Learning Disabilities Mortality Review

Caroline Johnson Excerpts

Tuesday 8th May 2018 Commons Chamber

[Caroline Dinenage]

I completely hold my hands up. I am not trying to mislead the House in any way. It is an independent document and the University of Bristol decided when it was going to be published. It was published on Friday without permission from or any kind of communication with the Department of Health and Social Care. I do not know what communication the university had with NHS England, but no information was passed to us. The beauty of having an independent document is that it can be published when the organisation sees fit and the Government will have to respond to it.[Official Report, 9 May 2018, Vol. 640, c. 8MC.]

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

During my career as a paediatrician, I have seen huge improvements in the care of children and young people with severe and moderate learning disability, many of whom have survived into adulthood when that would not have been the case years ago. Owing to the association between severe and moderate learning disability and other medical problems that may limit someone’s lifespan, it is unlikely to ever be equal to that of the general population, but we should always ensure that the care of the most vulnerable in society is as good as it can be, and I welcome the steps that the Minister is taking to ensure that it is. Such people are cared for jointly in hospitals and in the community, so will she confirm that hospitals and community care will work together following such reviews?

[Caroline Dinenage]

This is something that my hon. Friend, as a healthcare professional, obviously knows an awful lot about. She is right that a person having the ability to communicate, understand and identify when they do not feel well is important. These annual health checks, which are available to children from the age of 14 and into adulthood, are important because they enable any healthcare issues to be disseminated and communicated much more effectively between different healthcare and other providers.

Breast Cancer Screening

Caroline Johnson Excerpts

Wednesday 2nd May 2018 Commons Chamber

[Mr Hunt]

Absolutely. As my hon. Friend will know from his own medical background, it is impossible to know that until there is a detailed case note review, but we will certainly undertake that review for anyone who thinks they may have been affected.

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

I thank my right hon. Friend for his statement and for the work he is doing to ensure that women who are affected are supported and treated promptly, but what is he doing to ensure that people who are due for cervical and other NHS screening programmes are being properly called, and can he tell women who are affected—and, no doubt, very worried today—what they should do now? Whom should they call, should they be waiting for a letter, and how soon can they expect a scan if they wish to have one?

[Mr Hunt]

According to the advice that I have received so far, there is no read-across to other screening programmes, but obviously the independent review panel will look into that as it seeks to examine all aspects of the issue. We have made the commitment today that we will invite for scans all those who either should be scanned or should consider whether they wish to have a scan, and will offer them a date before the end of October, although we hope that in the vast majority of cases it will be much sooner than that.

Patient Safety

Caroline Johnson Excerpts

Wednesday 28th March 2018 Commons Chamber

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

Before I begin my speech, I draw the House’s attention to my entry in the Register of Members’ Financial Interests.

Doctors become doctors to help make people better. Patient safety and improving patient care are therefore at the forefront of every doctor’s practice. Indeed, when I went for my consultant interview, I was asked to give a presentation on how I would demonstrate to the trust board that paediatric services in that hospital were safe, and my answer, of course, was, “How safe?” As safe as going to a football match? As safe as travelling on the tube? As safe as flying in an aeroplane? Those activities are safe, but, like patient care, nothing is ever 100% safe. We need to ensure that care is as safe as it possibly can be, and that there are processes in place to learn from mistakes. No party has a monopoly on wanting to make the NHS as good as it can be, and all of us know that the increasing demand and complexity would make healthcare a challenge for any Government.

During my career, there have been significant improvements in patient safety, the most important of which is probably the establishment in 2009 of the Care Quality Commission, with its Ofsted-like reports. By 2017, it had inspected every trust, primary care and adult social care provider, and it continues to ensure they are meeting the highest standards. We now also have the regular revalidation of professionals, reflective practice and case reviews, as well as child death overview panels, which review in detail all unexpected child deaths. New maternity systems have been developed that have resulted in clear progress, as seen in the 20% fall in the stillbirth and neonatal mortality rate in England between 2003 and 2013.

[Jeremy Lefroy (Stafford) (Con)]

I congratulate my hon. Friend on securing this debate. Does she agree that the changes to and strengthening of the CQC’s remit through the Health and Social Care (Safety and Quality) Act 2015, a private Member’s Bill passed with all-party support, represent one step on the long road to ensuring that patient safety and quality care is at the top of the NHS’s agenda?

