care very deeply for the hospice movement, and I hope this funding will provide it with full reassurance of the Government’s commitment to and support for its incredible work.

[Dr Caroline Johnson]

I thank the Minister for this fantastic announcement, and I know the money will make a phenomenal difference to the lives of the poorliest children in this country.

[Caroline Dinenage]

I thank my hon. Friend for that. She must take some of the credit, because it is her work, along with that of her co-chair of the all-party group, that has helped to secure these strong commitments from NHS England, so I wish to pay tribute to them this evening. But there is more. We know that children’s hospices are not evenly spaced throughout the country, so NHS England has also committed to undertake a needs assessment to understand whether additional investment, nationally or from clinical commissioning groups, is required where palliative care is provided by means other than hospices.

[Catherine McKinnell]

I, too, thank the Minister for this announcement, which is very welcome, but I cannot pass up this opportunity to intervene, when NHS England is in the mode of looking to fund these services. The hon. Member for Sleaford and North Hykeham (Dr Johnson) gave as an example of children with life-limiting conditions those with Batten disease. A family in my constituency have two daughters with Batten disease. It has progressed in one, but the other is receiving totally innovative enzyme treatment that has stemmed any development of the disease. Yet at the moment NHS England is unwilling to fund this treatment for 13 children in England. So I just want to put on record that this is about not only supporting children with life-limiting conditions, but giving them access to the treatment that will prevent them from going down that road if we can.

[Caroline Dinenage]

The hon. Lady has powerfully put her sentiments on the record, and I absolutely with them. In parallel with the announcements that NHS England has made on the much-welcomed investment, it is working to develop commissioning models specifically for children and young people with palliative care needs, to support CCGs. We know it can be difficult for some commissioners to meet the needs of this vulnerable group, and these models will help them overcome the challenge of delivering services for small and geographically spread groups of patients, whose conditions can fluctuate over the course of their lives. Together for Short Lives is involved in this important work, and I also wish to put on record my thanks to it for its continued support.

My hon. Friend mentioned Acorns hospices, which is currently consulting its staff on the closure of one of its children’s hospices at Walsall. I have been made aware that there is a financial aspect to this consultation, but there are other aspects to it, such as a reduction in the number of bed days used by in-patients. As I say, this is a consultation at this stage and I am hoping that the announcement of this money will help to make a difference to its decision.

In “Our Commitment to you for end of life care”, we set out what everyone should expect from their care at the end of life, and the actions being taking to make high quality and personalisation a reality for all in end of life care. The choice commitment is our strategy for end of life care, which, through the NHS mandate, NHS England is responsible for delivering through its national end of life care programme board, with all key system partners and stakeholders, including Together for Short Lives. This presents the best opportunity to continue to deliver the progress we all want to see and make the choice commitment a reality for both adults and children.

Looking to the future, the NHS long-term plan has set out a range of actions to drive improvement in end of life care and deliver the choice commitment. In addition to the £25 million of investment in children’s hospices announced today, the NHS long-term plan has made a number of commitments that will improve palliative and end of life care for children.

[Dr Caroline Johnson]

Along with the all-party group and Together for Short Lives, we have asked the Minister for three things this evening, and we appear to have received two of them—the extra money and the NHS England review. We will keep pushing for the third—respite care and an army of babysitters—but as Meat Loaf said, “Two out of three ain’t bad”.

[Caroline Dinenage]

As I said at the beginning, my hon. Friend is nothing if not utterly tenacious and passionate in her pursuit of this. I will talk about the short breaks now. She is absolutely right on this; I do not think families are necessarily looking for big long holidays, they just need short breaks, but for those need to be reliable and consistent. People need not to be let down at the last minute. That is the message I am getting loud and clear. Local authorities have a legal duty to commission short breaks, as established by the Breaks for Carers of Disabled Children Regulations 2011. Although the NHS role is not statutory and is a matter for NHS commissioners, the NHS may provide the clinical aspects of care to support such services, if appropriate.

According to the 2018 Together for Short Lives report, 84% of CCGs reported that they commissioned short breaks for children who need palliative care. That is an increase on the support in 2017, when it was 77%, but I recognise that we have much further to go. Parents desperately need short moments of respite and to know that their children will be well cared for at such times. The breaks also need to be reliable, and we will continue to work on that.

[Catherine McKinnell]

I just want to make sure of something. The needs of the child who requires care and support in order for there to be that respite are often too great, meaning that local authorities feel it is not within their remit, yet the clinical needs do not necessarily meet the NHS thresholds, so many families just fall through the cracks in the requirements. That often results in really difficult family situations and sometimes in family breakdown, which is not in anyone’s interest at all. If the Minister can do anything to consider this issue holistically, across the local authority and the health service, to try to bring things together and close the gaps, that will change the lives of so many families up and down the country.

[Caroline Dinenage]

The hon. Lady makes an excellent point with her customary insight. I care deeply about this matter, totally understand what she says and very much recognise the point that she is trying to get across. The problem is that local commissioners are best at designing the local services that best meet the needs of their local populations, but occasionally we find that families fall between the gaps between children’s social care and local health commissioning. I would be happy to continue to meet both co-chairs of the all-party group and Together for Short Lives to look at ways in which the Department of Health and Social Care can help to address the gaps so that people do not fall through them.

I thank my hon. Friend the Member for Sleaford and North Hykeham for securing this debate. I hope she has been reassured by the commitments made on ensuring the future of palliative and end of life care services for children.

Question put and agreed to.

Adult Community Services

Caroline Dinenage Excerpts

Wednesday 26th June 2019 Westminster Hall

[The Minister for Care (Caroline Dinenage)]

It is a great pleasure to serve under your stewardship, Mr Gapes. I thank the hon. Member for Bristol South (Karin Smyth) for securing this debate. She spoke passionately on behalf of her constituents. It is right to bring such concerns to this forum. She asked the questions that any good MP should ask, and she has the right concerns. She spoke strongly about valued local services that no one wants to see lost, such as her Healthier Together service, and said that she fears for their future. I hope that some of the things I shall say will allay her fears, but if I do not cover anything she mentioned, we shall write to her to give her as comprehensive a response as possible.

