Oral Answers to Questions

Caroline Johnson Excerpts

Tuesday 15th January 2019 Commons Chamber

[Steve Brine]

Of course, health is devolved, but we talk to our opposite numbers all the time, as do our officials. Our north star ambition to halve child obesity by 2030 is right and it is shared and matched by our colleagues in Scotland, and we look to our colleagues in Northern Ireland to do the same. Any advice and support that they want from our world-leading plan is more than on offer.

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

Does the Minister agree with the campaign being advanced by Jamie Oliver to ensure that doctors in training are given more extensive training in nutrition and its benefits for health?

[Steve Brine]

Yes, I do. I was fortunate enough to visit Southend pier before Christmas to talk to Jamie and Jimmy about this. Nutrition training and the understanding of what is involved in achieving and maintaining a healthy weight varies between medical schools. Some courses have only eight hours over what can be a five or six-year degree. Together with the professional bodies and the universities, we will—as we said in the long-term plan—ensure that nutrition has a greater place in professional education training.

Nursing: Higher Education Investment

Caroline Johnson Excerpts

Wednesday 21st November 2018 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Davies. I congratulate the hon. Member for Wolverhampton South West (Eleanor Smith) on securing a debate on this very important subject and the Minister for Health on his new role.

I do not think there is anybody in Westminster Hall today who would doubt the value of nursing or the importance of good nursing and nurse training. I have worked for my entire career as a paediatrician; I am now a consultant paediatrician. Nurses and midwives have had a significant impact on both my career and my personal experiences. When I worked on a neonatal intensive care unit, many nurses influenced my career. However, there was one in particular—a lady called Mary Palfreman, a nurse in Nottingham—who had a profound effect on me, because she is such a fantastic nurse. On a personal level, I was cared for through several of my pregnancies by a midwife called Marie Robinson, who was able to balance treating me as a medic, who had more knowledge of neonates and babies than the average first-time mum, with treating me as a mum. She recognised that I was a bit of both and perhaps needed a slightly different approach from others—even a unique approach. She treated everybody as she found them, and she is a fabulous woman.

None of us, therefore, would doubt the value of a good nurse and the importance of making sure that there are adequate numbers of nurses. Nursing is a great and varied career, which is something we should be selling more. Nurses have the opportunity to nurse in many different fields. As their career progresses, they can go into administrative roles, managerial roles and specialist technical roles in the community or in a hospital, and develop a good and, at the high level, extremely well paid career.

So what should a good training scheme do? Obviously, it should provide high-quality experience, so that students develop the necessary expertise; it should provide the opportunity for continuing personal development; and it should ensure that there is an adequate supply of nurses. We have a change in demographics: the population is getting older, there are more people with complex health needs, and the population is increasing in size. So we need to ensure that the number of new nurses keeps up with both those developments and the natural attrition of nurses as people retire and so on. We also need to ensure—this is very important to me as a Conservative— that anyone who has the desire and the aptitude to train as a nurse can do so and is not limited by how much money they have or where they are from.

Looking at some of the figures, it is evident there has been a drop in the number of people applying to become nurses, but at this stage there are still many more applications for nursing than there are nursing training places. I was not a parliamentarian when the new policy was introduced, but I understand that the aim behind it was to ensure that more places were available so that more people with the desire and the aptitude could train. The figures I have been given show there are 13,000 more nurses on the wards now than there were in 2010.

In January I was a member of the Select Committee on Health when it produced the nursing workforce report that the hon. Member for Stockton South (Dr Williams) mentioned earlier. It showed specific shortages in mental health, learning disability and district nursing. I understand that the previous Minister undertook to give up to £10,000 to people training in that field, to try to address the shortages. Will the Minister tell us how that is working and whether it is increasing applications? Also, the Government had recognised specific challenges for people wishing to go back into nursing or to develop nursing as a career after having children. Is the Minister looking into what support can be offered to those with disabilities and those with children to make sure that they are still able to access nurse training and become the fabulous nurses that they can be?

The issue of part-time jobs has been raised. Most of the nursing students I have worked with in my career have had part-time jobs, usually as a healthcare assistant, often on the same ward that they have worked on as a nurse, so I am not sure the point that was made entirely reflects what I have seen.

Finally, I want to mention alternative routes into nursing. There is more than one route to achieving a goal. There are opportunities for people to work as nursing associates. Some of the healthcare assistants I have worked with have done that, and they really enjoy their training. There is also the opportunity to go into a nurse apprenticeship as an alternative way of training while working. That is not for everybody, because people want different things, but it is another way in which we can increase nurse numbers without having an impact on training. I am aware of the time, but will the Minister update us on—

[Philip Davies (in the Chair)]

Order. The hon. Lady’s time is up.

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[Stephen Hammond]

Inspiration has just reached me. As the hon. Gentleman will know, Health Education England recently published a report on attrition rates on nursing courses—I made the point earlier that the rate of attrition among all people applying for university places has gone down. However, I will write to the hon. Gentleman. The report published by Health Education England describes how attrition rates on those courses have fallen considerably over the past few years, but I will write to him to be absolutely clear. He may then choose to make that letter available.

[Dr Caroline Johnson]

“The nursing workforce” report, which was published by the Select Committee on Health in January, identified that 30% of students due to complete in 2015-16 or 2016-17 did not complete within that period. Significant variability between different training institutions was also identified. Will the Minister commit to looking at why some institutions have such high attrition rates compared with others?

[Stephen Hammond]

That is an extremely important point. There is not necessarily a universal reason why particular institutions have worse attrition rates than others, and that may well be key to retaining people who wish to stay in the profession.

In my last minute, I will finish on this point: NHS England, NHS Improvement and Health Education England are all working with trusts on a range of recruitment, retention and return-to-practice programmes. Some of those have met with some success: NHS Improvement’s retention programme works directly with trusts to support improvements in retention. However, I want to make clear that, as the newest member of the Government and of the Department, I regard the retention of our NHS professionals as a priority, and I am looking forward to making a contribution not only to things like the “Talk Health and Care” platform, through which there has already been positive engagement, but on this matter more generally. Retention is key, and we want to make sure nurses understand that we recognise how important they are. The long-term plan will set out a strategy to ensure a more sustainable future supply of nurses. They work incredibly hard, and it is absolutely right that this Government will commit to ensure that funding is dedicated to the supply—

Motion lapsed (Standing Order No. 10(6)).

Budget Resolutions

Caroline Johnson Excerpts

Tuesday 30th October 2018 Commons Chamber

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

The House of Commons Library tells me that I have listened to Budgets in the House 44 times, so I hope I am an experienced Budget evaluator. I always come to the Chamber to listen to the Budget, and I base my evaluation of its quality on two criteria. The first is the great global issues that we face, which for me are always the fragile planet, the environment, climate change and global warming, and the fact that the planet’s burgeoning population has to be fed, and fed sustainably. We also face the challenge of keeping the peace. Many of us thought that that could be taken for granted, but in the current global circumstances, keeping the peace has become a great concern for us all.

My second criterion for evaluating a Budget is what it will do for my constituents. I believe that I have a sacred duty to come here and represent my constituents, and to make sure that everything that I do—the contribution that my colleagues and I make in the House—adds to the welfare, health and prosperity of my constituents. Those are the twin criteria, and on both I believe that this is an uninspiring little Budget. It is lacking in passion, leadership and values. That is my sincere criticism of the Budget.

Let me go into a little more detail. I have been in the House at times when the country has been in great crisis. At a time of crisis, I have seen people whom one would have thought were pretty ordinary politicians suddenly stepping up to the Dispatch Box and showing the world that they had leadership quality, that they understood what was going on in the wider world, and that they could stand up to do the right thing. I take umbrage at the fact that a Chancellor of the Exchequer could stand in the Chamber yesterday and call the cataclysm of 2009 and the global meltdown of the world economy “Labour’s great recession.” I have to say that it must have been a very powerful Labour party and Labour Government who caused the world recession. What rubbish that the man who is supposed to be our Chancellor of the Exchequer could say such a thing—shame on him!

I saw Gordon Brown and Alistair Darling at that Dispatch Box, calm in the face of a hurricane in the world economy. They stood there and made the right decisions. They bailed out the selfish banks. They did what was necessary to save our country. This bunch over on the Government Benches should not tell us how to rise to our responsibilities. We showed leadership. We showed that we had the values. We worked incessantly to get this country back on track.

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

We understand that there was a global banking crisis, but is it not right that the Labour Government did not prepare the country for problems that might occur, given their chronic overspending of money that we just did not have, which left us in a great deal of debt when the recession happened?

[Mr Sheerman]

I hear what the hon. Lady says, but let us be serious. I recommend that she goes away and looks at a rather good book that I have recently read called “Reckless Endangerment: How Outsized Ambition, Greed, and Corruption Led to Economic Armageddon” by Gretchen Morgenson. Read it and learn it, because that was what we came through.

The Chancellor’s remarks yesterday did not really touch on many of the issues that affect my community. The fact is that we have a hospital in danger that suffers due to a private finance initiative scheme. All the Chancellor said was that Labour was responsible for PFI. I have been here long enough to know that the great charm offensive on PFIs was led by John Major. PFIs were the fashion among Members on all Benches. As Chairman of the Education Committee, I saw good PFIs and bad PFIs, but I also saw a lot of smart City types who danced rings around local authorities and local health authorities and gave them a rotten deal. That is the truth of PFIs—there were good ones and bad ones, but a lot of City spivs made a lot of money out of them. Nothing that the Chancellor said yesterday will rescue my local hospital and health trust from that burden.