[Dr Johnson]

I congratulate my hon. Friend on passing that private Member’s Bill, which has undoubtedly saved many lives.

I am proud to work in a health service that, just last year, was rated the best and safest healthcare system in the world by the independent Commonwealth Fund think-tank. To err is human: we all make mistakes. The consequences of a doctor’s error, though, are potentially catastrophic. Doctors live with that responsibility and, as a doctor, I live in fear of making a mistake because I do not wish for anyone to suffer harm.

[John Howell (Henley) (Con)]

My hon. Friend may have seen that the Medical Protection Society is asking for the bar to be lifted on criminal proceedings and for the General Medical Council to be shaken up a bit to improve its approach to dealing with this issue. Does she have any sympathy with that?

[Dr Johnson]

I will come on to that later, but I agree with my hon. Friend.

I have worked with at least two colleagues who made significant errors. Many lessons were learned and widely disseminated. Training was provided to stop recurrence, but neither doctor was prosecuted. Throughout my career it has been the case that, if a doctor does their best but makes a genuine error, they will not face criminal charges. Gross negligence manslaughter was seen to be an appropriate sanction for the doctor who refuses to see a patient, who turns up intoxicated or who deliberately does something wrong. That facilitates a no-blame or airline safety-style culture, promoted by the Secretary of State, in which errors are identified and continuous improvements are made.

Following the case of Dr Bawa-Garba, that safety culture and those improvements to patient care are now in jeopardy. Although she was newly back from maternity leave, had not received induction, was covering two people’s jobs, had inexperienced junior staff to supervise and had reduced consultant cover, a very busy unit and a broken IT results system to contend with, Dr Bawa-Garba was convicted of gross negligence manslaughter and, more recently, struck off the medical register by the GMC. Those events followed the very sad and tragic death of a little boy, which of course saddens all of us in this House and is something from which his family will never truly recover.

Whatever the rights and wrongs of this particular case, many professionals have seen sufficient ambiguity in the decision that Dr Bawa-Garba was criminally culpable that it has shaken their confidence that they understand the boundary between a genuine error of medical judgment and conduct so exceptionally bad that it amounts to criminal behaviour. It has, in the words of the chair of the Royal College of General Practitioners,

“shaken the entire medical community”.

Although the GMC is an independent organisation, the Government will be aware of concerns raised about its decision making on this case. Perhaps the most high-profile concern was raised earlier this month at the local medical committees conference, where GP leaders passed a vote of no confidence in the GMC. I would be grateful if the Minister elaborated on what the Government are doing in their work with the GMC to ensure it is executing its functions correctly and to restore medical and public confidence in it.

It is right that individuals are held accountable for their actions, but there is always a balance to be struck between accountability and blame. Where the balance is tipped towards blame, individuals become fearful and may attempt to cover their mistakes, preventing them and others from learning; the same errors will therefore be repeated. Since the case of Dr Bawa-Garba, many doctors have become fearful. That culture of fear means that some doctors are being advised to anonymise reflective practice and to avoid uploading those reflective practices on to their e-portfolio. They might unnecessarily escalate decisions previously undertaken themselves or refuse to do more than contracted. That cannot be good for patient safety.

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

This issue is not just the preserve of doctors; it, of course, cuts across all health professionals. One of the biggest triggers is the pressure that NHS staff are put under, particularly in respect of their not being able to fulfil their duty of care. Does the hon. Lady recognise that when we have a staff crisis it creates the biggest risk to patients?

[Dr Johnson]

I thank the hon. Lady for her intervention, and I agree that this issue of accountability and blame applies equally to all professionals across the health service. Everyone makes mistakes; I was reading online the incident report for the serious investigation done into this young boy’s death and I noticed that, although no doubt all care and attention had been paid to ensuring that personal information was redacted, the child’s initials appeared in at least one place where someone had forgotten to do that. That is a sign that none of us is ever infallible.

Sanctioning doctors for honest mistakes also runs the risk of discouraging people from joining the profession. At a time when the Government are looking to increase the number of people entering medical careers, through the creation of more places at universities and the establishment of new medical schools, the perception that an honest mistake made later in someone’s medical career could end up with their being struck off the register, or even behind bars, risks alienating just the type of young, forward-thinking, ambitious students whom the NHS needs to pursue a career in medicine. It is a testament to the youth of today that medicine still continues to attract the brightest and the best. However, by the same token, these straight-A students have other, more lucrative career paths open to them, and those will become all the more attractive when the risks inherent in a medical career become too high.