Community services play a vital role, but we have perhaps not emphasised them as much as we should have done in recent years and decades, so we must put that right. Effective community services mean that patients are treated where they are most comfortable—often their own home—and supported to manage their conditions and live independently. More widely, they are key to improving the patient experience. They provide preventative care and prevent people’s illnesses and ailments from getting worse. Crucially, they prevent reliance on the big acute hospitals.

The NHS long-term plan sets out our vision for community services. It highlights the need to move away from small, narrowly defined and often poorly co-ordinated community services to those which are more joined-up and operate over a larger footprint. It also encourages much longer commissioning times, to enable us to build the relationships that we want to continue to establish. Importantly, it will make it easier for patients to navigate the system without having to repeat their story multiple times, and will ensure that their care is delivered in a smoother, more timely manner. To help to deliver on that vision, as part of the extra investment in the NHS long-term plan, an extra £4.5 billion per year will be spent on primary medical and community health services by 2023-24.

That is why ideas such as this, from local areas such as Bristol, North Somerset and South Gloucestershire, which embed community services as a central component of their plan in a way that mirrors the vision of the NHS long-term plan, appear very attractive. By awarding all its adult community services in a single contract, we can see that the CCG is aiming to promote a cohesive, integrated approach, which will improve consistency and efficiency across its entire geography.

The CCG’s 10-year funding approach also reflects the NHS long-term plan and will enable transformative change, through the kind of long-term relationships we need, based around strong, collaborative partnerships across not only the health and care system, but also the third sector, which the hon. Lady mentioned and which plays such a crucial part in the delivery of some of our most vital community services. We think that the length of the contract will allow the local area to design its services not only for the current need, but to address the future needs of its population, while also giving greater certainty to the workforce.

Additionally, the plans contain key commitments on community services set out in the NHS long-term plan. These include delivering care through multidisciplinary teams, the deployment of rapid response teams and providing services in central hubs located in people’s communities, where they can get the holistic support that will enable them to stay healthy and well.

We think that all those things will ensure that patients receive timely, integrated and holistic care in their community, with a greater focus on treating the whole person rather than merely their condition. This approach will join everything together, so that people no longer slip through the gaps or get pushed from pillar to post or from A to B, and it will provide a one-stop shop where people have a named contact and a real integration of community, mental health and adult social care services and the third sector.

The hon. Lady spoke with great passion and knowledge about the importance of transparency and engagement when deciding service provision, something that of course I entirely agree with. At the same time, it is right that these decisions are made by local areas, such as CCGs, local authorities, sustainability and transformation partnerships or integrated care systems, because those people decide how services should be configured to meet the needs of their local area. When they do so, we have clear expectations of them: they must involve patients, carers and the public in decisions about the services they commission, and be clear and transparent about their decisions.

That could be where we appear to have a difference of opinion between how the hon. Lady feels that her CCG has communicated and the way the CCG feels that it has. I have spoken at length to the director of commissioning and the chief executive, who say that in this particular case they have made considerable efforts to meet those expectations. They report that they engaged with 500 local people, including health and care professionals and representatives from the third sector, and that patients and carers have been supported to engage with the process through a public reference group, which I know she mentioned.

Additionally, the CCG says that it has engaged with a range of organisations and partners from across the local system, including hospital and mental health trusts as well as local authorities, to better inform the contract process. Those organisations have met bidders for the contract to discuss service provision. The CCG says that that collaborative process will help the contract holders to build relationships and allow patients to receive integrated services, which is what we all want.

The CCG also says that it has taken steps to ensure a transparent process, including press releases, letters to stakeholders, engagement events and making key information available online. Additionally, the CCG reports that the procurement is being overseen by a programme board that includes patient and carer representatives.

The hon. Lady made the point that it might be premature to go out for tender while the NHS long-term plan’s proposals for amending procurement requirements are being considered. That is a very good point, but unfortunately considerations around legislative changes do not change the CCG’s duty to comply with current procurement law, nor do they change its duty to use its resources as efficiently and effectively as it can.

The CCG has agreed that if the legislation changes during the procurement process it will review and evaluate that process, but more widely, by law it must ensure that there is no gap in access to services. Its contracts for adult community services will expire in the coming years, and by law cannot be extended. The CCG has informed me that if the procurement was halted, it would create the risk that when the current contracts expired, local people would be left without vital community services, which the hon. Lady knows they rely on. Of course, that simply cannot happen.

The hon. Lady also rightly noted that we must ensure that contracts are given the necessary external support and scrutiny. To that end, NHS England’s and NHS Improvement’s integrated support and assurance process—for which we use another of those attractive acronyms, ISAP—provides a co-ordinated, consistent approach to reviewing complex contracts, which is intended to ensure that complex contracts are cost-effective, robust and in the interests of patients.

On 17 October, NHS England and NHS Improvement held an early engagement meeting with the CCG, where they discussed this contract under ISAP. Following that meeting, NHS England and NHS Improvement were assured of the need to have a single contract that runs for 10 years. A full ISAP process is triggered when a procurement is found to be sufficiently novel and complex. NHS England and NHS Improvement found that in this case these requirements were not met, meaning that the full ISAP process was not required. Instead, NHS England and NHS Improvement regional teams will provide assurance that is informed by ISAP principles, which will include ensuring that the contract provides value for money, that it is centred around patient care and, crucially, that some of the key parts of patient care that the hon. Lady spoke about are not lost. The regional teams must also jointly ensure that the correct processes are followed, and that any chosen provider has the capacity and capability to deliver the services set out in the contract. Importantly, the regional teams must then give further formal, joint approval before the CCG can award a contract.

With that in mind, scrutiny of how we award contracts for delivery of health services is clearly vital. We must be assured that due care is taken so that patient outcomes are absolutely first and foremost, and that services are organised and delivered with prudent financial planning. To that end, NHS England and NHS Improvement will continue to closely monitor this contracting process. I welcome the close attention that the hon. Lady has paid to this contract; I know she has looked at it very thoroughly and I am grateful that she has raised her concerns. We believe that the CCG’s approach in this case is right, but we will continue to engage in every way possible with all parties to help ensure its successful delivery.

Question put and agreed to.