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

There is much to digest in the Budget, so I shall focus on only a few of the announcements that were made. In line with the theme of today’s debate, I shall start with those on health.

As a children’s doctor, I work on the frontline of the NHS. Throughout my career, I have become increasingly concerned about the number of young people with mental health problems. More than half of those problems start before the child is 14, and 75% have started by the time the child is 18, so early intervention is critical to try to avoid crises further down the line. I therefore welcome the Government’s announcement of £2 billion more for mental health, which will ensure that every school has a dedicated mental health team to tackle what is becoming an epidemic of eating disorders, depression and self-harm among young people. It is a welcome step as part of the Government’s commitment to develop parity of esteem for mental and physical health problems. More work needs to be done to identify the cause of these problems so that they can be tackled earlier.

As my right hon. Friend the Secretary of State for Health and Social Care thinks about how to spend the Government’s £20 billion increase for the NHS, will he consider how much money is given to children with life-threatening and life-limiting disorders? Many of their families struggle from day to day, so extra money to help to fund children’s hospices, as well as the availability of respite care, would be most welcome.

I have spoken in the Chamber previously about the challenges facing ambulance services in rural areas. My beautiful constituency of Sleaford and North Hykeham covers some 433 square miles. Ambulances have to rattle along lots of little tiny winding roads, at speed, to get to patients. Increasing the number of ambulances available to East Midlands ambulance service would help.

Ambulances do not just travel by land. Air ambulances provide an incredible service to our most unwell patients. They are funded entirely by philanthropy, and such services are under constant pressure to fundraise so that they can buy and maintain aircraft and pay for staff. I welcome the Government’s announcement of £10 million of capital funding for air ambulance trusts, which will contribute towards these life-saving services.

For ambulances on the ground, the challenge is not just distance but the road network along which they travel. The additional £28 billion investment in roads will represent the biggest single upgrade of the network since the expansion of the first motorways in the ’60s and ’70s. I will continue to campaign for extra money to complete the Lincoln bypass, and to improve the A46/A17/A1 junction and areas of the A1 and A15, so that roads in Lincolnshire are safer and we can travel more smoothly.

The money for potholes has been mentioned by other right hon. and hon. Members. Potholes are a big problem in Lincolnshire, so I am pleased that extra money will be spent on them, particularly as winter is coming.

I am glad that the Government are investing in our physical infrastructure, but in the 21st century, digital infrastructure is also extremely important. We rely on the internet more and more in our daily lives, so the lack of high-speed broadband in some rural areas can create a real sense of isolation. Whether for the person who cannot download their papers, the small-business owner who cannot submit their taxes online or the studious schoolgirl who cannot complete her homework on the online maths platform, a poor internet connection affects all aspects of work, family life and opportunity for rural constituents. I am therefore delighted that the Government are providing an extra £250 million for high-speed broadband in rural areas. It will be a welcome boost, if it is ensured that the money is directed towards connecting the remaining 5% to 8% who are not yet connected rather than towards getting faster speeds for those who already have a reasonable connection.

A Government’s first responsibility is always the protection of their citizens. As we mark the centenary of the end of the first world war, we remember the sacrifices that were made by many, and also remember the sacrifices made every day by our brave servicemen and women. I participated in the Royal Air Force branch of the Armed Forces Parliamentary Scheme, through which I met many service people at all levels. I heard about their concerns and worries, and about the pressures they were facing. They do an incredible job in the most challenging and, often, the most terrifying of circumstances. It is vital that we provide them with the support that they need, and the Chancellor’s announcement of an extra £1 billion for our armed forces will help to ensure that our armed forces can continue to operate at the very highest level.

Finally, I welcome the Government’s commitment to making work pay. Increasing the work allowance and decreasing the taper rate further for universal credit will help even more people into work. Some 1,000 more jobs are created in the UK every day, and we also have one of the lowest unemployment levels in Europe, which affects young people in particular. Young people in this country have a much better chance of getting a job than those in other parts of Europe, which is something of which we should be proud.

Furthermore, increasing the personal allowance to £12,500, which fulfils our manifesto promise a full year early, allows people who have gone out to work to keep more of what they earn to spend as they wish. The best stability that someone can have is a monthly pay packet, and this Government’s effort will ensure that a record number of people have that stability.

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[Fiona Onasanya (Peterborough) (Lab)]

It is a pleasure to follow my hon. Friend the Member for Sheffield Central (Paul Blomfield) in this important debate.

It is important that we pay attention to the fact that the Prime Minister announced the end of austerity, yet yesterday it was announced that austerity is “coming to an end”. Which is it and when will this be? Austerity was a political choice, not an economic necessity. How will the Government alleviate and redress the devastating impact of austerity? Austerity has not tackled the deficit; rather, the onus of who pays has been shifted to teachers, police and nurses. After eight years of this Government’s hard austerity, too many people are suffering and too many vital public services are in crisis.

Yesterday, we heard not a penny announced for the day-to-day costs of schools, even though school funding has been cut by 8%; not a penny for regular policing, even though 21,000 officers have been cut and violent crime is on the rise; and not a penny for local councils to close the funding gap of £7.8 billion by 2025—and they are facing cuts of £1.3 billion next year, too. The Government are not fixing the fundamentals. Must it always take a tragedy to effect meaningful change?

Take a look at our fire service: rather than fighting fires, it is having to fight for funding. It is beneath contempt not to pay those who work in our fire service properly. Indeed, real wages are lower today than they were in 2010, while CEOs are paid 143 times the wage of the average worker.

The late Audrey Hepburn once said: “As you grow older, you will discover that you have two hands: one for helping yourself, the other for helping others.” When will the Government stop and realise that? Rather than help, the Government have shown again through the Budget that they know the price of everything, yet the value of nothing. Once again, they are saying, “Your price is way too high; you need to cut it, cut it, cut it, cut it.” It is like the emperor’s new clothes: the emperor seeks to describe an elegant, flamboyant gown that he is wearing, but he is actually completely naked.

This Budget does not mark the end of austerity. The NHS has experienced the slowest spending growth in its history. When the Government created the Budget, clearly ignoring the issues caused by their austerity, it seems they had 99 problems but did not consider the state of the NHS to be one if they believed that £20.5 billion was sufficient to repair the damage caused by eight years of under-investment.

According to the Health Foundation, the £20.5 billion promised is simply not enough. The £2 billion that has been announced for mental health is welcome, but it is half what is needed, and let me be clear: this is not new money and these are not new resources. These financial gimmicks fool no one. The Health Secretary has said that it would take a generation to establish parity of esteem under this Government. However, people with severe mental health conditions cannot afford to wait five years for meaningful action from this Government. Too many people, including children, are already waiting months to access the treatment that they need, leading to a devastating mental health crisis.

In my constituency, there has been a real-terms cut of 10.6% in adult social care, almost double the national average, and the Government consider their announcement of £650 million for long-term adult social care services an accomplishment when it is less than half what the King’s Fund estimates is required to meet demand. Nearly 1.5 million elderly people are not getting the care that they need—an increase of 20% in just two years. The sum of £84 million over the next five years to expand children’s social care programmes is pitiful compared with the £3 billion needed by 2025. Services are over- stretched, and the recent trends in the level of funding are unsustainable and unacceptable. The needs of Peterborough —my constituency—have been attended to on the cheap for far too long. As a consequence, cracks are beginning to appear in our services. Our needs have not been properly or adequately assessed, or indeed addressed, and the current settlement is blatantly below par.

[Dr Caroline Johnson]

Does the hon. Lady agree that one of the biggest challenges facing Peterborough hospital, which serves her constituency and in which I work, is the financial burden of the PFI that was used to build the hospital? It is a beautiful hospital, but so much money was spent on it that we are burdened with this PFI. It was a Labour Government who did that and we are now having to pay for it.

[Fiona Onasanya]

I thank the hon. Lady for her intervention. Yes, I know that very well about the PFI, which is why Labour is seeking to end PFIs. [Interruption.] Before she says that we signed it, I would like to talk about now and the fact that PFIs actually came in under John Major. Talking about now, Government are pursuing efficiency to the point of ineffectiveness. I end on this poignant note: investment now is lower in relation to GDP and we are ranked 22nd in the world. The time for warm words is over. Austerity has dire consequences and a little extra just will not cut it.

Paediatric Cancers of the Central Nervous System

Caroline Johnson Excerpts

Monday 22nd October 2018 Commons Chamber

[Chris Elmore]

I thank my hon. Friend for her, as ever, courteous and heartfelt intervention. I know of the trauma she is facing in her family life. Richard and Lorraine are extraordinary people, as are their wider family. I have been impressed by their courage throughout Cian’s illness and, now, his passing.

We must not forget those who are lucky enough to survive such aggressive forms of cancer. Survivors often face a lifetime of other health complications, including mobility issues, cognitive challenges, infertility, growth complications and other conditions that require a high level of medical support. We must ensure that aftercare for those children is world class, and that they are able to lead as full, happy and long a life as possible.

