EU Working Time Directive (NHS)

Charlotte Leslie Excerpts

Thursday 26th April 2012 Westminster Hall

[Charlotte Leslie (Bristol North West) (Con)]

It is a pleasure, Mr Brady, to serve under your chairmanship. We have heard a lot during the past few months about structural reform of the NHS, but today I want to concentrate on something that underlies the success of any structural reform now or in future: safeguarding the expertise and professionalism of our medical work force, and our future consultants. I think we all agree that the NHS is not a system; it is the people who work within it. The expertise, dedication and professionalism of our clinical staff are what give the NHS its tremendous robustness to adapt to and, dare I say, withstand political restructuring. That is largely what has enabled it to meet the ever-increasing demand being placed on it by an ageing population, rising expectations, and all the other factors that we so often talk about. If the NHS loses that clinical expertise and professionalism, it will no longer exist as we know it. Under our watch, doctors are warning with increasing urgency that that professionalism and expertise is being severely eroded, and the expertise of our future consultants is being jeopardised, so patient care is being compromised daily.

What is having such a damaging effect on the future of our NHS? With the previous Government’s very badly structured new deal, the threat to the NHS is the European 48-hour working time directive. It was introduced with the reasonable aim of putting an end to junior doctors having to work 100 hours or more a week. Obviously, that was bad for junior doctors, and dangerous for patients. No one wants to be operated on by someone who has had a ridiculous lack of sleep. We do not want to return to those bad old days, but the effects of this well-meaning directive are devastating, and it would be utterly wrong and immoral to dismiss the arguments about the 48-hour working time directive simply by presenting a simplistic either/or argument: either a 48-hour working time directive, or a return to 100-hour weeks. That argument would be misleading, it has no strength, and it is wrong.

Doctors have been making the case strongly, and trying to get the political class to hear. They have warned that the working time directive is devastating the NHS in three ways. First, on doctor training, it is eroding the professional ethos that upholds the NHS, and beginning to replace it with a clock on, clock off culture. New generations of junior doctors will know only that. They will never know the old ethos that sustained our NHS. Secondly, the safety of patients—our constituents—is being seriously jeopardised daily. Thirdly, I am sure the Minister appreciates that the financial cost is absolutely massive. I will deal with those three issues in turn, before concluding on the final, biggest blow, which is that the directive does not achieve its aim of a better work-life balance for doctors, and in some cases it makes matters worse.

The previous Government estimated that the introduction of the European working time directive, given the existing new deal limitation of a 56-hour working week for doctors, would be the equivalent of taking 4,000 doctors out of circulation. The Royal College of Surgeons estimated the loss of surgical time per month to be 400,000 hours. To put that into perspective, that is equivalent to 45 years of surgical time per month being lost to the NHS. That means that doctor training is limited in two ways.

The first is simply the amount of time that doctors have to train, and we can all appreciate that. It is important to appreciate that the quality of the training that doctors can access has also been severely eroded. Hospital trusts have had to adopt a shift rota system to incorporate the working time directive. Under the old on-call system of working, a medical specialist—an expert—was always on call in case a problem arose, or there was an emergency out of hours. A specialist was always on hand to help any doctor on duty, but with the new system, that is not always the case, so patient safety is jeopardised.

Doctor training is also jeopardised. Trainees complain that they do not get the training they used to receive because they are increasingly meeting the demands of staffing hospitals out of hours and at night without the training and accompaniment of a consultant. The team-working relationship between trainee and consultant is what is so valuable to trainees, and its breakdown is detrimental to the quality of and amount of time for training. The Association of Surgeons in Training reported that two thirds of trainees believed that their training had seriously deteriorated since the introduction of the directive. Sadly, most doctors report that they break the rules—I will return to that—to access the sort of training they want. We are dealing with a work force that values clinical excellence and the welfare of their patients.

My second point is about the welfare of patients. From the patient’s point of view, the directive massively damages continuity of care. Under the shift system, we are seeing a clock on, clock off system, with a dramatically increased number of handovers between doctors. That is clinically risky, because handovers are when vital information may be missed, and under the directive those handovers take place under increasing time pressure. As with Chinese whispers, messages are distorted down the line.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

My hon. Friend makes an excellent point, but is it not also the case that medicine is traditionally about providing continuity of care for patients through having a dedicated team of doctors looking after them? If we move towards a clock on, clock off culture, as we now are, and a shift-based job, continuity of care will be lost, patient care will be damaged, and bad things will happen to patients.