Living with Dementia

Caroline Dinenage Excerpts

Tuesday 25th June 2019 Westminster Hall

[The Minister for Care (Caroline Dinenage)]

As ever, Mr Paisley, it is a great pleasure to serve under your stewardship. I thank the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) for securing this important debate, the hon. Member for Cambridge (Daniel Zeichner) for supporting her in doing so, and the Backbench Business Committee for allowing time for it. I also thank all the other Members who have taken part in the debate, and in some cases shared very personal journeys and stories about their family’s experiences with dementia and, indeed, some interesting and inspiring best practice from their constituencies—things that other areas can learn from.

I also thank the hon. Member for Oldham East and Saddleworth for her personal commitment and dedication to people living with dementia, both through her work on the all-party parliamentary group on dementia and in her constituency. She is so committed to making Oldham East and Saddleworth a really dementia-friendly place to live; she sets an excellent example of what we as Members of Parliament can do in our own communities, and I welcome her vision of making Westminster the first dementia-friendly Parliament. I will do everything I can to support her in that endeavour, because I know that her passion is driven by her experience of having a close family member living with dementia.

Other Members have spoken about their own experiences, and I have also had two very close family members living with dementia: my grandmother and my uncle, who passed away just before Christmas. I have experienced at first hand the impact that dementia has, both on the person who is living with it and those who love and care for them. Hon. Members from across the House have spoken about the importance of carers, and I have seen at first hand the impact that caring for my grandmother had on my mum—on her relationships, her professional life and her health and wellbeing. Those carers’ commitment should never be taken lightly. A dementia diagnosis is more than a diagnosis for that individual: it is a diagnosis for the whole family, their loved ones, their community and their workplace.

[Jim Shannon]

In my constituency, 1,152 people live with dementia. As the Minister rightly said, it affects a lot of families as well as the wider family circle. Has she given any consideration to respite care for those families to give them a break from the physical, emotional and mental pressure that they are under?

[Caroline Dinenage]

Respite care was one of the themes of the carers action plan that we published last year. SCIE is putting together guidance for local authorities on how they can best provide that crucial respite moment for those brilliant carers. [Interruption.]

A diagnosis is very much for an individual, but also for their families and loved ones and for their communities and workplaces. When those come together, it is possible to live well with dementia, as my hon. Friend the Member for Witney (Robert Courts) said. Such personal experiences make me passionate about my responsibilities as a Minister. The hon. Member for Halifax (Holly Lynch) challenged me to continue to push the Government to keep dementia as a priority, and I always will. I am proud of the Government’s commitment to deliver on the dementia challenge 2020 in full to make this the best country in the world to live for anyone with a dementia diagnosis.

The challenge aims to transform the lives of people with dementia, as well as their carers and their families, through better awareness, care and research. We have made significant progress as part of the challenge, but we know, as we have heard today, that there is still much more to do. We have already started our work on our strategy for the period beyond 2020. This is not something that finishes in 2020. It is simply the start of the next phase and we will publish our thoughts on it early next year.

One of the key successes of the challenge has been improved diagnosis. We are meeting our ambition, and today two thirds of people living with dementia receive a diagnosis, but we clearly still have some way to go. Of course, not everybody wants a diagnosis, but we know that a timely diagnosis enables a person with dementia to access the advice, information, care and support that can help them to live well with the condition and remain independent for as long as possible.

We are focusing on reducing the variation in local dementia diagnosis rates. There is a real geographical variation, and targeted support to identify and engage the areas most in need of assistance will really help. Reducing the gap in diagnosis rates will ensure that people with dementia have consistent access to a diagnosis wherever they are in the country. We also know that receiving good quality care improves the lives of people with dementia. Equipping our health and social care workforce with the skills that they need is therefore crucial to the quality of care for those living with dementia.

Since 2012—the hon. Member for Bradford South (Judith Cummins) mentioned this—1 million episodes of the tier 1 dementia awareness training have been completed by NHS staff, and more than 1 million care workers completed the care certificate, or common induction standards. We continue to work to meet our commitment that staff have the training appropriate to their role. We want to see more people doing the tier 2 training, which is much more robust, so we are exploring options to see how we can increase take-up for anyone who needs it.

[Dr Whitford]

Is there an audit of hospital environments? Just before I left to come here, my hospital was redesigned using coloured zones and imagery to help people with early dementia move around the hospital independently. Are there similar projects elsewhere?

[Caroline Dinenage]

That is an interesting question. I do not know the answer, but I would be keen to look into it to find out. We are looking to explore ways to encourage the take-up of tier 2 dementia training. I recently co-signed a letter to health and care organisations with the chief executives of Skills for Care and Health Education England to highlight the importance of dementia training and education, which is a really important part of our discussions.

We are also meeting our commitment on Government funding for dementia research of £60 million or more each year, to reach at least £300 million invested over the five years up to 2020. The figure is actually more than £60 million this year—it is £83.5 million. In addition, we have the UK Dementia Research Institute, which is funded to the tune of £290 million: £190 million from Government and £50 million each from the Alzheimer’s Society and Alzheimer’s Research UK.

[Patricia Gibson]

I thank the Minister for giving way and apologise for the earlier interruption; I am glad it did not put her off her stride.

Much of what we have discussed today—the issues around this illness—are devolved to Scotland, but I want to press her on an issue that is not devolved: legal protection for older people with dementia. What measures can be put in place for financial institutions to have a legal duty of care to look after those people? In the debate we have focused on the practicalities of care, which is important, but we have to think about how we protect people in law in financial terms.

[Caroline Dinenage]

I thank the hon. Lady for that intervention. I am sure the slight disturbance caused by her mobile created a welcome distraction for everybody from my speech. I took note of what she said in her speech and she makes an excellent point about protections.

To go back to research funding, the incredible dementia discovery fund, which other Members have mentioned, was launched by David Cameron in 2015. It is the world’s largest venture fund aimed at a single disease area that looks to develop novel pre-clinical therapies. Our continued commitment to support research has also seen increasing numbers of people involved in the joint dementia research programme, with 20,000 people taking part in dementia research studies. To answer the question asked by the hon. Member for Vale of Clwyd (Chris Ruane), I am happy to meet and discuss any other research that comes forward.