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

I congratulate the hon. Gentleman on securing this Adjournment debate to raise awareness of an important health condition. He described how the tumour affecting his constituent was in the cerebellum and is now discussing the long-term effects for survivors of childhood brain tumours. Both treatment and recovery are determined to some degree by the location of the tumour, which can vary widely. I remember clearly a young patient who had a tumour so close to her brainstem—the part of the brain that controls breathing, which we do not think consciously about—that she had to live in intensive care for many months during her treatment, because at any point she could stop breathing. I remember sitting with her when she was making a cotton wool collage of a winter scene and she simply stopped breathing. When she was awake, one could say, “Breathe,” and she would make a conscious effort to breathe; if she was asleep or distracted, or no one was paying attention, she would have passed away. She needed that constant reminder. That is why it is important to ensure not only that we have research and medical treatment during illness, but that for recovery there is a multi-disciplinary team—physios, speech therapists, occupational therapists and so on—so that children who survive these awful tumours make the fullest possible recovery and can live the fullest possible lives afterward.

[Chris Elmore]

I agree with the hon. Lady entirely. There is clearly a need to look not just at treatment but at what comes next. If we are to improve survival rates, which we must—research is a key part of that—then we need to look at what comes next for these families and for the children who, touch wood, will survive.

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[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

I, too, wish we were not here, but let me congratulate my friend the hon. Member for Ogmore (Chris Elmore) on securing this evening’s debate. I commend him on his support and the incredible tribute he gave to Cian and Cian’s family this evening, and on the way he has handled the debate. For those who know him, in both the Government and the Opposition, it is rather typical of the man.

From what we have heard this evening, it is clear that Cian was a very special little boy who touched many people in his short life. I have seen his “Cian’s Kicking Cancer” campaign online, including the picture of him with his hands out in front of the No. 10 Downing Street door—it is a lovely photo—and I pay tribute to the determination of Cian’s parents to raise awareness of paediatric cancers. The way that they have been supported by their local MP is brilliant.

As the cancer Minister, I all too often hear of the devastation that this terrible disease can bring to people and their families, but nothing is as heartbreaking as when a child is affected. I said last week in the breast cancer debate that a life lived long or a life lived short is still a life lived, and I passionately believe that a life lived, short or long, still leaves an indelible mark on this world and still changes this world forever, even in a small way. From what the hon. Gentleman has told the House this evening, there is no question but that Cian has left his mark and changed the world a little bit. We will do our best to honour that and see whether we can change it a bit more.

Every day, at least 12 children and young people are told that they have cancer. When they are born—I have children myself—we all imagine bright futures for our children and the things that we want them to do, but cancer robs many children of that future and the opportunity to fulfil their potential. As the hon. Gentleman said, it is relatively rare in young children, but that is absolutely no consolation to the parents of a child with cancer. It can even be worse to know that and inevitably leads to questions such as, “Why me? Why my child? They haven’t made any lifestyle choices.” Cancer is indiscriminately cruel, and that is one of those awful truths that we face in life.

It is great that we have so much time for this debate. I know that there has been a bit of knockabout that the business finished early again this evening, but I genuinely believe that there is a reason why that happened, and we are going to make the most of it. I start by reassuring the House and those watching that cancer absolutely is a priority for me—I think most people know that—and for this Government.

I happened to be in the Tea Room before coming into this debate and the Prime Minister popped in after her marathon stint on her statement this afternoon. She asked me what I was working on and I said that I was doing this debate tonight. We spoke about how remarkable the way in which the House comes together in these debates is and how there is a concentrated audience for such debates. I know that the hon. Gentleman has put out on social media networks, as I am sure many others have, the fact that this debate is happening tonight, and I know, many people will be watching, so let us be clear: fighting cancer is absolutely central, as the Prime Minister said in her conference speech, to our long-term plan for the national health service in England—I have to say “in England”, because I am an English Health Minister, and the English cancer Minister. It will build on the progress already achieved in the cancer strategy and will set out how we will achieve our ambition that some 55,000 more people in England will survive cancer for five years each year from 2028.

I am absolutely committed to ensuring that our plan transforms outcomes for children with cancer over the next 10 years. The fantastic work being done by NHS cancer doctors and nurses, as well as the invaluable support that we get from our incredible cancer community, is helping us to achieve our vision of transforming cancer services for children and young people.

As I have said, childhood cancers are mercifully rare, but 1,600 children under 15 are still diagnosed each year in the UK. Central nervous system cancers are estimated to account for 25%, with 400 children diagnosed each year. Brain cancers alone account for more than 100 CNS cancers, making each cancer extremely rare.

It is true that survival for children’s cancer has gone up over the past decade, with five-year survival for children’s CNS cancers at 75%—that is how we measure it, but, of course, if people develop a cancer in their 70s, a five-year survival rate is a more significant achievement than for those who develop a cancer when they are under five. The survival rates have gone up, but there is not an ounce of complacency in me; we will and must keep working hard to go further and faster.

Treatment of CNS cancers varies depending on several factors—age, the tumour growth rate and the location and size of the tumour—but, as the hon. Gentleman said, it will usually involve a combination of surgery, chemotherapy and radiotherapy, depending on the clinical need. To ensure that patients have access to the latest, most cutting-edge technology wherever they live, we have invested heavily—some £130 million—to modernise NHS radiotherapy equipment. Over the past two years, 73 trusts have had their older linear accelerators, as they are known, upgraded or replaced, and that is an important thing that we have done—[Interruption.] Cheltenham is one of them, says my Parliamentary Private Secretary, my hon. Friend the Member for Cheltenham (Alex Chalk)—who says that PPSs do not speak in the House? He sits there diligently day in, day out, so why not?

The hon. Member for Ogmore mentioned proton beam therapy and I want to touch on that. In the past few years, there has been an increase in the use of PBT—for those who do not know, it is an advanced form of radiotherapy—for treating children with CNS tumours. It uses high-energy proton beams to treat the cancer much more precisely. These targeted doses of treatment have less impact on surrounding healthy tissue and fewer side-effects. In childhood cancers, that is critically important—the hon. Gentleman mentioned side-effects of treatment with regard to fertility, for instance.

Until now, PBT for children has been commissioned from overseas. We have sent children to America and to Germany. That is why we have invested £250 million to provide PBT services in England. I am delighted that the first NHS centre, at the Christie in Manchester, is scheduled to begin treating patients this autumn. A second facility is due to open at University College London Hospitals in London in 2020. I had the pleasure of visiting the Christie shortly after delivery of the giant ProBeam proton system, which is a significant engineering feat. The scale and complexity of the technology is truly breath-taking, and I am tremendously excited that we will shortly be providing PBT on the NHS in England, sparing patients the upheaval, discomfort and cost—I will come on to that—of travelling abroad for treatment.

Although survival rates for CNS cancers have been improving, some children will unfortunately suffer relapse, as we heard in Cian’s case, and treatment options can sadly be limited, even for palliative care. That is why NHS England is reviewing whether additional radiotherapy treatments, such as stereotactic radiosurgery and stereotactic radiotherapy—there is a difference—would be suitable for these patients. I am following that work closely, as I am interested in and excited by its potential.

This month, NHS England published the draft national genomic test directory for cancer, setting out how whole-genome sequencing for paediatric brain tumours and other genetic tests are now being considered for CNS cancers. I hope that introducing those tests will support better tumour identification and more targeted treatments for CNS cancers in children, and give hope to many others.

Perhaps the most exciting development in our efforts to treat childhood cancers successfully is the increasing availability of personalised treatments such as CAR-T therapy, about which there is understandably a lot of excitement in the medical community. With the introduction of more personalised and targeted treatments and different treatment options for children with CNS cancers, NHS England is reviewing how best to ensure that children receive the available treatment and from the relevant clinical team, now and in the future. We expect the availability of more personalised treatments to be a real game-changer for childhood cancers. The work is still in its early stages, and it will involve clinicians, service providers and charities as it progresses, but I will of course update the all-party group, which I will come to in a moment, as it develops.

Research, which the hon. Gentleman mentioned, is a crucial part of the fight against brain tumours. In May, we announced £40 million over five years for brain tumour research through the National Institute for Health Research, as part of the late Tessa Jowell’s brain cancer mission, which includes research for children with brain cancer. I only met Baroness Jowell once, unfortunately, but I was left in no doubt about what she wanted me to do—her legendary determination was very much in evidence. I very much enjoyed meeting her and Jess, her daughter, who is carrying on much of the work.

The hon. Gentleman talked about research projects. Baroness Jowell’s mission is about stimulating quality research projects—a point that the late baroness was able to nail as soon as she started to look into it. Although the NIHR spent £137 million on cancer research in 2016-17—the largest ever investment in a disease area—it does not allocate funding for specific disease areas. It does not have a basket for each disease area. Spending has to be driven, therefore, by scientific potential and the number and scale of quality funding applications.

The baroness was very pithy and understood immediately that we needed to stimulate the market in brain tumour research to enable quality research proposals to come forward. After that, the clinical research network, which is recruiting for or setting up more than 700 cancer trials and studies, including studies into childhood cancers and brain tumours, can press forward and do its work. Funding for paediatric cancer research is critical.

The hon. Gentleman also talked about international research. I absolutely agree that international collaboration is key for successful research on rare diseases such as CNS and childhood cancers. The Prime Minister has made it very clear that we want to work closely with Europe in science and research and that the UK is committed to establishing a far-reaching science and innovation pact with the EU, facilitating the exchange of ideas and researchers and enabling the UK to continue to participate in key programmes alongside our EU partners. Whatever “take back control” meant—one day I will be told—it did not mean that we are not to work with our EU partners in such areas. I am determined that it will not mean that, as are the Government. The Chancellor has also made it clear that he will guarantee EU structural and investment funding and underwrite payments for competitive EU research awards through the Horizon 2020 underwrite guarantee, which is a very important project.