This culture of fear not only risks discouraging people from joining the profession, but drives away highly skilled doctors already working in the NHS. As an NHS doctor, one is already expected to work in very challenging conditions, working long hours in an incredibly high-pressure environment. Again, if a perception develops among doctors that they may be treated as a criminal even if when working to the best of their ability, it will quite simply drive doctors away. The world-renowned medical schools we have here in the UK mean that British doctors are in high demand, and they may take their skills to the private sector or further afield to less litigious health services.

The Government recognise these problems and have commissioned an urgent review to look at the threshold for what constitutes gross negligence. This will report by the end of April. I understand that the GMC has also commissioned its own review, although it is not expected to report until the end of the year. Will the Minister tell the House how the Government will act in the meantime to reassure doctors, especially those in high-risk specialties such as paediatrics and obstetrics, that they will not be unduly punished for mistakes?

Overall, it is important that the Government act swiftly on the findings of this report, and consider carefully the impact of the threshold on both the recruitment and retention of medical staff, and safety and improvements to patient care. Doctors want to make people better—it drives all they do. We must stand with them and for them, for all our futures will depend on it.

Mental Health Act: CQC Report

Caroline Johnson Excerpts

Tuesday 27th February 2018 Commons Chamber

[Jackie Doyle-Price]

The hon. Lady raises an issue that is close to my heart. In my opening statement I highlighted the discrimination faced by black people in detention, but I could just as easily highlight the discrimination faced by women. As she says, if they become victims of domestic abuse or coercive relationships, they often face mental health challenges as a result, and they are more likely to be detained in those circumstances. I co-chair the women’s mental health taskforce with Katharine Sacks-Jones from Agenda, and towards the end of the year we are looking to bring forward concrete actions to tackle exactly this kind of discrimination and make mental health services more responsive for women.

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

As a doctor, I know how carefully doctors and other health professionals consider individuals before resorting to detention under the Mental Health Act. Does the increase in detentions under the Act reflect a general increase in mental health problems in the population, or can it be better explained by a greater proportion of people becoming so unwell that they need to be detained in order to support their care? What research is the Minister doing to determine which is the better explanation, and to ensure that we identify those people who are going to become severely ill in time to treat them?

[Jackie Doyle-Price]

Clearly, if we can determine the causes of the increase in mental health detention, that will become part of the toolkit that we use to tackle the issue. This is one of the things that we are asking Sir Simon Wessely to look at. There are anecdotal examples of why this might be happening, but the fact that we are seeing higher rates of detention among the black community and among women raises some interesting questions that will bear further examination. I recognise my hon. Friend’s point completely. Good medical practitioners will use detention under the Mental Health Act only as a last resort, and we must ensure that that good practice is spread as far as possible.

East Midlands Ambulance Service

Caroline Johnson Excerpts

Wednesday 21st February 2018 Westminster Hall

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

Demographically, patients attending A&E, which treats accidents and emergencies, not anything and everything, are the very sickest patients, or those patients requiring treatment such as X-rays that cannot be delivered in centres such as a general practice. The review into the walk-in centre, as I understand it, and as it has been explained to me, was actually done by clinicians rather than politicians. The clinicians are telling us that it will not have an effect because, demographically, the patients going to the walk-in centre are those who are relatively well. If the walk-in centre was closed, they would be making their own way to the hospital, a general practice or a pharmacy, rather than calling 999.

[Ruth George]

The fact is that walk-in centres are open late in the evenings and at weekends, and in most GP practices it is not possible to get an urgent appointment without phoning at 8 am exactly. In my constituency, people have to wait at least two weeks to get an appointment.

--- Later in debate ---

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

It is a pleasure to serve under your chairmanship, Mr Davies. I thank the hon. Member for High Peak (Ruth George) for securing this debate, on an issue that is incredibly important to her, to me, and to all of our constituents. As a children’s doctor, I have been required to deliver full intensive care to children, particularly babies, who are being transferred in East Midlands ambulance service ambulances through the night, through the day, hurtling along in the back of the ambulance as it travels on our rural country roads, round corners and down the hard shoulders of motorways at great speed, so I understand some of what they do. It has given me a deep appreciation of the work of ambulance crews and has also highlighted to me the unique challenges and pressures that they face, particularly in our rural areas.