Ahead of developing new treatments, we need to be able to support people to live well with dementia in their communities. The Dementia Friends programme, which a lot of people have mentioned—I am also a Dementia Friends champion—is a great example of increasing public awareness. Through the dementia-friendly communities programme—365 so far this year in England— we are making society more inclusive. We are supporting the National Dementia Action Alliance’s work to promote dementia-friendly hospitals across England through its charter to improve the care that people receive.

My hon. Friend the Member for Witney asked me about writing to the Department for Work and Pensions about improving its guidance to employers, which I will commit to do. We know that careful reforms are required to ensure that the social care system is prepared for the challenges of an ageing society, including for those with dementia. Many Members, including the hon. Member for Cambridge, mentioned adult social care funding. Many Members also talked about cuts to local authorities, but over the past year we have given councils access to an additional £10 billion: an 8% real-terms increase.

However, the fact that we are still talking about the social care system being on the point of crisis, at a tipping point or under huge pressure, shows the scale of the problem. That is why we have committed to publishing the adult social care Green Paper at the earliest opportunity. I share everybody’s frustration about the delays, but it will set out ideas for an element of risk pooling to save individuals from catastrophic costs, which some have spoken about today. We are committed to ensuring that everybody has access to the care and support they need. More short-term social care funding will be agreed alongside the rest of the local government settlement in the forthcoming spending review.

The NHS long-term plan sets out a 10-year strategy, outlining how the NHS will spend the £33.9 billion cash terms annual increase that will go into the NHS budget. We now know that around a third of dementia cases are preventable. Since 2018, every person attending an NHS health check in England—the hon. Member for Burnley (Julie Cooper) mentioned prevention—receives information about how to reduce the risk of developing dementia. It includes advice on smoking, safe levels of alcohol and being physically active. Between 2013 and 2018, nearly 7 million people attended health checks.

My hon. Friend the Member for Chichester (Gillian Keegan) mentioned Careline in her constituency. There are lots of innovative ways that technology can improve the lives of people with dementia. Jelly Drops are an ingenious way to tackle dehydration using sweet-like capsules. My local county council in Hampshire uses existing technology such as Amazon and wearable technology to help people maintain their independence, stay safe and combat isolation. All those achievements, brought together in the dementia challenge 2020, help to improve the lives of people with dementia, but we know that more needs to be done. We are committed to continuing to improve the lives of people with dementia, and of their families and carers.

[Ian Paisley (in the Chair)]

I call Debbie Abrahams to wind up.

Oral Answers to Questions

Caroline Dinenage Excerpts

Tuesday 18th June 2019 Commons Chamber

[Emma Dent Coad (Kensington) (Lab)]

1. How many care homes are rated good and outstanding for safety.

[The Minister for Care (Caroline Dinenage)]

No compromise can be made on the safety of care homes, and that is why the Government introduced robust inspection regimes led by the Care Quality Commission. Latest figures from 3 June show that 80% of care homes have been rated good or outstanding for safety, with 84% of adult social care providers rated as good or outstanding overall.

[Emma Dent Coad]

I draw the Minister’s attention to one example of a care home run by a private provider: Ellesmere House, which offers residential care for dementia sufferers. In February 2015, there was a serious safeguarding incident leading to the death of a resident after an incident with another resident, yet its latest CQC report underlines continued failures in management. Is the Minister confident that we have a generation of providers with the skills, training and facilities needed to keep dementia sufferers safe and well cared for?

[Caroline Dinenage]

I thank the hon. Lady for that question. It is of course incredibly concerning when we hear cases of abuse or neglect in care homes. That is why the Government asked the CQC to inspect them in the first place and why we have put in place training through Skills for Care and given councils access to a lot more funding to help support them. However, abuse and neglect of any kind must not be tolerated.

[Andrew Bridgen (North West Leicestershire) (Con)]

I welcome the fact that the latest report from the Care Quality Commission indicates that four out of five adult social care services in England are rated either good or outstanding, but there is no room for complacency. Will the Minister expand on how she will ensure that that becomes five out of five?

[Caroline Dinenage]

My hon. Friend is absolutely right to highlight that four out of five care homes are rated good or outstanding. That is largely down to the more than 1.5 million adult social care professionals, who work with great professionalism and integrity. We drive up quality by supporting them better and ensuring that we can recruit more people into this incredible profession. We have had a very important adult social care recruitment campaign called, “Every day is different”, which looks to attract people with the right values into the sector to drive up quality and provide robust social care.

[Dr Rosena Allin-Khan (Tooting) (Lab)]

I know from my family’s personal experience that just because care homes have a CQC rating of good does not mean that there are not dangerous and serious issues lurking beneath the surface that impact patient safety and care. Will the Minister outline today what the Government are doing to look into reports from CQC homes that are rated good?

[Caroline Dinenage]

The hon. Lady has often spoken very movingly in the House about her personal experiences, and she is absolutely right: abuse of vulnerable people is absolutely abhorrent. We are very determined to stop it, and we want to prevent it from happening in the first place through the tough inspection regime. We want to shut down poor-quality homes and, most importantly, we have made sure that across the country, police, councils and the NHS work together to help to protect people in the long term.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

The integrity of CQC ratings was dealt a mortal blow by the uncovering of abuse at Whorlton Hall by BBC “Panorama”. Watching the abuse on that programme is made worse by the knowledge that the abuse may have started five years ago. The unpublished inspection report from August 2015 described allegations of assaults on patients, the undocumented use of a seclusion room and the use of rapid tranquilisation not backed by an organisation policy. I do not have any confidence that the review called by the CQC will uncover the truth behind that abuse. Will the Minister agree to set up an inquiry into this matter, so that we can establish whether the care regulator is fit for purpose?

[Caroline Dinenage]

The hon. Lady is absolutely right: abuse of any kind must not be tolerated, and we have heard horrific accounts of abuse that must be tackled. That is why in May, we announced much stronger commissioning oversight arrangements, where people are put in place out of area. Local commissioners must visit regularly. The CQC has commissioned two independent reviews, and the findings and recommendations of both will be published. The point is that opportunities to intervene have been missed, and we must be open and transparent in getting to the bottom of what happened.