The hon. Gentleman mentioned the Eliminate Cancer Initiative, which the late Baroness Jowell made sure I was acutely aware of. Its tagline “Making cancer non-lethal for the next generation” is really neat, and we certainly support it. It has huge global potential and reach. As he mentioned, given my international health brief, I travel to talk to Ministers from around the world. I was at the G20 earlier this month. The G20 and G7 have Health Minister meetings, as they should do; I certainly hope they will when we have the chair. I would like to see international research collaboration, specifically on cancer, on one of the G20 or G7 agendas. The hon. Gentleman’s point was well made. I will take it up with my officials so that, as we lobby for the chair of the next meetings, we talk about that. It would be an interesting piece of work that we as fellow Ministers could do. I know that people think that sometimes these international meetings are talking shops, and of course there is an element of that, but actually an awful lot of good stuff goes on and an awful lot of other agencies—the OECD, the World Bank, the EU—are part of those meetings. If Ministers decide that this is part of our agenda, that will make a difference and move the dial.

Several Members have talked about awareness of childhood cancers and I thank the hon. Gentleman for what he said about the all-party group on children, teenagers, and young adults with cancer. I am pleased to see my friend the hon. Member for Bristol West (Thangam Debbonaire) in her place. I welcome the establishment of that all-party group on the specific needs of children and young people with cancer. It is an excellent all-party group—several of its members are or were here. I was delighted to give evidence to its patient experience inquiry earlier this year. She had some of her patient advocates there, who asked great questions as well, and I commend it for an excellent report. I do not have to do this for all-party groups—I do for Select Committees—but I have undertaken that the Department will respond line by line to its report. I will definitely do that. It is not ready yet, but it will happen.

One of the all-party group’s recommendations was on signs and symptoms, which I will come on to, and another was on the cost of travel. The hon. Member for Alyn and Deeside (Mark Tami) mentioned the CLIC Sargent report that highlighted the financial impact of travel on the families of young cancer patients. It is a really good piece of work. I assure hon. Members that the Government are working to review the service specifications for children and young people with cancer. This will help us to consider how some aspects of the patients pathway might be provided more locally to reduce the travel burden for patients and their families. There is the other element: sometimes that cannot be done and people have to travel for treatment. The NHS cannot do everything brilliantly everywhere—clearly, specialisms are sometimes needed. That is why we have the healthcare travel costs scheme, which is part of the NHS low income scheme. It allows for patients’ travel costs to be reimbursed if they are in receipt of a qualifying benefit or are on a low income. The scheme helped some 337,000 applicants to receive financial help with their NHS treatment. I am very interested in the recommendations of the all-party group on that and I assure its members that I am taking great note of them.

[Dr Caroline Johnson]

I am pleased to learn that my hon. Friend takes such an interest in reports from all-party parliamentary groups. Will he undertake to look equally carefully at the report that will be produced tomorrow by the all-party parliamentary group for children who need palliative care, known as Together for Short Lives, which I co-chair with the hon. Member for Newcastle upon Tyne North (Catherine McKinnell)? It looks at how we provide palliative care for children with cancer and other life-limiting and life-threatening conditions.

[Steve Brine]

I will now take an intervention from the hon. Member for Ilford North (Wes Streeting).

Childhood Obesity

Caroline Johnson Excerpts

Tuesday 16th October 2018 Commons Chamber

[Ms Nadine Dorries (Mid Bedfordshire) (Con)]

Let me first declare an interest: I am currently taking part in a television experiment relating to obesity.

The United Kingdom is now the third most obese nation in the world. That is a shocking fact, especially when, as we know, the second biggest preventable cause of cancer is obesity. This is a crisis, and as always when there is a crisis, the innocent victims are the children. The obesity crisis that is hitting the UK is no exception: the victims are the vulnerable, the poor and the children.

I pay tribute to Andy Cook, the director of the Centre for Social Justice. The work of that prestigious organisation does not receive the praise or recognition that it should. A report produced by the CSJ, “Off the Scales”, provides an in-depth analysis of the obesity crisis facing the UK and makes a series of recommendations that complement the Government’s own obesity strategy report of 2016. However, the difference between the two reports is fundamental.

The CSJ report takes a holistic, headline view that is workable and suggests pathways towards the measuring of deliverable outcomes and progress. It highlights the success of implementing a joined-up cross-organisational and cross-departmental strategy to solve a problem that is costing the taxpayer more than £30 billion a year, and, more importantly, costing the lives of a future generation. It highlights some of the weak areas in the Government’s childhood obesity plan, which was published by the Department of Health in August 2016 and aimed to reduce childhood obesity rates in England over the next 10 years. It is a good plan, but it has little chance of making any impactful difference, as there is little in the way of joined-up thinking or leadership, or accountability, on the part of individual Departments.

Let me explain, in the starkest terms possible, why this issue is so important. For the first time ever, one in four children of the next generation will die younger than their parents. Nearly a third of all children aged between two and 15 are overweight or obese, as the Government report itself highlights. Younger generations are becoming more obese at earlier ages, and obesity doubles the risk of dying prematurely, so this is an incredibly serious problem. I am not sure that many parents know that, but they should, and we should be doing more to make sure that they do.

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

I congratulate my hon. Friend on securing this debate on such an important topic. Does she agree that this is a major health crisis affecting young children? Not only will those children die younger than their parents and before they would have expected to, but they will experience more suffering during their life due to the ill health caused by obesity.

[Ms Dorries]

I thank my hon. Friend for that intervention. She is a doctor and knows more than most about the health impacts of obesity, which include diabetes and other illnesses that are costly both to life and the Government.

--- Later in debate ---

[Ms Dorries]

The hon. Gentleman nearly got a speech in there. As I said, I will go on to address funding issues.

The parents on whom this issue impacts the most, and who are most likely to be affected, are those who make the poorest nutritional choices. They do not take The Times, or spend time on the internet reading the news or visiting any other sites where information about the effects of obesity on their children is likely to be repeated. They are also the parents who live in areas of higher deprivation. The fast-food, junk-food giants place more of their outlets in such areas than in areas of affluence, which makes the temptation easier and the consequences more impactful.

What can we as a Government do? I want to praise the headteacher and staff at Shillington Lower School in my constituency. Every morning after assembly, every child joins in with 15 minutes of vigorous exercise. Some are outdoors, running around the field perimeter, while others are in the hall doing boot camp with the cyber coach. That is in addition to their normal PE lessons and physical activities. The school actively encourages walking to school, and I have to say that Shillington Lower School’s efforts are there to be seen, but that is one approach, in one school in one village.

I am doing my little bit by embarking on a tour of schools in my constituency, and I am speaking to public health officers at Central Bedfordshire Council to find out how much more we can do locally in my Mid Bedfordshire constituency. However, this piecemeal approach is part of the problem. We have local council initiatives, as well as individual schools, teachers, parents, elected Mayors, public health officers, social workers and health visitors all doing their own little bit, and while that is all incredibly worth while, no one knows what the other is doing. The approach is taken on the basis of good intentions, but it is far from being an effective plan to deliver any measurable results.

This issue should be a governmental and departmental priority, regardless of Brexit and the noises off. This crisis has nothing to do with Brexit and everything to do with the lives of our children, yet there is no plan that co-ordinates a national strategy to make dealing with this issue a priority, and there is zero leadership from the top—I am very sad to say that. A national crisis requires leadership and a holistic, co-ordinated headline plan. Tackling this problem needs to be one of the Government’s top five priorities, and that needs to include funding.

The Minister is very much doing his bit, in line with the Government’s obesity plan. That is a great achievement, but sadly it is nowhere near enough to tackle the problem. The Minister is a good, conscientious and pragmatic man, and the father of healthy and very beautiful young children. I know that he personally is as worried about this as anyone else, but he is just one Minister in one Department, although I accept that his is the Department that should be leading on this, in accordance with the Government’s aims and objectives in this area. However, if we had some high-level leadership and direction, we could have all the Departments working together towards one strategy and working together as one taskforce to establish our short, medium and long-term goals to reduce the weight of the nation and in particular of our children.

In fact, the Minister is the only person who is accountable for tackling this national crisis. As “Off the Scales” highlights, there is little or no direct accountability among Departments for the childhood obesity plan, other than the Department of Health and Social Care and a small requirement on the Department for Education. What about the Ministry of Housing, Communities and Local Government? What about the Department for Digital, Culture, Media and Sport, given that sport is one of the biggest players in the fight against obesity? What about the Department for Environment, Food and Rural Affairs, the Department for Transport and the Treasury? We know that the Treasury is the place where all good ideas go to die, regardless of which party is in power, and it is not giving this national crisis serious consideration. So many people—from the wonderful staff at Shillington Lower School all the way up to the Department of Health and Social Care—are doing their own thing, but, sadly, none of this can be monitored or measured, because it is all entirely disjointed and unconnected.

The NHS has recently enjoyed a £20 billion cash injection. At present, only 0.2% of the NHS budget is allocated to Public Health England to deal with obesity and to put in place preventive strategies with regard to childhood obesity, yet the Government’s plan places huge responsibility on Public Health England to tackle this issue.