[Charlotte Leslie]

My hon. Friend makes an extremely good point, and I know that he has first-hand experience in this area.

Professional expertise and intuition, not looking at a list of tick boxes, enables doctors to spot that something is wrong with a patient. If doctors are not able to make a subtle comparison between how a patient was yesterday and how they are today, their intuition and expertise will be undermined. We have all seen constituents who have felt that they have been subject to an endless conveyor belt of doctors, and have been made to feel like a product on a conveyor belt instead of the focus of a dedicated team looking after them. The move to treating patients as products on a conveyor belt is worrying, and undermines the very good ethos of our NHS. Clinicians back that up. One third of surgeons in a recent survey said that handovers had been inadequate and, worryingly, the Royal College of Physicians found that three in 10 thought that their hospitals’ ability to deliver continuity of care was poor or worse. A similar survey of GPs found that one third thought that their hospitals’ treatment was dangerous. I cannot emphasise enough the urgency of the matter.

[Mr Robin Walker (Worcester) (Con)]

To add to the chorus of support, one of my constituents is John Black, a famous surgeon from Worcester, and past president of the Royal College of Surgeons, who told me that if there was one thing the Government could do for the NHS, it would be to take up this issue and get it sorted out. Does my hon. Friend agree that the Government must take up the cudgels with Europe and fight for our interests?

[Charlotte Leslie]

My hon. Friend anticipates a point that I will come to later. I pay tribute to the work of John Black and others on this issue. If there was only one target that the NHS should enshrine, it is continuity of care, because after that so many things follow.

European Court of Justice rulings—I do not want to be too technical, but they are the SiMAP and Jaeger rulings—have caused tremendous problems for the profession. First, inactive on-call work is required to be counted as working time. Therefore, if a doctor is on call but inactive and perhaps sleeping on the premises, it is counted as on-call time, which makes life very difficult for hospital trusts organising rotas and getting the time available. Secondly, if a doctor overstays their allocated shift, perhaps because they are about to hand over, but have to stay on for an extra hour, perhaps because a patient has had a cardiac arrest, they are required to take compensatory rest to make up for that immediately afterwards. If that doctor has a clinic some time the next day, they will have to take an hour of rest time, cancelling that clinic, because the European Court of Justice dictates that. Potentially, patients who have turned up at hospital and are ready and prepared for surgery will have their clinic cancelled because the Court ruling says that the doctor must be forced to take rest. That is obviously a tremendous inconvenience for patients, beyond continuity of care, and a nightmare for the hospitals trying to make accommodations.

[James Wharton (Stockton South) (Con)]

I congratulate my hon. Friend on securing this important debate. She has spoken eloquently about the challenges that the rulings cause for the running of hospitals, and the problems that they cause in the care of patients. Does she agree that treating doctors in such a way, commoditising the patients they work with and clocking their work on and off damages their ability to do their job professionally, which affects their health too?

[Charlotte Leslie]

Absolutely. My hon. Friend makes an extremely good point. An interesting point that I shall come to later is that the Royal College of Physicians reports that sickness rates have soared because of the stress on clinicians as a result of not being able to perform their duties with the professional excellence that they espouse. The directive has a detrimental effect on the professional ethos of the NHS, and on the individuals whom it was designed to help.

[Chris Heaton-Harris (Daventry) (Con)]

My hon. Friend is doing a fantastic job of articulating the problems that the working time directive has brought to the NHS. On the question of the Jaeger ruling at the European Court of Justice, is my hon. Friend aware that the Republic of Ireland has had problems, and has tried to exempt training from its definition of work, so that trainee doctors fall outside the scope of the directive? In the Netherlands, trainee doctors are apparently classed as autonomous workers: the Netherlands, too, tries to sideline the directive. Across Europe, it is causing problems in health services.

[Charlotte Leslie]

I know that my hon. Friend has done a tremendous amount of work in this area. The ways in which other countries get round the directive will be the conclusion to my speech. The Minister has a choice whether to prioritise political process in Europe or patients. Will we put everything into finding a way to give patients the care, and the professions the flexibility and respect, that they deserve? I thank my hon. Friend the Member for Daventry (Chris Heaton-Harris) for anticipating that point.