[James Cartlidge (South Suffolk) (Con)]

2. What steps he is taking to increase NHS access to new technology.

--- Later in debate ---

[Dr Caroline Johnson (Sleaford and North Hykeham) (Con)]

9. What steps he is taking to ensure that people can access Changing Places facilities when they use NHS services.

[The Minister for Care (Caroline Dinenage)]

Last year, I announced £2 million funding for NHS trusts in England to install Changing Places facilities in hospitals; this is now available for trusts to bid for. We estimate that 250,000 people in the UK cannot use standard accessible toilets, and the fund could help to install well over 100 more Changing Places facilities.

[Dr Johnson]

Many of the disabled children who use Changing Places facilities also have a life-limiting or life-threatening condition. I welcome the increase in Changing Places facilities, but in this national Children’s Hospice Week could I ask my hon. Friend to go further in protecting these vulnerable children by increasing the children’s hospice grants to £25 million to give them the financial security they need?

[Caroline Dinenage]

I am really pleased that my hon. Friend has mentioned that it is Children’s Hospice Week. It is a great opportunity to pay tribute to the incredible work that children’s hospices do up and down the country, supporting some of our most poorly children and their families. I thank my hon. Friend for the work that she does on the all-party parliamentary group for children who need palliative care. The short answer to her question is yes; the NHS will match fund CCGs that increase their investment in children’s palliative care, including hospices, by up to £7 million. That is increasing support to a total of £25 million a year by 2023-24.

[Nic Dakin (Scunthorpe) (Lab)]

There are only about 40 Changing Places facilities in the NHS at the moment. I congratulate the Minister on the work she is doing on this, but will she continue to work with campaigners like Lorna Fillingham in my constituency to make sure that it not only happens quickly and on a timely basis but that we build on it in the future?

[Caroline Dinenage]

I am grateful to the hon. Gentleman because it was he who introduced me to Lorna Fillingham and the amazing Changing Places campaigners in the first place. It is really down to their incredible work that we have seen the growth of this very important issue. There are about 38 Changing Places facilities on NHS England estates at the moment, but the £2 million pot will definitely help to improve that number significantly.

[Mr Philip Dunne (Ludlow) (Con)]

10. What steps he is taking to improve the retention of NHS staff.

--- Later in debate ---

[The Minister for Care (Caroline Dinenage)]

The Care Act 2014 gives councils a responsibility to provide residents with a choice of quality care options in a local area. More broadly, we are backing up councils with increased funding. Over the last three years, we have increased funding in real terms by 8%. That has given councils access to about £10 billion to help ensure that there is provision in local areas.

[Mr Philip Hollobone (Kettering) (Con)]

T7. Will the Secretary of State assure my constituents in Kettering that taking advantage of the local government reorganisation in the county to establish a combined health and social care pilot is one of his Department’s very top priorities?

--- Later in debate ---

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

T6. In York, it has taken 46 weeks for children and young people to commence the diagnosis process for autism—and demand and the number of referrals is going up. It takes a further 12 months, once there is a positive diagnosis, for parents even to access the SEND—special educational needs and disability—course. Precisely what service improvements can families expect to see in the next 12 months, and how will they be achieved?

[Caroline Dinenage]

The hon. Lady is absolutely right to draw attention to this issue. We are very concerned about the diagnosis times, which is why we are reviewing our autism strategy this year and are extending it to include children, whereas before it catered only for adults. We want to ensure it remains fit for purpose. We have launched a national call for evidence and have already received in excess of 1,000 responses.

[Jeremy Lefroy (Stafford) (Con)]

Patient safety in the NHS depends on compassionate care training and staffing levels, but it also depends on patient safety systems. What progress is the national health service making towards implementing those systems in every place where patients are cared for?

[Caroline Dinenage]

Patient safety, as my hon. Friend suggests, remains an absolutely key priority for the NHS. NHS Improvement and NHS England are developing a national patient safety strategy, which will sit alongside the NHS long-term plan. It will be published this summer and will build on existing work to provide a coherent framework that the whole NHS can recognise and support.

[Jo Swinson (East Dunbartonshire) (LD)]

T8. There are fears that NHS medical data could be on the table as part of a desperate post-Brexit trade deal with the US on digital services, where patient data would be mined by companies to develop medical technology that would then be sold back to the NHS. What guarantees can the Secretary of State give that private companies will not be profiteering from NHS assets in that way?

--- Later in debate ---

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

Will the Secretary of State support one of the key recommendations of the joint report from the Health and Social Care Committee and the Housing, Communities and Local Government Committee into the future funding of social care, which is for a German-style system of social insurance?

[Caroline Dinenage]

Absolutely. We are very keen to look at the Select Committees’ recommendations and the contributions of all key stakeholders. We are committed to ensuring that everyone has access to the care and support we need. The Green Paper will include ideas to protect people from high and unpredictable care costs.

[Stephen Lloyd (Eastbourne) (Ind)]

T9. Over the weekend, I was contacted by a number of parents of severely disabled children with very distressing news. Up until now they have been receiving five pads a day, because their children, grown up or otherwise, are very severely disabled. However, they have been told by the clinical commissioning group that that has been cut to three. This is incredibly distressing. Some of the parents are on universal credit and the additional cost they will have to pay themselves will be £80 a month. That is unacceptable. Will the Secretary of State agree to meet me and representatives of my constituents, the parents of these very disabled children from Eastbourne, so that we can try to sort this out before it really gets out of hand?

Whorlton Hall

Caroline Dinenage Excerpts

Thursday 23rd May 2019 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

(Urgent Question): To ask the Minister if she will make a statement on the treatment of people with learning disabilities and complex needs at Whorlton Hall.

[The Minister for Care (Caroline Dinenage)]

Many of us here today, and many of those listening and watching this urgent question, will have seen the very disturbing footage shown on the “Panorama” TV programme last night. It was footage detailing the incredibly traumatic experiences of vulnerable people with learning disabilities and autism at Whorlton Hall—somewhere they should have been safe, somewhere they should have been cared for. The actions revealed by the programme are simply appalling—there is no other word to describe them—and I condemn any abuse of this kind completely and utterly.