[Dr Caroline Johnson]

Does my hon. Friend agree that money spent on managing obesity is money well spent? In fact, the money that is invested in helping people to be more healthy will be recouped, because there will be less NHS spending on their ill health.

[Ms Dorries]

I think that my hon. Friend has seen my speech; my next point is that we are putting the cart before the horse.

There is a huge responsibility on Public Health England, yet it has only 0.2% of the NHS budget. The Government have reduced the public health budget by £600 million between 2015 and 2018 and increased the NHS budget for acute and hospital care. This complements my hon. Friend’s point, because they are pumping all that money into hospitals and acute care, but putting very little into strategies to prevent people from going into hospital in the first place. This imbalance in the NHS budget demonstrates how little attention and importance are being given to this crisis at the top of the Government by No. 10 and No. 11—particularly No. 11 and the Treasury.

As I said, the cart is being put before the horse. As a nation, we are allowing people to become ill. We are failing to prevent that from happening, but we are providing state-of-the-art hospitals and doctors in our amazing NHS to treat them. We should be placing our focus on preventing obesity, which is the second biggest preventable cause of cancer after smoking, and keeping people out of hospital.

Of all the nations that fund healthcare, we have one of the highest healthcare budgets in the world. We spend more each year on treating obesity and diabetes then we spend on our police, our fire service and our judicial system combined, yet we allocate only 0.2% of the NHS budget to Public Health England. When we cost out Public Health England and take out its accountable costs, we see that only a tiny fraction of that 0.2% is given over to obesity prevention and treatment in real terms. The chasm between treatment and prevention highlights the critical need for the Government to develop their approach to the delivery of public health services further and to ensure that prevention receives the investment it so desperately requires.

It is time for the Treasury to think forwards, not backwards, by reversing the reduction in councils’ public health budgets and providing local councils with the funding they need to tackle this problem head on. Local councils should be the major player in this strategy, yet they have seen their funding for public health services cut. They know their own demographics. They know the problems in their area, and they know how to deal with them. Local councils have already engaged as much as they can with this issue, and they are saving the lives of the next generation.

I cannot say it often enough or strongly enough: one in four children will die younger than their parents. If we lined up 50 parents and told them that figure, they would be shocked. Parents needs to know that information.

How much of the new £20 billion that the Government are allocating to the NHS will be made available to Public Health England and, in turn, towards funding the Government’s childhood obesity plan of 2016? As much as people scream and shout that the NHS is being starved of funding, the truth is that the recently announced £20 billion, along with savings from the £20 billion Nicholson challenge, amounts to a £40 billion uplift to treat people who are taken to hospital with illnesses induced by obesity.

Given that Public Health England has been given responsibility for decreasing the proportion of children leaving primary school overweight over a 10-year period, why is so little of the NHS budget allocated for preventive medicine? What uplift was PHE given to address this childhood obesity crisis? How is it supposed to achieve the aims and objectives set out in the 2016 plan? Does the Minister not believe that there should be a cross-departmental strategy, devised by Ministers, to set out in detail what each Department will do to achieve pre-determined goals? If that is not the case, we should engage in a national information and media drive to warn parents of the dangers of obesity. Allowing a child to become obese is almost as dangerous as putting cigarettes in their mouth.

I understand why the Department of Health and Social Care introduced a policy to cap the calories in various types of junk food, but it will not work—people will buy two. The voluntary sugar reduction targets in the 2016 plan have not been met by the main producers and providers of these foods.

Is it not time to introduce a mandatory approach? I am aware that the money raised by the sugar levy—I probably should have mentioned this earlier—is to be allocated to implementing some of the aims and objectives set out in the 2016 plan, and the Government’s approach is a welcome step, but where and to whom will that money go? Will it be allocated to local councils? Is it enough?

As we have seen with food producers that are not meeting the requirement to reduce sugar in food, will the same happen with the sugar levy? Will it actually make a difference? Will it give us the funding that we need to tackle this crisis? I would say not, because we are basing our plans on something subjective and unknown. We do not know how much the levy will raise. We do not know whether producers will reduce sugar in drinks and food. We do not know to what degree the sugar levy will work. As this is such a crisis, should we not be looking at more quantifiable measures?

Where will the money go? Is it not time to consider the recommendations of the Centre for Social Justice and develop a frontline approach? I cannot think of any Government policy on which all Departments work together and on which there is a non-political taskforce above the Departments run by an independent body to pull together policies from each Department to tackle an issue—that goes entirely against our culture—but that is what we need. Should we not work with companies that load food with sugar and set them mandatory goals, not voluntary goals, to reduce the amount of sugar over a period of time? Should we not introduce financial penalties? We have seen producers of products such as breakfast cereals do just that, but the problem is that it is not happening fast enough, it is not consistent and it is not equitable, because only some producers are doing it.

Only by adopting a long-term approach that is nationally led and locally driven, with the councils involved and heading it, that is overseen by an independent body outside the influence of party politics and that is championed by committed political, cross-party leaders will an effective childhood obesity plan ever be delivered. I do not want to chuck a bucket of cold fizzy drink over the Minister’s 2016 plan, because it is a great initiative and I hope it will make some difference, but I hope he understands my concern that the money just is not there to tackle this problem head on now. I go back to the substantive point in what I have just said: 0.2% of the NHS budget going to Public Health England, despite the sugar levy and the taxes we are going to raise, is just not saying, “We are committed to doing this,” and the money has to go to local councils.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

Let me start by reiterating what my hon. Friend the Member for Mid Bedfordshire (Ms Dorries), my good friend, has said: childhood obesity is one of the top public health challenges for this generation, if not the top one. I thank her for mentioning my two beautiful children—we are not sure where they get it from, although undoubtedly it is Mrs Brine. They are watching us right now, so for once I shall be useful to Mrs Brine and say, “Surely it must be time for bed after you’ve seen daddy.”

As Members will be aware, figures released only last week in the national child measurement study continue to show that our child obesity rates remain far too high. About a fifth of children are overweight or obese when they start primary school, and that rises to about a third by the time they leave. What is worse, as we have heard, is that the burden of obesity does not fall evenly across our society. The number of severely obese children living in the most deprived areas is more than four times that of those living in the least deprived areas—this is one of the burning injustices of our age. The effects of obesity have a profound impact on a child’s opportunities in life—on both their physical and mental health. We know that obese children are more likely to be bullied and have low self-esteem as a result. They are also more likely to become obese adults, which will give them a higher chance of developing certain types of cancer, type 2 diabetes, and heart and fatty liver disease.

So the Government are determined that we will lead the way in tackling childhood obesity. We have already heard from my hon. Friend about our 2016 childhood obesity plan, part 1—there was a clue in the title—and I agree with her that it is a good plan. It introduced bold, world-leading measures, such as the sugary drinks levy. I was in Argentina at the G20 earlier this month, giving a presentation about the work we are doing in this area. Many other countries around the world look to what is happening in England and are copying it. Since bringing in the levy, we have seen the equivalent of a staggering 45 million kg of sugar taken out of soft drinks through reformulation. As a result, hundreds of millions of pounds have been poured into improving opportunities for physical activity for children. My hon. Friend asked where the money was going—that is where it is going. It is going into the sport premium in schools. The Treasury has kindly agreed to double that sum. I will expand on the point about where it is being spent. She mentioned one example, but I have others.

We also challenged manufacturers to reduce the sugar content in some of the foods children eat most, and they responded. Tesco, Lucozade Ribena Suntory, Kellogg's, whose people I met this afternoon, Waitrose and Nestlé are just some of the companies that deserve credit and deserve a mention, as they are dramatically lowering levels of sugar in their products.

[Dr Johnson]

Will the Minister give way?

[Steve Brine]

Very briefly, because we do not have long.

[Dr Johnson]

I have a quick question: are these manufacturers of food and drinks products removing the sugar and making the products less sweet, or are they replacing the sugar with artificial sweeteners?

[Steve Brine]

They are doing both. As the representatives from Kellogg’s were at pains to say to me today, it is about healthy eating and quality taste. I passionately believe that that is true.

We were always clear that our 2016 plan was just the start of the conversation, and we are clear that more needs to be done. We always said that we reserve the right to do more, which is why in June this year we published chapter 2 of the child obesity plan. My hon. Friend the Member for Mid Bedfordshire asked whether there is a cross-departmental strategy; yes, chapter 2 is very much a cross-departmental strategy. It sets a bold ambition—what we like to think of as a north star—to halve child obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030. As with our initial plan, the new policies were informed by the latest research and emerging evidence, including from many debates in Parliament and various reports from key stakeholders. Those stakeholders include the Health and Social Care Committee and, yes, the Centre for Social Justice. In fact, the latter’s “Off the Scales” report is on my coffee table in the Department. It was the Centre for Social Justice that told me all about Amsterdam and it is because of it and its good work that I went to Amsterdam to see the work being done there.

Key measures in the next chapter include looking to address the heavy promotion and advertising of food and drink products high in fat, salt and sugar on television, online and in shops. Alongside that, we want to equip parents with the information that they need to make healthy and informed decisions about the food that they and their children eat when they are out and about.

My hon. Friend mentioned Brexit. Of course, there is never a debate in which we do not mention it, but there is a Brexit connection for this debate. One thing that campaigners call for is traffic-light labelling on the front of products. We are unable to do that while we are an EU member state, but once we are no longer, we will have new freedoms in that regard. I do not know whether that is what was meant by taking back control, but I put that on the record for the House.