My constituency of Sleaford and North Hykeham in north Lincolnshire has a dispersed population, a rural road network and some NHS staffing challenges, all of which have contributed to the ambulance service failing to meet its national targets. As the overnight closure of Grantham A&E, which is just adjacent to my constituency, requires ambulances to now travel greater distances to Boston, Nottingham and Lincoln, every few weeks I receive a letter from a constituent who has waited an unacceptable amount of time for an ambulance. Indeed, I myself, as a member of the public, have been at the side of the road trying my best to treat casualties, waiting a long time for an ambulance. One gentleman died, although it is likely that that would have been the case anyway.

There is no quick fix to improving ambulance response times in rural areas. It is easy to identify and talk about the problem, but we also need to talk about potential solutions. One example would be the effective cohorting of patients when they arrive in A&E to allow ambulance crews to get back on the road sooner.

We have heard about the problems faced by ambulance crews waiting a long time to hand over in A&E, and it is right and proper that the care of patients is properly handed over before the ambulance crew leave, but it is worth noting that when a crew is with a patient, that patient is effectively receiving two-to-one care. I appreciate that paramedics and nurses have different skills, but that is higher than the dependency level provided for intensive care, where there is a one nurse to one patient ratio. Many of those patients, since they are waiting in corridors—unacceptably, I would say—are at the lower level of dependency as compared with the patient that has been taken straight into resus and received immediate treatment. So when three consecutive ambulance crews come in with three patients, there are six members of staff caring for them, and that is not necessary. One crew could care for them while the other two crews go out and see patients.

It is also worth noting that the patient who is at home is at a greater level of risk than the patient in the hospital. In the circumstance I have described, we have six ambulance crew looking after three patients in a hospital. The patients are of moderate ill health—they need to be in hospital and need to be seen, but they do not need to go into resus right at this moment. Equally, they are at a lower level of risk than the person sat in their home in a rural area of my constituency, say in Nocton, waiting for an ambulance to come, who has no access to medical care at all. If the person at home deteriorates, they cannot be wheeled round the corner immediately into resus, while being continually observed by a paramedic in the meantime.

Following my work in A&E over the Christmas period—I still practice as a paediatrician—I met the Secretary of State for Health and Social Care to discuss that point. I understand he and the civil service are looking at it, and I would be grateful for an update from the Minister on how that work is progressing. I believe that it would improve not just patient care but also the ambulance response times in the community.

The second issue I want to talk about is the type of ambulance crew. Many people are of the view that when an ambulance crew arrives, it contains the same level of skill mix, regardless of which ambulance comes, but that is actually not the case. There are highly trained specialist technicians and there are paramedics, who have additional levels of skill. There can be situations where, because we need to direct the correct crew to the correct problem—for example a particularly ill patient might need a paramedic and another patient might need a technician—there might be two crews near two patients going in opposite directions, taking longer to get to somebody. That is because they are not all paramedic crew. Although that probably makes little or no difference to response times in a city centre, in a rural area, where response times will always be longer because of the geography involved, we should increase the number of paramedics, perhaps having all paramedic crews. If we were in a position where all crews were paramedic crews, an ambulance would always go to the nearest casualty and not necessarily the matched one, which would improve response times. In addition, we can increase the number of patients who receive care en route.

We hear a lot about the golden hour—patients that need treatment within that first hour of care. If they get treatment in that first hour, we know they get better outcomes in the long term. If we are sending a technician crew who are perhaps not able to provide some of the treatments that a paramedic crew can, the patient is not getting that. Again, in a city centre where the transfer time might be five minutes, perhaps that does not matter as much as it does in a rural area, where once the ambulance has got to the patient, simple geography may mean that it takes 40 or 30 minutes to get back to the hospital.

In summary, we hear a lot about the problems that the ambulance service has. I agree with my hon. Friend the Member for Gainsborough (Sir Edward Leigh) that a Lincolnshire service would provide a better solution than one that covers such a wide geographical area as the east midlands, but I would be grateful if the Minister could look at the other potential solutions.