I want to begin by saying that I can only imagine the impact of those experiences on the people themselves, and the lasting damage and trauma that it will have caused to them and their lives. It must also have been incredibly distressing for their families, watching what has been happening to their loved ones, unable to step in and unable to do anything to help them. It is utterly, utterly tragic. On behalf of the health and care system, I am deeply sorry that this has happened.

As hon. Members will be aware, unfortunately, this is not an isolated incident; we have heard reports like this before. That is why there have been a number of reports published even this week on the care of people with learning disabilities and autistic people in in-patient settings. All those reports have been commissioned directly or indirectly by the Government, and all of them have found very clear evidence of care that has fallen way below the standard we expect and the standards that people absolutely deserve.

The allegations of abuse at Whorlton Hall were shared with my Department, NHS England, the Care Quality Commission and the provider ahead of the programme airing yesterday. Immediate steps were taken to ensure the safety of patients, including ensuring that safe staffing levels were maintained following the suspension of a significant number of staff by the provider. A Whorlton Hall incident co-ordination group was established, involving NHS England; NHS Improvement; Cygnet, as the owner; the CQC’s regional head of inspection; the local clinical commissioning group; and the local authority.

Durham constabulary opened a criminal investigation earlier this month, and the CQC and NHS England are supporting its enquiries. While that investigation is ongoing, I cannot comment on the specific incidents or individuals depicted, as Members will understand. The evidence presented, including but not limited to the “Panorama” footage, must be thoroughly examined, and where those investigations find that allegations of abuse are substantiated, action will be taken.

One thing we can all be clear on is that what was shown last night was not care, nor was it in any way caring—suffice it to say that I am clear in my mind the nature of what was occurring at Whorlton Hall.

There are three questions that we need to consider urgently. First, was the activity in Whorlton Hall criminal? The police investigation is looking into that. Secondly, is the regulatory and inspection framework working for these types of services? We want to know why, after whistleblowing concerns had been raised, was the outrageous culture and behaviour at Whorlton Hall not identified? What went wrong? We will be working to understand in detail the timeline of events, the actions taken and where things might have been addressed earlier. Thirdly, was the oversight of commissioners fit for purpose? Where were the CQC and NHS England in this?

More broadly, there is a range of questions about whether these types of institutions and these types of in-patient settings are ever an appropriate place to keep vulnerable people for any extended length of time and why community provision is not sufficient. Work is continuing on all those subjects as well. We know the problems that exist in the system and we are utterly determined address them.

[Norman Lamb]

I thank the Minister for that response. Last night’s “Panorama” was deeply shocking and particularly distressing for any family who have a loved one in an institution and are worried about their safety. We saw people with learning disabilities and autism mocked, intimidated, taunted and provoked, and care workers admitting to deliberately hurting patients—behaviour appropriately described as psychological torture. The individuals responsible must be held to account, but so must the provider that allowed this dreadful culture to persist. Will there now be an investigation by the Health and Safety Executive into the possibility of criminal prosecution against the provider?

The truth is that, seven years on from Winterbourne View, the system continues to sanction a model of care that is outdated and wrong. If people are contained in institutions a long way from home, awful things will happen behind closed doors. Will the Secretary of State now take personal responsibility for closing down institutions that provide the wrong model of care? Why does the CQC continue to register new institutions that offer inappropriate institutional care? Does the CQC need new powers? What lessons must we learn from the fact that the CQC rated this place as good? Is this another case of whistleblowers not being listened to? How much was Cygnet charging the NHS per week for this awful abuse and neglect?

This horror comes in the same week as a damning CQC report on segregation, an equally scathing report by the Children’s Commissioner on children being wrongly placed in institutions where force is routinely used and the LeDeR—learning disabilities mortality review—report confirming the extent to which people with learning disabilities and autism are fatally failed by the system. Does the Minister accept that we are tolerating widespread human rights abuses? Is it true that the Government moved forward the publication of the CQC report to pre-empt the “Panorama” report? What families want is not another review; they want action to protect their loved ones.

Will the Government take action to end the endemic use of restraint—including face-down restraint against adults and children—five years after I issued guidance to that end? When will the Government tell us what will replace the transforming care programme? It ended in March and we are still waiting—there is hardly a sense of urgency. Finally, will there now be substantial investment in the development of community facilities, so that people with learning disabilities and autism have the chance of a good life that the rest of us take for granted?

[Caroline Dinenage]

These exchanges reflect the views that I am certain we all hold, and I thank the right hon. Gentleman for raising all those questions. The culture and behaviour shown on yesterday’s television programme are absolutely abhorrent and we must stamp them out. More broadly, it is clear from the reports published earlier this week, which the right hon. Gentleman refers to, that we need to do much more to improve the quality of care in mental health wards for anyone with a learning disability or autism. I want to reassure the House that we absolutely recognise that, and steps are being taken to address it.

Societies are rightly judged on the way we treat our most vulnerable citizens. This is not just about reviewing a few individual cases in which things went wrong; it is about a system across health, education, social care and criminal justice—it all needs to change. Today, people will rightly be very angry about what has happened and what was shown on last night’s television programme, and they will want answers. They will also rightly be very angry that, eight years after Winterbourne View, we have another scandalous case in which vulnerable people with learning disabilities or autism are on the receiving end. They will rightly ask what action has been taken and what more we need to do.

As the right hon. Gentleman will know, six months ago the Secretary of State commissioned the CQC report on segregation, seclusion and restrictive practices. It was published earlier this week simply because the original publication due date of 31 May is during a recess, and he will know that the Department has come in for enormous criticism in the past for publishing reports when Parliament is in recess, post elections or when the House is not sitting and for publishing late. We wanted to avoid all those things. That is why the date was brought forward. The publication was ready and we took the view to publish it. The publication of the LeDeR report was a matter for NHS England, of course, it being an independent document.