I was pleased to hear of the efforts of Shillington Lower School in my hon. Friend’s constituency. Staff there are obviously doing all the right things to encourage children to take part in physical activity. I have seen great examples in my own constituency, most recently at Western Primary School, and I am sure that many other Members have seen good examples, too. Yes, it is about recognising that we need foods to be reformulated, but it is also very much about the importance of physical activity in tackling obesity. Yesterday, I opened a major physical activity and health conference across the way at the Queen Elizabeth II centre. It is going on all week and will consider the benefits of physical activity and health. As part of chapter 2, we are promoting a new national ambition for all primary schools to adopt the initiative of an active mile—or healthy mile; people call it different things.

I agree with my hon. Friend that achieving our ambition to reduce child obesity will require a concerted effort from many others, including families, schools and local authorities, which she mentioned. At the recent Local Government Association conference, I announced the trailblazer programme, which will work closely with local authorities to show what can be achieved and find solutions to barriers at a local level to address child obesity. I took great inspiration from what has been done in the city of Amsterdam. My hon. Friend is absolutely right that local authorities know their local areas best. By sharing ideas with each other—some very good things are going on—they can achieve the full potential of the powers and levers that they have. Many local authorities already have great powers and levers to change their areas. For instance, they have powers over junk-food advertising in the areas around schools. We want to see those powers used better.

As part of the second chapter, we have already launched the consultation on banning the sale of energy drinks to children—the message is clear: we do not think that they are appropriate for children—and the consultation on calorie labelling for food and drink served outside the home, or in the out-of-home setting, as they say. Later this year, we will launch consultations on restricting the promotion of fatty and sugary products by location and by price, and we will consult on further advertising restrictions, including a 9 pm watershed on high fat, salt and sugar products. Currently, products deemed HFSS are banned from being promoted only during programmes predominantly aimed at children. We will consult on taking that through to a 9 pm watershed. That work is with the Department for Digital, Culture, Media and Sport, the sugary drinks levy—the sugar tax—work is with Her Majesty’s Treasury, and the trailblazer programme work is with the Ministry of Housing, Communities and Local Government, so I gently reject the idea that this is not a cross-Government strategy. These consultations are genuine and are open to everybody, and we welcome full and considered responses from across society and industry.

So far as the future is concerned, we continue to learn from the latest evidence; my hon. Friend mentioned evidence. The Policy Research Unit informs us all the time of new approaches from across the UK. We welcome the action taking place in Scotland, which is consulting on its own obesity plan at the moment. It is good to see that many of our ambitions align. As I said, I often talk to partners in other countries about work going on internationally—I have mentioned Amsterdam a couple of times—and about where we can learn from them and, possibly, where they can learn from us..

My hon. Friend is also right to mention the additional £20.5 billion a year for the NHS that will support the new long-term plan. I cannot pre-empt what the NHS will put into the plan—the Prime Minister set NHS England the challenge of writing it—but we have been clear from the outset, and the new Secretary of State has been clear, that prevention should be a key part.

Our ambition is bold but simple. We have a lot to gain by reducing obesity, and we have an awful lot to lose. We believe that the hard, evidence-based actions that we propose will encourage healthier choices and will make those choices more readily available and identifiable to parents. Taken together, we are confident that those actions will have a real impact on child obesity. We will continue to monitor progress and emerging evidence. As we have always said, this is not the end of the conversation. We watch things like a hawk.

Finally, I reiterate my thanks to my hon. Friend for securing the debate, and to you, Madam Deputy Speaker, for facilitating it.

Question put and agreed to.

Dangerous Waste and Body Parts Disposal: NHS

Caroline Johnson Excerpts

Tuesday 9th October 2018 Commons Chamber

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

I welcome the fact that there has been no gap in service provision and no public health risk and that the Minister has confirmed that nobody’s operation has been delayed because of this build-up of clinical waste, but it is still concerning that the contract was not properly delivered. How long has he given the site to return to compliance and what action is he taking to supervise the remaining contracts?

[Stephen Barclay]

The key issue for performance under the contracts is what, contractually, the legal requirements on HES are and whether those contractual terms have been breached. Part of the lessons learned is to look at whether contractual enforcement powers are sufficient. In terms of moving forward in respect of the other HES sites, that will depend on the contracts that the supplier has and whether it is in breach of those contracts or of enforcement action from the Environment Agency. To date, the Environment Agency has served one partial suspension, on the Normanton site. As I referred to, the Environment Agency was at the other site over the weekend. This is an area of significant scrutiny, but it will be for the Environment Agency to determine whether the company is not in compliance with its permits.

Baby Loss Awareness Week

Caroline Johnson Excerpts

Tuesday 9th October 2018 Commons Chamber

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

I wish to join my colleagues in commending the Members who have so bravely recounted their own experiences of baby loss here tonight and at last year’s baby loss debate. As many have said, the loss of a baby is one that no parent should ever have to bear. I am fortunate not to have suffered such a loss, but as a children’s doctor I have, unfortunately, been the bearer of such bad news on too many occasions.

In my experience, the first reaction of a parent confronted with the tragic death of a baby is to ask, “Why? Why did this happen? Why my child? Why me?” In these agonising circumstances, answers as to why this situation has occurred can help to provide respite. The second reaction, one that is testament to the incredible empathy human beings have, even in the most difficult circumstances, is the desire to ensure that lessons are learned from their personal tragedy so that no one else has to endure that same heartbreak. I am in awe of colleagues, such as those here this evening, who have been through such a traumatic experience and found the strength not just to share that experience, but to use it to campaign successfully for improvements in care and to highlight areas to improve so that others do not experience such suffering in the future. I commend the work of the all-party group and my hon. Friends the Members for Colchester (Will Quince), for Eddisbury (Antoinette Sandbach) and for Banbury (Victoria Prentis) for their work to develop the bereavement care pathway. I have worked in hospitals where there has been excellent bereavement care, with the bereavement suite that has been described, and in others where the care has been less well developed, and I have seen the importance of the national bereavement care pathway. I congratulate them on it.

Although he is no longer in his seat, I also congratulate my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) on his private Member’s Bill, which has developed child bereavement leave. As my hon. Friend the Member for Colchester has said, it will enable mothers to have an extra two weeks of maternity leave and fathers to have a doubling of their leave—some extra time to reflect and be at home with their family.

One recent improvement that the Government have made is the introduction of independent investigations by the Healthcare Safety Investigation Branch, which will look at every case of stillbirth or life-changing injury. That will help to meet the needs of parents in respect of that first question—“Why did this happen?”—and to prevent it from happening again. When the lessons are disseminated throughout the health service, doctors and midwives will be able to learn from previous experience to ensure that problems do not occur in future. It will be important—I look to the Minister to respond on this—to ensure that health professionals can speak openly in investigations without fear of blame. A blame culture will deter people from speaking openly and prevent improvements to patient safety. I have spoken numerous times in the Chamber about patient safety, and I am hopeful that the national roll-out of investigations will help us to meet the NHS’s goal of becoming the safest healthcare system in the world in which to give birth.

One development in neonatal care that I have seen in my 17 years of practice is the increasing centralisation of neonatal care, with the smallest and sickest infants now transported to specialist centres. I have worked in these centres and, although they provide exceptional care, they are often many miles away from the hospital where the child was first admitted or where the family live. For example, if a baby’s family live in Sleaford and North Hykeham, their nearest tertiary centre is in Nottingham. If the centre in Nottingham is full, the family may be sent many hours away to Norwich, Sheffield or Leicester. For working families on low incomes, the need to visit their sick baby several hours away imposes significant travel costs. Some families go through intense financial difficulty to meet that need to travel, while others have the distress of being physically unable to travel to see their baby as often as they would wish because they do not have the money to get to the tertiary centres. I raised the very same issue in the debate last year and would be interested to hear an update from the Minister on any measures being taken to help struggling families, many of whom work, to meet the travel costs in such an extremely distressing situation.

[Tim Loughton (East Worthing and Shoreham) (Con)]

My hon. Friend makes a good point about safety. In respect of smaller hospitals retaining maternity services, some years ago there was an attempt to downgrade Worthing Hospital and St Richard’s Hospital, such that they would lose their maternity departments and the service would be centralised in Brighton or Portsmouth. Fortunately, we defeated those proposals, and Worthing maternity department is now rated outstanding. It is also rated as the safest maternity department in the country; indeed, many mums now come from Brighton to Worthing because of its success. There is clearly a case for larger specialised hospitals for particular ailments and problems that need specialist treatment, but in most cases we need a good-quality, safe and trusted maternity service closer to where the parents live.

[Dr Johnson]

I congratulate the hospital in Worthing for its outstanding success. My hon. Friend is right that there is a balance to be struck between the centralisation of care for babies who require very low-volume but high-specialist care, and the need for care to be delivered as close as is reasonably practical to the individual family concerned. That is true of all medical specialties, really. In the case of neonates, we probably have the balance roughly right, but a trend may be starting whereby people ask for things to be centralised that in my perception do not really need to be centralised. As a professional, I often see babies who are not returned to the step-down care as quickly as they could be. Babies are sometimes kept in the tertiary centres for longer than is absolutely necessary. There are complex reasons for that, but I would be grateful if the Minister looked into the issue so that babies can be returned closer to home as soon as possible.