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

I congratulate my hon. Friend on securing this important debate. We will all be aware that it has recently been reported in the media that the mortality rates for someone unfortunate enough to be taken into hospital on a Friday night, Saturday or Sunday are about 20% worse. Does my hon. Friend think that the working time directive is exacerbating the situation and preventing us from dealing with the problem of continuity of care?

[Charlotte Leslie]

I suspect that that is a problem in hospitals in colleagues’ constituencies, and I look forward to hearing about those. It is not just politicians in the Houses of Parliament who say these things, but, crucially, clinicians on the ground, whose prime concern is looking after patients. I certainly agree with my hon. Friend’s point.

One area in which the restrictions of the working time directive become apparent is in the case of a flu pandemic. The guide to the implications of the European working time directive for doctors in training makes it clear that even in a flu pandemic there are no exemptions from, and there is no flexibility about, the 48-hour rule. It is true that individuals can opt out of the directive, but they are still limited by the previous Government’s new deal to working 56 hours a week. However, there is no mechanism to compel doctors to opt out of the 48-hour working time directive.

[Matthew Hancock (West Suffolk) (Con)]

I am grateful to my hon. Friend for making such a powerful case. Can she explain why this is an EU issue at all, since the directive is meant to engender a single market, but the NHS is a British-only institution?

[Charlotte Leslie]

My hon. Friend makes an extremely good point. That issue was contested to some extent when the directive was first introduced, but the previous Government saw it as a health and safety issue, and therefore the NHS was included in it. There are many reasons why we need not be in this position. There are many aspects of the negotiation that are deeply regrettable, and I agree with my hon. Friend. Although this is going over old ground, it is vital to look at that to find out how to get out of our current situation and secure patient care.

[Mr David Nuttall (Bury North) (Con)]

My hon. Friend will be aware that maternity units have closed in many constituencies, including mine. I was told that one reason why the health authority wanted to reconfigure the unit, as it put it, was the impact of the working time directive. Does she find that impact of a European regulation on my constituents in Bury North as shocking as I do?

[Charlotte Leslie]

I find it shocking and outrageous that that is allowed to happen. Its importance cannot be overestimated. Lives are being put at risk because of Brussels bureaucracy that does not even begin to protect the workers whom it says that it is designed to protect. This is one of the most important issues in the NHS, and I urge the Minister to do everything possible to work with colleagues in the Department for Business, Innovation and Skills to sort it out.

To return to the point about the flu pandemic, many people say that things will be okay because the 48-hour week is an average that can be measured over six months; so if there is a pandemic everything will be fine, because the doctors can sort it out and go back to normal afterwards. Well, if the pandemic were to last more than six months, I do not know where that would leave us. If it were to last less than six months, we would not have any doctors able legally to perform routine functions. That demonstrates how rigid, bureaucratic, badly thought-through and frankly dangerous the directive is.

The cost, however, is not only human: it is financial, and it is massive. Colleagues are concerned about the closure of their constituency hospitals and the ability of those hospitals to find coverage. Hospitals are floundering and struggling to find staff for an ever-increasing demand on the NHS. Let us not forget that the restriction on staff is happening at a time of unprecedented demand on our health system. Stafford hospital closed its accident and emergency department in the evening because it could not find cover. Other hospitals are taking other measures and spending exorbitant amounts of money on temporary staff to fill the gaps. Many colleagues will have read about the £20,000-a-week temporary doctor who was brought in to fill the gaps. Hon. Members will be shocked to learn that a staggering £2 billion has been spent in the past two years on temporary staff in the NHS. If we think about the financial challenges that the country faces and where else that £2 billion could have been better spent, that figure demonstrates how crucial the issue is. One hospital trust spent £24 million on temporary staff because of the staffing problems caused by the directive.

As I have hinted, the grim irony is that, for all the contortions and scheduling arrangements that hospitals, doctors and trusts go through to accommodate the directive, it is not even doing what it was supposed to do and make the work-life balance for doctors better. I received an e-mail from a junior doctor who is soon to get married and wants to spend time with his fiancée and plan his wedding, and who is frantic, not only about the erosion of his training and his future professionalism, but also about the destructive influence of the directive on his home life and his work-life balance. He writes:

“The directive certainly hasn’t made any impact on quality of life. Having worked 60-70 hours a week, now doing 48 hours, I am no less tired...the stated aims of improving work life balance and improving training are farcical.”