The action we announced in response to the CQC report on Tuesday confirms how seriously we take this issue. We are adamant that no stone should be left unturned in identifying problems, poor practice and care that falls short of what we would expect for our own family members. That said, this is not about segregation or seclusion or failings at specific hospitals, but about the need for far better oversight more generally. Where it is essential that somebody be supported at a distance from their home, we will make sure that those arrangements are supervised. We will not tolerate having people out of sight and out of mind. Where someone with a learning disability or an autistic person has to be an in-patient out of area, they will now be visited on site every six weeks if they are a child and every eight weeks if they are an adult.

The host clinical commissioning group will also be given new responsibilities to oversee and monitor the quality of care provided in their area. This is an issue not just for the regulator, but for those who commission the care. We must be clear that improving the quality of specialist in-patient care is critical, but we are committed to preventing people from entering crisis and having to be admitted to in-patient care in the first place, and that is what the transforming care programme is about. This programme has not finished. As was highlighted in the NHS long-term plan, the transforming care programme and the building the right support plan continue, and we are renewing and redoubling efforts to reduce the number of people in an in-patient setting by 35%. So far, it is down 22% from 2015, but that endeavour continues. The right hon. Gentleman highlights the report from the Children’s Commissioner on Monday. We take the issues they spoke about very seriously.

The right hon. Gentleman asked lots of questions, many of which I think were answered in the three questions I highlighted earlier—the questions that we will be addressing over the coming weeks: criminal liability, oversight and commissioning. Where there have been failings, these will be addressed. Autistic children often have a range of needs or supports that must be joined up, which is why we are reviewing our entire autism strategy and will extend it to include children. As part of the NHS long-term plan, there will be a concerted effort to implement arrangements to ensure that those at the highest risk of admission to a specialist hospital get the help they need, and we will ensure that every area has a dynamic support register in place.

We think that staff in these settings must be much better trained in awareness of learning disabilities and autism, which is why we conducted a thorough inquiry and public consultation on training for learning disabilities and autism. In the coming months, we will set out our response to that consultation and proposals to introduce mandatory training for all health and care staff. We will continue to bring those in-patient numbers down and take every step to take the best practice in health and care and make it the norm everywhere. We will root out toxic cultures and behaviours of the type we saw last night so very painfully on our television screens, but I am fully aware that there is no room for complacency.

[Several hon. Members rose—]

[Sir Desmond Swayne (New Forest West) (Con)]

What happens at the Care Quality Commission’s headquarters when a story such as this emerges? Are the inspectors who so recently rated the facility summoned in for a meeting without coffee, or perhaps with the rough end of a pineapple?

[Caroline Dinenage]

The Care Quality Commission is taking the situation incredibly seriously. Some massive concerns were raised last night, and Paul Lelliott from the CQC apologised and said that the matter would be very thoroughly addressed and investigated by its team.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I appreciate the Minister’s response, but the Secretary of State really should be here to deal with this. The abuse shown on the BBC “Panorama” programme last night was appalling, and it should never have been allowed to happen. The fact that it is eight years since the Winterbourne View scandal and nothing has changed should be a source of shame for the Government. Rather than warm words—the Government seem to be getting good at warm words these days, but little else—will the Minister take personal responsibility and tell us what she is doing to ensure that this never happens again?

The abuse that was shown was tantamount to psychological torture, with residents sworn at, threatened and intimidated. Other residents were violently restrained or deliberately hurt by care staff. As the Minister has mentioned, other cases—such as Mendip House and Thors Park—show that this is not an isolated incident; it is part of a pattern of cruel and callous behaviour in such institutions. There is only one sure way to end this abuse, and that is to close down the institutions and move people into supported placements in the community.

Many of the people who were abused at Whorlton Hall were hundreds of miles from their families. Does the Minister recognise that cutting people off from their support networks allows such abuse to carry on without anyone noticing? Labour has pledged £350 million extra per year to ensure that people can move from such institutions and be supported in the community instead. Will the Minister match that commitment?

In 2011, the Government pledged to end the use of units such as Whorlton Hall. Eight years later, however, there are still more than 2,200 people detained in inappropriate institutions. More recent targets, which were less ambitious, were also missed. After years of broken promises, autistic people, people with learning disabilities and their families cannot trust the Government to deliver on their promises. Is it not time the Government brought in an independent commissioner to oversee the closure of such units?

[Caroline Dinenage]

I do not agree with the hon. Lady that what I have said today is about warm words; it is about action. The CQC report that came out on Tuesday was commissioned by our Secretary of State to really shine a light on the matter. We are shining a light on some of the most distressing information so that we can address it—so that we cannot brush it under the carpet and speak warm words about it. Not only did we accept all the CQC’s recommendations, but we made more recommendations of our own that we intend to put into practice.

In answer to some of the hon. Lady’s questions, I am very clear that as far as possible, people should be treated in a community setting. If they have to go into an in-patient setting, they should be as close to home as possible and they should be there for the shortest possible time, with a very clear route out and plan for their future. To help to deliver that, we have committed £4.5 billion to community funding as part of the NHS long-term plan, and I expect a good proportion of that money to be spent on investing in the community settings that we need.

[Barbara Keeley]

Why not close them?

[Caroline Dinenage]

The hon. Lady is saying from a sedentary position that we should close settings, but we are talking about very vulnerable people who have complex needs and require special care, and we need to make sure that there are sufficient services in the community to support them. It would be a complete dereliction of our duty and responsibility to take people out of one setting that is not working for them and put them into another setting that will be as bad, or worse.

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

I thank the Minister for her robust efforts to get to grips with the matter. I have heard from my constituents overnight that they have no confidence in the CQC if it thought it could get away with assessing Whorlton Hall as good. If it takes an undercover investigator to highlight a message that whistleblowers are not getting through, why are the Government not taking immediate action properly to investigate every single in-patient centre so that the Minister can look us all in the eye and say, “I know which places are safe and which are not”?

[Caroline Dinenage]

My hon. Friend is absolutely right to raise that point. I think the CQC itself admitted to this. In fact, some of its social media engagement over the past 24 hours has been unprecedented in its level of frankness and openness, and in the way in which it has shown a desire to change and make this situation better. It has been very disturbing for everybody concerned, and it is true that NHS England has started enhanced oversight and scrutiny of this particular group’s other learning disability and autism settings to try to ensure that we are not going to uncover any more stories of such horror.