I welcome the Government’s ambitious aims to halve the rate of stillbirths and neonatal deaths by 2025. That will be possible only by reducing the number of pre-term deliveries, which are the leading cause of neonatal death in the UK. The Department of Health and Social Care’s goal of reducing pre-term birth from 8% to 6% will require a lot more research and intervention. We have a healthier population of women, but the number of pre-term babies continues to increase. More funding is needed for pregnancy research, and particularly for research into the causes of pre-eclampsia, cervical length and infections such as group B strep, as well as for the identification of small babies with early scanning. There must also be more work to discourage smoking, which we already know is an established risk factor for pre-term delivery. I welcome the previous Secretary of State’s saying in November 2017 that the Government will reduce smoking during pregnancy from 10.6% to 6% and raise awareness of foetal movement. All those things will contribute towards the reduction of the number of neonatal deaths and stillbirths. Through that work, the Government are best placed to meet their “halve it” aim, and in doing so save 4,000 lives.

Finally, I wish to discuss those babies who die in the post-neonatal period—that is, under the age of one but after 28 days of life. Currently, 1.1 in every 1,000 babies die in the post-neonatal period. The major reason is babies having congenital malformations, and the second most common reason is sudden infant death, the rate of which has recently increased, although the cause is not clear. What is the Minister doing to identify the reasons for the recent increase in sudden infant deaths? What is being done to prevent the number of sudden infant deaths from rising further and, indeed, to bring it down?

Oral Answers to Questions

Caroline Johnson Excerpts

Tuesday 24th July 2018 Commons Chamber

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

14. What steps he is taking to reduce rates of childhood obesity.

[The Secretary of State for Health and Social Care (Matt Hancock)]

We published the second chapter of our world-leading childhood obesity plan on 25 June. It builds on the progress we made since the publication of chapter 1 in 2016, particularly on the reformulation of products that our children eat and drink most. We will continue to take an approach that is based on evidence and we are determined to act.

[Matt Hancock]

I pay tribute to my hon. Friend’s work at the Department for Digital, Culture, Media and Sport on this matter. It is critical that we have a cross-Government approach. The obesity plan is led by the Department of Health and Social Care, but it is a cross-Government plan. There is a whole range of actions we need to take—from education through to culture and broadcasting—to make sure we get it right.

[Dr Johnson]

One of the reasons why tackling obesity in children is so important is the fact that it has such long-term detrimental effects on health. Now that the Government have published chapter 2 of their childhood obesity strategy, will the Secretary of State outline how it will have a long-term impact on children’s health and tackle issues such as diabetes and heart disease?

[Matt Hancock]

My hon. Friend is absolutely right that obesity, especially in children, is one of the underlying conditions that often leads to much worse long-term health conditions. Some 22% of children aged four and five in reception are overweight or obese; that number is too high and we have to act.

NHS Trusts: Accountability

Caroline Johnson Excerpts

Tuesday 10th July 2018 Commons Chamber

[Sir Mike Penning]

I agree almost completely; I would just say that sometimes these people do not even leave the NHS—they stay within the structure of the NHS, but just go to a different trust in a different part of the country. Then they just reappear again and again.

I have often wondered about something. A director of nursing should clearly have come up through the nursing ranks; I understand that. Clearly, also, clinicians have to be involved in the clinical side. But why does NHS management have to be completely incestuous in how it works? If someone started as a nurse or doctor, how on earth do they have the necessary qualifications to run a massive multi-million pound organisation? Yet that is how it seems to happen. It took a long time for Mr Ron Glatter to get the figures when he was challenged. When we eventually got them, it was like pulling teeth: was it a package or a salary? “This is personal information.” This is taxpayers’ money. One of the most difficult things is to find out exactly where the money is going.

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

My right hon. Friend mentioned nurses, doctors and other clinicians taking on managerial roles. To what extent is that driven by a desire to reduce the number of managers in hospitals—to call them “nurse managers” and claim they are nurses when they are actually fulfilling a management role?

[Sir Mike Penning]

My hon. Friend brings great expertise to the debate, and I thank her for joining us. She is absolutely right. I declare an interest: my mother was a nurse in the days of “sister” and “matron”. Then there were nurse managers and other managers—all of a sudden, we went that way, but we seem to be coming back again. We can change the name on the Titanic, but it is still the Titanic: a manager is a manager, no matter what title we put on them.

It seems to me that we are not reducing the number of managers. I vividly remember that there were 11 primary care trusts in the Dacorum area of my constituency. Then the number reduced to two—one, actually, because there was only one director of finance. When we looked at the head count, the cost analysis, which should have massively reduced, it had actually gone up.

I want clinicians to be involved in the day-to-day care of my constituents, but I am not convinced that a GP should chair a clinical commissioning group, especially given that in most cases they do not seem to be full time in the role. What qualifications do they bring? I know that GP practices are much more business-orientated now than ever before, but they employ practice managers—the partners do not run things.

More recently, there has been an understandable concern in my constituency about the proposed closure of one of the facilities called Nascot Lawn; it is not in my constituency, but was playing a vital role in looking after the most vulnerable children in my community. Brilliantly, the families and loved ones came together to challenge the closure. They got the MPs on board and we were involved. I then scratched my head and said, “Hold on a second, I remember being told that Nascot Lawn was going to provide the respite care for my constituents when they closed a place called Woolmer Drive.” Woolmer Drive was a desperately needed respite centre where young people could go, and where their carers and loved ones could spend a bit of time. So not only did Woolmer Drive close, which meant that patients had to go to Nascot Lawn, but Nascot Lawn was closing. That was challenged, but there was very, very little consultation.

I will talk about consultations in quite a lot of depth. Frankly, most consultations are a sham. The decisions are made before they consult. They make the decision to close, put it in their budgetary regime and then consult. They then come out and say, “We’ve listened to the consultation and we are going to ignore you.” So what is the point of the consultation?

--- Later in debate ---

[Sir Mike Penning]

I was coming on to that point, but let me meet it head on now. I speak to nurses and other frontline staff who look after my local patients, including some doctors, and they are petrified of telling their own MP what is going on in case of retribution. Perhaps the Minister will help me to get to the bottom of the number of gagging orders out there at the moment in my trust, whereby things have been settled and people have been gagged. The types of threats in the gagging orders that are put on them are very severe.

There was a consultation panel in my constituency about the future of health, and the people allowed on the panel had been gagged. These are members of the general public who have been told categorically not to talk to me. They are not to tell me what is going on in the NHS in my own local community. They will be thrown off the panel if they do, and it is worse for the staff who have gagging orders against them. This is very serious.

We see the amount of money the NHS uses in litigation, whereas our patients have to raise money themselves. The NHS seems to settle very easily when there are threats against it relating to malpractice or when something has gone wrong at the trivial end of things, but when things are really serious and deaths have taken place, down come the shutters. Nationally, we have seen what happens—it has happened recently in Gosport and in Staffordshire when I was a shadow Minister—unless the staff have 100% confidence that they can go to their MP or their line management and tell them what has been going on. Sometimes it can be quite trivial, but often it is very serious, and there is clearly retribution against them should they do so. That is something we need to sort out.

[Dr Caroline Johnson]

It is extremely important that all health professionals in hospitals are able to report any concerns that they have. I understand that there is to be a whistleblowing champion for each trust. What does my right hon. Friend know of those, and does he think they will help?

[Sir Mike Penning]

It is all well and good saying that there should be, perhaps in legislation, but unless people have the confidence that their career is not going to be curtailed, or unless they are close to retirement and are not going to put their pension at risk, they are not going to blow the whistle. What really upsets me is that although I was sent to this House to represent people and for them to be able to tell me, in confidence, anything that they needed to, so that between the two of us we could discuss how to take it forward—often without using their name, but if necessary we can—that is not happening. That really worries me an awful lot.

To go back to Nascot Lawn, we went to a judicial review. We have done that before in our part of the world. The judge sided with the patients, but all that happened—it was about process, of course—was that it went back to the CCG, which turned around and said, “We will consult slightly differently. We will address what the court said, and by the way, we are going to go ahead and do it.” It is a sham, and we should be honest about that in the House.

When we tried to prevent our acute hospital from being closed—I pay tribute to my community for that—we did everything in the world. We got a coffin on a trolley, and thousands of us pushed it from my A&E that was going to close to the nearest one at Watford hospital, which it was proposed people should go to, in order to show just how much passion there was. We managed to get the money together to go to judicial review—a lot of money; in excess of £60,000—and the judge said, “You have a moral case. You have an ethical case. I agree with you, but you don’t have a case in law because all the powers are with the trust and the PCT”, as it was then. I ask the Minister: how can it be right that people must be so concerned, not just in my constituency but elsewhere?

Lastly on this part of my speech, let me talk again about what happened when we lost our A&E. I have raised this in the House before, so the Minister knows what I am talking about. To go back a bit further, St Albans, Hemel Hempstead and Watford are covered by West Herts, and at one time all three had A&Es. We are a massively growing population. The largest town in Hertfordshire is Hemel, which will have a projected 20,000 new homes in the next 20 years. St Albans is expanding, and so is Watford. There was a consultation, but the public were ignored. The A&E was closed and made into an elective surgery facility in St Albans. The public promises to the people of St Albans were that Hemel’s A&E would look after them. It is not a particularly long ride—it is clearly not in St Albans town centre, but that was going to be that. However, a few years on, those responsible said, “Let’s shut Hemel’s A&E and move it to Watford, because that can look after West Herts,” so the promises went out the window. The public went mad in St Albans and in our area. They were all on the streets, and what did we get? An urgent care centre, some out-patient services and a fracture clinic. Really and truly, that is all that is left in Hemel.