Medicines and Medical Devices Safety Review

Caroline Johnson Excerpts

Wednesday 21st February 2018 Commons Chamber

[Mr Hunt]

As the right hon. Gentleman knows—we have had these discussions at the Health Select Committee—this country makes an enormous contribution to medicines regulation across Europe, because of our extensive scientific base, and we very much hope that those links continue.

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

I welcome the review of the yellow card process. The first responsibility of the doctor is always to do no harm, and every doctor, when making any prescribing decision, always balances the potential improvement in patient care with the known risks. Sometimes, as more drugs are given to more people, rarer side effects will come through, and the improvements in the yellow card system will mean that those are identified earlier.

My other point is about Roaccutane. It is a drug given to treat acne but is known to be exceptionally toxic in pregnancy. I remember from my time working in dermatology that to get a prescription women had to attend monthly and have a negative pregnancy test before the next prescription was issued. I wonder whether that approach could be more widespread in the prescription of some of these drugs, which do provide some benefit but are known to be harmful.

[Mr Hunt]

My hon. Friend’s question demonstrates how useful it is to have people with medical experience in the House. To be honest, I am slightly overwhelmed by the detail in her question, but her broad point is absolutely right. The difficulty with the issues today is how much they affect women, particularly pregnant women. Through the review, we want to establish whether we are doing less well than we should on women’s health issues. Given that Baroness Cumberlege has done more campaigning on women’s health issues than pretty much anyone else in either House, I think she is the right person to take the review forward. My hon. Friend is absolutely right about strengthening the protections for pregnant women.

Oral Answers to Questions

Caroline Johnson Excerpts

Tuesday 6th February 2018 Commons Chamber

[Jackie Doyle-Price]

The hon. Gentleman is right to highlight that, and we are always keen to respond to any representations made on this very important issue. We are also very keen to learn from the other nations about this area, because it is clear that the more we can do with early intervention in childhood, the better we protect people’s long-term health. I will look more specifically into that.

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

As a children’s doctor, children’s health is very important to me, and the case of children’s doctor, Dr Bawa-Garba, worries me and doctors up and down the country. In NHS practice, I have seen the adverse effect on reflective practice and the impact that it has on staff morale. Ultimately, that will impact on patient safety. I know that the Secretary of State shares my concerns, and I ask him to tell the House what he is going to do about it.

[Jackie Doyle-Price]

My right hon. Friend the Secretary of State will be addressing that in a little while. The whole issue of reflective learning is important. We should not, through this case, prevent people from being honest about the experiences that they have had.

NHS Winter Crisis

Caroline Johnson Excerpts

Wednesday 10th January 2018 Commons Chamber

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

May I begin by disagreeing profoundly with the hon. Member for Wirral West (Margaret Greenwood)? As a health professional and as a doctor who has worked in the health service for 15 to 20 years, spending more than two hours listening to Opposition Members putting negative after negative on the NHS has been profoundly taxing, and it has been hard for me to remain in my seat.

I worked in the NHS in A&E in the Christmas and new year period. Yes, I saw people waiting much longer than we would like. I also saw a seriously injured child who came in and received the very best treatment. People and equipment were available, and all the necessary hospital staff were available for his treatment. At times there were a dozen people around his bed, and I am pleased that we could give him the treatment that he needed to survive. We need to get away from always picking out the negative points. We must remember that more people are being treated and survive, and that they are real, genuine people who go on to live long, healthy lives and are really pleased with the NHS treatment that they receive from people such as me and the millions of NHS staff working over Christmas and on new year’s day.

We have heard a lot of negatives from the Opposition, but we should look at what we can do to improve. I did not hear anything from the shadow Secretary of State about what he was going to do to make things better if he was in charge.

[Siobhain McDonagh (Mitcham and Morden) (Lab)]

I will not take much time, but I have some suggestions. It is the over-75s who are mainly going to A&E. They are more unwell than they used to be. Why do we not get volunteers with medical experience to phone up people on every GP list and make sure that the over-75s are okay? They could urge them to turn up at the GP as soon as they become unwell, and not to wait until they reach a state in which they need intravenous drugs and have to go to A&E.

[Dr Johnson]

I thank the hon. Lady for her intervention, but I fear that she is mistaken because the people most likely to attend A&E are the under-19s. The over-65s represent about 20% of attendances at A&E but, following their attendance, the vast majority require admission to hospital, so they are in a slightly different category.