Then he goes on to talk about the realities that junior doctors face. He says:

“There is simply not enough time in the 48 hour week to get trained, particularly in the craft specialities, so we all go in on our days off. If we don’t, we don’t get trained and it is us, our careers, and ultimately the patients who suffer. Training used to happen in our official working hours, now we work just as hard, but get trained in our time off, and don’t get paid.”

And he is not alone. The Association of Surgeons in Training reported similar exhaustion because of the directive, and the Royal College of Physicians, as I have already mentioned, reported soaring sick leave since it was introduced.

I have spoken to junior doctors who report worrying signs of things to come. Given the contortions of shift working under the directive and the changes to on-call working time, junior doctors increasingly report that they are reluctant to specialise in disciplines that have more arduous on-call demands and require presence at the hospital, such as acute medicine, general surgery, obstetrics, gynaecology and anaesthesia. An unofficial straw poll of senior house officers in one city showed that they nearly all did everything they could to avoid being on the acute register because that was such a nightmare. They just thought, “Why would we?”

Statistics showing the number of applications and the number of positions available in those disciplines suggest that junior doctors who report such trends are not wrong. We are beginning to see our most talented doctors moving away from the disciplines that put the most stress on their work-life balance because—let me stress this—of the directive. When making lifestyle choices, doctors are looking at those specialist disciplines and thinking, “Why would I go into that?” which is extremely worrying for the future of our NHS provision. We have to stop that trend before it becomes more cemented.

[Mr William Cash (Stone) (Con)]

My hon. Friend is making a most compelling speech on a matter of extremely great importance. Does she recognise the problem that everything that she has said stems from a system that is based on treaties and backed up by the European Court of Justice? Therefore, we cannot make changes unless we renegotiate the treaties. In a matter of such importance, will the Minister make the necessary adjustments to achieve the objectives sought by my hon. Friend and ensure that we get a result?

[Charlotte Leslie]

I thank my hon. Friend. He has done a tremendous amount of work in this area, and I bow to his expertise. I see the solution as twofold and two-speed. First, we must ask why we are in this situation, and we must look at the treaties. Open Europe has suggested an interesting double-lock mechanism for negotiating our way out of what was the social chapter and creating a situation in which we are not bound by the rulings of the European Court of Justice. Those are big, radical steps and will take time, but it is something that we should look at.

This issue is of great importance on a daily basis. Each year that passes, a new generation of doctors enters a system that is systematically undermining the most important element of our NHS. Because issues to do with Europe are so tangled, difficult and frustrating, we need to look at more practical and instantaneous ways of getting around the directive with which we are inflicted. I take my hon. Friend’s point, but a two-speed approach is vital because of the issue’s importance.

[Andrew Bridgen]

My hon. Friend said something about medical professionals going to work on days when, under the working time directive, they are legally supposed to be at home or on holiday. Is she as concerned as I am that that could raise serious problems and create confusion and grey areas about professional negligence for medical professionals who are supposed to be on holiday but are actually working in the hospital? Will the Minister explain where they would stand on that matter for insurance purposes?

[Charlotte Leslie]

My hon. Friend raises a good point that will be of great interest as things progress. In a culture in which litigation against the NHS is becoming more and more common, what will happen if patients feel that their safety has been compromised because of the lack of training received by their doctors? The European directive raises all sorts of issues about patients’ rightful expectations of those who treat them.

[Neil Parish (Tiverton and Honiton) (Con)]

I thank my hon. Friend for the excellent speech that she is delivering. This, of course, is the social chapter that Tony Blair signed up to in 1997 kicking in, and I suggest that the Government might want to get us out of that legislation. I feel that irrespective of what length of time doctors might work, it is down to them to negotiate that with hospitals, rather than have it imposed by a directive. That is the biggest problem; things must be done by negotiation and not by directive.

[Charlotte Leslie]

Again, I agree with my hon. Friend. One of the most destructive things is that the directive puts a cap on excellence. If people want to put in extra time to become excellent in their field and be a world-leading expert, they will not be allowed to because someone in Brussels and the new deal says no. That worries me tremendously in terms of our competitiveness with the rest of the world. We have some of the world’s leading experts in many fields of medicine, but America and Australia do not have such restrictions and they will pull away because we simply will not see talent coming through. Worse than that, a country that says to bright, talented young people who are going into a service occupation to serve the public, “We are going to put a cap on your endeavour” is a country of which none of us would want to be part. The precedent that that sets is absolutely diabolical.