[Sir Mike Penning]

That is absolutely what I hear every day in my constituency. I also hear, “What are you going to do about it, Mr MP? Get off your backside and do something about it!” I am doing everything I possibly can—I am meeting Secretaries of State and trusts—but what happens? I get ignored, because I have no powers at all; it is all in the hands of bureaucrats.

[Dr Caroline Johnson]

We have a similar situation in Grantham A&E, which serves my constituency. My hon. Friend the Member for Grantham and Stamford (Nick Boles) and I have been working to try to get Grantham A&E reopened around the clock since it was closed without consultation in August 2016.

[Sir Mike Penning]

If the A&E was closed without consultation, that is illegal. I think the Minister will confirm that it is illegal to make major changes to a community’s health provision without consultation.

Hemel Hempstead A&E closed after a bogus consultation, and everything moved to Watford. We were promised that it would all be okay, and that we would have a 24-hour urgent care centre manned by GPs. Let us go back to just before Christmas 2016. There had been chaos—and I mean chaos—at the acute admissions unit in Watford hospital, which has just recently come out of special measures. All the ambulances were getting held up in big bottlenecks at the A&E at Watford. The big, new, bright idea was that we would close the urgent care centre that had replaced the A&E in Hemel Hempstead, and that that would be okay.

I had a meeting with the chief executive of the trust, who told me, “Mike, we are only doing this on safety grounds, because we cannot get the GPs to cover the hours.” That was really surprising to me, because there is a GP drop-in centre in the next room—not across the other side of town or even in a different part of the complex, but in the next room. I was told, “That is a different contract. We can’t touch that, mate; it’s nothing to do with us.” The chief executive said to me, “Don’t worry, Mr Penning, we can’t close the 24-hour service, because we have not consulted. This is just a temporary, emergency measure.” She went on the local radio station—I did not ask her to do that—and reiterated exactly what she had told me. In fact, she went further and said that the centre would be closed for only a couple of months and that it would reopen, because it would be categorically illegal to change the hours without consultation.

Reducing the hours of an urgent care centre—which used to be an A&E—from 24 to 10 is a major thing. Eighteen months later, the trust consulted on a proposal to turn the 24-hour urgent care centre into an urgent treatment centre, which would shut at 10 pm. Perhaps the Minister can explain to the general public the real difference between an urgent care centre and an urgent treatment centre, because I struggled to do so. I know that there is a methodology within the Department, but all that Joe Bloggs, my constituents, saw was a downgrading.

By the time of the consultation, the centre had already been closed for 18 months, so what choice did we have? We could not rewind the clock 18 months. The trust misled us by saying that the measure was temporary. The chief executive promised me that to my face, and she repeated that promise on the local radio station. That commitment was not worth the paper it was written on—or rather the voice that spoke it. My constituents have suffered a massive loss of trust in brand NHS. Their trust has been decimated, because promise after promise has been broken.

Naturally, the vast majority of consultation responses —do not quote me on this, but I think it was about 80%—said that the centre had to be open 24 hours. Guess what, Madam Deputy Speaker? It is not. It has been renamed an urgent treatment centre, and it closes, allegedly, at 10 o’clock at night. Within the last few days, however, a very senior person in my constituency whom I trust implicitly saw someone collapse outside the centre at approximately 9.30 pm—half an hour before it was supposed to close—but the doors were locked. It was only because a member of the public opened them from the inside that the patient was seen. The doors were not opened by the NHS staff who were inside, even though they must have known that the patient was there. I hope and pray that she is okay.

I am now told that the doors are regularly locked at any time after 9 pm. That is disastrous for my constituents when they turn up there, but many of them simply do not trust the centre to be open at night. What is going on? Naturally enough, although sometimes inappropriately, they go to the A&E at Watford, which is causing it even more of a problem—but can we get anyone to listen? No, we cannot.

Watford General Hospital is in the middle of Watford, next to a football club about which a great many of my constituents are passionate, Watford FC. It used to be the home of Saracens, and I am passionate about them as well. The hospital was built in Victorian days, and the best way to describe it is “not fit for purpose”. The people of Watford will probably say, “Please do not run down the hospital, because it might be closed”, and I fully understand that, but the truth is that we all need a new hospital.

Although, as we heard earlier from my hon. Friend the Member for Redditch (Rachel Maclean) about her area, the population is growing massively, we are now supposed to listen to the management telling us what they are likely to provide. I have attended meetings with the Secretary of State and NHS Improvement about the applications from my local acute trust and clinical commissioning group, and it petrifies me that yet again they are not going to listen—I do not mean to me, or to the Minister, who knows that he has no powers and will be treated with the disrespect that I often receive; they just ignore us—but to the people whom they are supposed to be serving, and who pay their wages out of their taxes.

I am not a clinician, although I was a paramedic in the armed forces and I know a little bit, but surgeons, GPs and frontline senior nursing staff have been speaking to me privately. It is fundamentally wrong and dangerous to keep saying that Watford can cope with the ever-growing population of west Hertfordshire.

I have met representatives of NHS Improvement with a delegation from my hospital action group, led by the brilliant Betty Harris, with Edie Glatter and her team, Jan Maddern and others, and we have joined forces with a separate campaign from St Albans. We were promised that the NHS management, as they looked at the applications for healthcare regeneration in my part of the world, would ensure that the CCG and the acute trust had more than one option on the table, rather than just ploughing more money into the Victorian hospital. I know that there have been conversations about a greenfield site, which is owned by us because it is Crown Estate land. It is by the M1, close to the M25, between St Albans and Hemel Hempstead. It is perfect for an acute facility—the infrastructure could not be bettered—but I think we are being ignored again. I cannot prove that, but it is my gut feeling, and it is certainly the feeling of the thousands of people in my constituency.

I am a loyal member of the Conservative party. I was a Minister for seven years in seven Departments, and I was on the Front Bench in opposition for four and a half years. I have to ask myself why I am supporting a Government who are allowing my constituents to be ignored. The Minister must not take this personally, but the present situation is crazy. The Department of Health and Social Care—I was not in that Department, but I have been in many others—actually has very little control over what is going on out there in our wonderful NHS. We have inspections, my local hospital goes into special measures and then comes out of them, it gets into debt and then comes out of it. However, the truth in my part of the world is that if NHS management are not accountable to Ministers or to me as their MP—and, much more importantly, are not accountable to the people whom they are supposed to be looking after—we have a serious problem. If my constituents cannot come to me and express their concern about what is going on in the NHS, there is a serious problem with our democracy, and that is something that I cannot live with.

--- Later in debate ---

[Stephen Barclay]

I beg to differ from my right hon. Friend on that, because this gets to the crux of the issue. The NHS must evolve. It has to move with technology and with the skills mix. Alongside the significant funding injection that the Prime Minister announced at the Royal Free Hospital, the NHS must also deliver productivity. At the specialist level, such as oncology or neuroscience, we often have populations of 3 million that need to be treated. Look at the footprint of the Christie NHS Foundation Trust, for example.

If we look at the other end, we need to deliver more care in the home and not have acute trusts soaking up so much investment. We need dynamic reconfigurations without acute trusts being the sole focus of our attention. We need service changes but—this goes to the core of my right hon. Friend’s remarks—they must be taken forward with clinical leadership and in a way that delivers trust.

I am happy to continue to engage with my right hon. Friend’s specific allegations on a case-by-case basis.

[Dr Caroline Johnson]

The Minister talks about dealing with things on a case-by-case basis, so I wonder whether he will consider Grantham’s A&E, which has had to close overnight for nearly two years, to see what can be done to facilitate its reopening as soon as possible.

[Stephen Barclay]

Again, I am happy to consider that issue. I have been up to visit the United Lincolnshire Hospitals NHS Trust and have met the chief executive and the leadership team, so I am aware of the issues, which are partly due to geography. However, we are straying slightly away from Hemel Hempstead.

As I said, I am happy to engage with my right hon. Friend the Member for Hemel Hempstead on his specific allegations. It is important that service changes are done at the local level with clinical leadership in a way that builds trust, and I will continue to engage with him in the weeks and months ahead.

Question put and agreed to.

Gosport Independent Panel: Publication of Report

Caroline Johnson Excerpts

Wednesday 20th June 2018 Commons Chamber

[Mr Hunt]

I thank the hon. Lady for her comments. I do not want to jump to a conclusion about any changes to the draft Bill. However, we should definitely reflect on any legislative changes that might be needed as a result of this report, and that Bill could be a very powerful vehicle for doing so.

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

My right hon. Friend has mentioned trust, and as a doctor myself, I am very aware of and humbled by the fact that people come to me with their children and put their trust in me to look after them. When events such as this occur, trusts can be shaken, and it is therefore important that these things are dealt with quickly. In this case, the investigation, since complaints were first received, has been going on for far too long. What will my right hon. Friend do to reassure people that any such complaints will be dealt with much more quickly in future, and that opportunities to save lives will not be lost in the meantime?

[Mr Hunt]

That is the big question we have to answer for both the House and the British people. However, I would say to the hon. Lady that I am confident that, where there is unsafe practice, it is surfaced much more quickly now in the NHS than it has been in the past. I am less confident about whether we have removed the bureaucratic obstacles that mean the processes of doing such investigations are not delayed inordinately so that the broader lessons that need to be learned can be learned.