[Helen Goodman (Bishop Auckland) (Lab)]

What was revealed on “Panorama” last night was truly horrific. This was public service broadcasting at its best, but it should not have taken the BBC to uncover the case; the CQC got this totally wrong. However, whatever the failings of the CQC, ultimate responsibility must lie with those who own and manage these homes and make money out of them. I am therefore extremely concerned to hear that the Minister has put Cygnet on the body that is to look into this matter. There is a clear conflict of interest because Cygnet may end up needing to be prosecuted. Finally, the Government need to fund these services properly. It is no good having people who are not qualified and not properly paid working with the most vulnerable people in society.

[Caroline Dinenage]

Let me clarify what I said, because I think the hon. Lady might have slightly got the wrong end of the stick. I did not say that Cygnet was being put on a group that is investigating this situation. I said that a group was established to deal with the immediate problem as soon as the issue came to light. That immediate problem was the safety of the individuals living in this particular setting and the conduct of those whose behaviour had been so outrageous. At that point, we were told that 21 people had been suspended. The safety of the individuals living in the setting was therefore our immediate concern, as well as finding alternative places for many of them to go. At that point, there was an incident co-ordination group that included Cygnet because it is the owner, but that group was set up to deal with the immediate situation that needed to be dealt with very promptly.

[John Howell (Henley) (Con)]

The NHS has been using a system of ambulatory care, particularly to deal with elderly patients by treating them in their home, plus a hospital visit. Why has this not been rolled out quicker to those with learning disabilities and autism?

[Caroline Dinenage]

That is what we are looking towards, which is why the Government are putting so much more money—£4.5 billion of the extra investment in the NHS—into the sorts of community services that we need to make exactly that a reality. There are cases where people do end up in an in-patient setting, often because services have failed and their situation has almost reached crisis point. The transforming care and building the right support system that I spoke about earlier is all about ensuring that we get people out of those settings as quickly as possible and into the right kind of support in the community.

[Dr Sarah Wollaston (Totnes) (Change UK)]

Too many people are ending up in terrible institutional care hundreds of miles from home for the want of much more appropriate community care, including social care. The Minister has spoken about not wanting to delay the publication of reports, but she will know that the delay to the social care Green Paper has been unaccountably prolonged. Will she bring forward the social care Green Paper, because this issue lies at the root of inappropriate admissions?

[Caroline Dinenage]

The hon. Lady knows that I listen very carefully to what she says. I completely share her frustration about the delays to the social care Green Paper, but I do not think that we should ever be held back from making progress on all the things that are wrong in society that we care very deeply about because we are awaiting the publication of such documents. We will therefore be pushing forward with all the work on a lot of the issues that I have spoken about today as a matter of great urgency.

[Bob Blackman (Harrow East) (Con)]

Mencap has called for a cross-Department ministerial working group to review the system, and a taskforce made up of people with real-life experience of dealing with people with learning disabilities and autism. Will my hon. Friend confirm that she will set up both such groups so that we can get some action in helping people who are suffering?

[Caroline Dinenage]

There is already a cross-departmental working group on disability, and quite rightly, this could be part of its work. In addition, as part of the response to the CQC report published on Tuesday, the Secretary of State has committed to set up a group made up of academics and experts, including experts by experience, to look at exactly that.

[Mr Barry Sheerman (Huddersfield) (Lab/Co-op)]

I chair the Westminster Commission on Autism. The Minister will know that people on social media are asking why it took a television programme to reveal this. Can we learn the lessons quickly? I make no party political point—these crises have happened under other Governments, but we have to learn the lessons and reappraise the whole sector. Some people have said this morning that we should keep these children and adults close to home, in their communities, and that is right. We should also look at something that has really worked, which is the Children’s Commissioner, especially with someone like Anne Longfield in the role. That has been an enormous success, and perhaps we need a commissioner for autism, who would give a voice and a personality to this kind of crisis.

[Caroline Dinenage]

I greatly respect all the work that the hon. Gentleman does with autistic people, and I know he is passionate about this. He is right. We have committed to review the autism strategy. The Autism Act 2009 is the only condition-specific piece of legislation in British law, and we want to ensure that it continues to be fit for purpose. The consultation on the autism strategy review has just closed, and we will look carefully at everything that comes out of it.

[Tom Pursglove (Corby) (Con)]

What protection is in place for those who come forward to shine a light on allegations relating to such grave care? What is the Minister’s message to people who have concerns?

[Caroline Dinenage]

I am grateful to my hon. Friend for raising that, because it is the whistleblowers who have brought these concerns to everyone’s attention. It is deeply regrettable that whistleblowers brought this to people’s attention before, and it was investigated, but this abuse was not rooted out and stopped. We need more protection for whistleblowers. We have accepted some of the CQC’s recommendations on encouraging whistleblowers to come forward, and we are always looking at more ways to offer protection and encourage them to do so. It is always wrong when deeply disturbing practices have to be brought to light by those who shine a light on them.

[Mr Steve Reed (Croydon North) (Lab/Co-op)]

Children with autism and learning disabilities are still being pinned face-down on the floor, tied to beds or locked up in seclusion rooms. The Government promised five years ago to publish guidance to prevent that kind of abuse, but they still have not done it. After Whorlton Hall, we desperately need a date. When will the Government publish that guidance?

[Caroline Dinenage]

The Secretary of State commissioned a report on exactly that—segregation and restrictive practice. It was published on Tuesday, and we have accepted all the recommendations. We are working very hard on this. There will be guidance, but it is more important than that. As shown in the TV programme last night, there was training and guidance on the restrictive practices to be implemented, but it was ignored, and restraint was recorded incorrectly. This is a much bigger issue than the one the hon. Gentleman highlights.

[Rachel Maclean (Redditch) (Con)]

I see more and more families in my surgery with loved ones who suffer from autism or learning difficulties being failed by the system. Will the Minister give an assurance to my constituents and their families that there will be a genuine focus in the NHS long-term plan on these vulnerable people?

[Caroline Dinenage]

I thank my hon. Friend for that question; she is right to raise it. Autism and learning disability are both mentioned as clinical priorities in the NHS long-term plan. That is absolutely right, and we must relentlessly continue that focus.