Let me come to an issue that is much more difficult. It is easy to sit and point to problems, but some things are much more difficult, especially, as hon. Members have said, when they involve the dreaded E-word—Europe. What can we do? There is no doubt that there is a massive consensus across the medical profession that something needs to be done. The Royal College of Surgeons, the Royal College of Physicians, the NHS Confederation and NHS employers all say that they have massive concerns about the country’s health service. However, an interesting omission from that list is the British Medical Association, which seems absolutely content. It wants to keep the opt-out, but it seems absolutely content with the SiMAP and Jaeger rules that are playing havoc with our hospitals and with situations that are driving many junior doctors to despair and sick notes. I guess that it negotiated the new deal, but it is odd and disappointing that, on this issue, it seems so unrepresentative of so many fields of the profession.

Ministers have said that they are working urgently with Europe for a solution. I have no doubt that that is true, and I appreciate the complexity of the situation. However, I am beginning to think that waiting for a solution to come out of Europe is like waiting for Godot. As hon. Members will know, this debate has been revolving around the European Commission and the European Parliament for almost a decade. It has come back again, and people are still trying to agree on what they are going to discuss. They have until September this year to agree that, but given past history, I have no faith whatsoever that an agreement is on the cards, let alone any results, and the precedent that has been set is not encouraging. While that farce has been going on in Europe, the clock has been ticking every day. Every day, patients’ lives are put at risk; every year, new generations of doctors enter a system that does not serve them, their patients, or the country.

What can we do? First, we should look at what we want. As I have said, no one wants a return to the bad old days when junior doctors were working ridiculous hours and were too tired to function, and patient safety was put at risk. The professions say that they want flexibility. For example, the Royal College of Surgeons has said that a working week of up to 65 hours, with a bit of flexibility, would be extremely good, and that will differ from discipline to discipline. Anaesthetists may want something slightly different from the surgeons, but the point is that our professionals know what they are talking about and what they are doing, and they deserve the flexibility to drive their services as they see fit. The Government have taken seriously the agenda to put professionals in the driving seat. We want flexibility, not arbitrary limits on times.

What can we do? My hon. Friend the Member for Daventry (Chris Heaton-Harris) has already mentioned what some other countries do. In the Netherlands, for example, doctors are classed as autonomous workers, because they earn more than three times the average wage in that country. We can look at such a classification, although that might be a complicated solution.

[Caroline Dinenage (Gosport) (Con)]

Let me add my voice to the chorus of praise for my hon. Friend who has secured this debate. A number of medical professionals from my constituency have raised this issue, and some of them feel so strongly about it that they are present in Westminster Hall today. Other services such as the armed forces, the police and even deep-sea fishermen have been granted an exemption from the working time directive. Does my hon. Friend think that the Government should issue an exemption for medical professionals?

[Charlotte Leslie]

My hon. Friend makes a good point, although we do not want to return to ancient history when things were conducted in a regrettable way. It is of great regret that, when trade unions and the BMA were negotiating with the then Government about how to implement the directive, the option of a sectoral opt-out was removed. Other hon. Members will have greater expertise on this matter, but I have been looking at the ways that a sectoral opt-out can now be negotiated. However, because time has passed since the original negotiation, it is now a lot more difficult to go for a sectoral opt-out. None the less, the common sense of the comment is apparent to everyone. It is a disgrace that the previous Government oversaw the implementation of one of the single biggest damaging factors to our NHS, as well as supplanting it with the new deal. We should make more of that because it has eroded so much confidence in our profession and it will have ramifications for a long time to come.

Spain applies the 48-hour limit to contracts and not to individuals, which is something that we could consider. In Ireland, training is not counted as work time. I am sure that there are lawyers all over the place who will say, “We can’t do that.” They will give all sorts of reasons why not. Again, I say to the Minister that this is a question of priorities. There are always procedural reasons why not, but if we consider what is at issue, the stakes could not be higher.

In conclusion, I urge the Minister not only to continue his energetic negotiations in Europe with colleagues in the Department for Business, Innovation and Skills, but to look again carefully at what practical measures we can take to alleviate and mitigate the effects of this absolutely disastrous directive on our NHS.