Those who are awaiting admission after they have been seen are the group who are waiting on the trolleys in A&E. People are waiting for those patients to be moved on to the wards so that the ambulances can be freed up and those patients treated. I have a solution to suggest, about which I met the Secretary of State earlier this week following my work in A&E over the winter period, when I observed ambulance crew waiting next to trolleys with their patients. They could not leave until they had properly handed over their patients.

It is really important that patients’ care is handed over properly, but equally we need those ambulances back out on the streets to collect the patients who are waiting at home. We could do much better if we cohorted the patients. For example, if three ambulances came in with six ambulance crew members on board, one ambulance crew could look after the patients while the other two went back out to see more patients. It is not all about money; some of it is about the inventive use of staff to create safe and efficient protocols.

I want finally to talk about the postponement of operations, which is very upsetting when someone has waited a long time for an operation and psyched themselves up for the pain and distress they know they will experience, and they may be nervous and fearful.

We have several choices. We could run hospitals at a very low capacity all summer—which is hugely expensive—so that there is a lot of free capacity ready for the winter; we could say that we will not do as much elective work over the winter, but then we might cancel operations that do not need to be cancelled—we may be giving more notice, but patients might have been able to have their operation; or we tell people that we will plan their operation but there is a possibility that if the winter is acutely busy, it will need to be postponed. None of those choices is ideal; all have pros and cons. We need an adult, cross-party discussion about the best way; otherwise, whichever option is chosen by the Government of whichever party is in power, the other side will criticise.

As many hon. Members on both sides of the House have suggested, we need to take the politics out of the health service, recognise that the vast majority of patients receive excellent care from the health service, which is doing more than ever, and consider together how we improve the areas that need improvement.

Maternity Safety Strategy

Caroline Johnson Excerpts

Tuesday 28th November 2017 Commons Chamber

[Mr Hunt]

We must give doctors, nurses and midwives our full support, because they do an extraordinary job. Sometimes there are difficult issues and the centralisation of certain maternity services can improve patient safety if it means that there is round-the-clock consultant cover and so on. In my experience, the most important thing is to spot the most risky births early in the process. I am not a doctor, but there is sometimes an assumption that it is all about what happens at the moment of labour when women go into hospital. Actually, a lot of this is about thinking earlier in the process about higher risk mums—mums who smoke and mums from lower socioeconomic backgrounds—and intervening earlier. That will be important for the hon. Gentleman’s constituents and for mine.

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

Pregnancy and childbirth are a time of joy for most families, but during my professional career, I sadly had to look after a number of babies who died. I therefore welcome the Secretary of State’s commitment to halving the number of neonatal deaths by 2025. In my professional experience, many babies who are stillborn were already dead or in serious trouble inside the mother before they arrived at hospital. Will the Secretary of State therefore confirm that the investigations will look at pre-hospital care, as well as hospital care, including things such as the measurement of babies’ growth? Will he also encourage expectant mothers to monitor foetal movements, as we know that a reduction in those can be a sign of distress?

NHS Continuing Care

Caroline Johnson Excerpts

Monday 27th November 2017 Commons Chamber

[Norman Lamb]

Depressingly, I have. Earlier this evening, when I was giving the Speaker’s lecture, I made the case that we need, ultimately, a pooled budget for both health and care to stop these awful arguments between the health and social care silos.

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

In my experience, trying to define which is the social care part of an individual’s need and which is the medical part can be very challenging, as many people will have a combination of both. Does the right hon. Gentleman agree that the Government’s proposal for accountable care systems in which one group is responsible for meeting both needs is a great step forward?

[Norman Lamb]

If it were happening, I would. I totally agree that we need to bring health and social care together in localities, with a single budget and single commissioning. I think that we need to work across parties to come up with an ultimate long-term settlement for the NHS and the care system.

Families are also in the invidious position of being asked to provide, in effect, a top-up for care if they want their loved one to remain at home, rather than being forced into a care home. That is fine for those who can do it, but not good for those who cannot afford it. It is also completely contrary to any notion of personalisation —the concept of the person, what is important to them and their priorities being at the heart of decision making—which the Government accept. When I was working with the Conservative party in coalition, we passed the Care Act 2014. Its fundamental principle was the individual’s wellbeing, yet now are saying to people, “No, you’re going to go into a care home because it’s cheaper.” That is not acceptable, but it is happening around the country.