--- Later in debate ---

[Andrea Leadsom]

All I am saying is that, under the Lisbon treaty, member states that do not like certain legislation have the opportunity to club together and to propose that the European Commission look at it for possible deletion or significant amendment. That happened with the working time directive at two points in the past, in 2004 and 2010, but the attempts to amend it came to naught. The great tragedy is that with 27 member states there is simply a Chinese whispers effect. Someone says, “This is ridiculous, it is harming our national health service”; everyone agrees, “Yes, it’s ridiculous”, and therefore an amendment is proposed; but by the time it has gone around 27 member states, it is completely lost and gets nowhere. That is the fundamental problem with negotiating amendments.

My original point was about the importance of the time line of the working time directive. In 1990, the European Commission tabled the proposal for the working time directive as a health and safety measure. In November 1993 the UK was outvoted 11 to one at the European Council negotiations. The European Commission stated that the working time directive was

“a practical contribution towards creating the social dimension of the internal market”—

it was all about health and safety for employees, and employees in the real economy overworking; it was not intended to have the profound impact it has had on the national health service. David Hunt, who was Employment Secretary under the then Conservative Government, said that he would fight the legislation and not accept it. He tried hard, by going to the European Court of Justice to challenge the legal basis of the directive as health and safety legislation, but the UK was outvoted.

In 1996 the ECJ ruled against the UK, and Labour implemented the working time directive in 1998. The directive requires a maximum working week of 48 hours, a rest period of 11 consecutive hours a day, a rest break when the day is longer than six hours and a minimum of one rest day per week, as well as the statutory right to four weeks’ holiday. Such a list of requirements highlights the directive’s complete inflexibility; it clearly cannot be applied to absolutely every type of worker in our economy. In the end, the European Union had to admit that there were certain exceptions, which is why in some countries trainee doctors are treated as autonomous—in other words, self-employed. That is used as a means to get round the rules, because it is never going to be possible to enforce that kind of rigidity on people who are self-employed. There are all sorts of unintended consequences from a prescriptive and damaging set of rules.

In his response, will the Minister confirm whether the NHS has caused some of those problems—not necessarily deliberately—by offering contracts to doctors and junior doctors that are subject to a maximum of 48 hours? We should remember that the NHS is not allowed to invite new employees to opt out of the 48-hour working week at the same time as they sign their contract, because of fears of coercion. Does the Minister have a view about whether the NHS has created part of the problem by telling junior doctors and other health workers in their contracts that they will be paid for a 48-hour week, and then inviting them to opt out at a later date? There is a wealth of evidence to suggest that many doctors are working hours that are unpaid because their contract allows them to be paid for only 48 hours a week. Perhaps the Minister will comment on that in his response.

[Charlotte Leslie]

Does my hon. Friend agree that there are inconsistencies across the landscape? When I applied to work for the BBC, although I cannot remember exactly how it was worded in my contract, I was left under no illusion that if I wanted a job, I was to tick the little box that signed me out of that 48 hours business.

[Andrea Leadsom]

That is very interesting. Clearly, my hon. Friend’s contractual employment was not correct because she should not have been asked that question at the same time as signing the contract.

I would like to cite a case study of a junior doctor who was employed under the working time directive in foundation training between 2009 and 2011. This is his story:

“When I was on my surgical placement as part of my training, we were told by the hospital to take a mandatory ‘zero hours’ day off every week, as we were working 8 am to 6 pm on the other weekdays, as well as some longer on-call days and on-call weekends at times. The purpose was to keep our average working week within the 48-hour limit.”

That is utterly bizarre.

“We rotated who took the day off among our team, but this meant that on any particular day only one or two doctors would know the patients who had been admitted the day before. However, those particular doctors might not be there the next day, so would have to hand over patient information to a colleague. Unsurprisingly, much information was ‘lost in translation’. Trainee doctors would also not know which registrar, or even consultant, to expect on any particular day, due to the irregular working patterns of these people also caused by the limits on working time.

Furthermore, patients no longer knew who would see them on the ward round. The effect was poor patient experience, as patients were unable to build a rapport with individual doctors. People would be very frustrated that the doctors seeing them did not know what the same medical team had planned/achieved the day before.

There is also much less time for on-the-job training for junior doctors. This was compounded by the fact that we often had to cover for other trainees who were rostered off due to the working time directive, missing our regular teaching sessions. Lack of training time has made it difficult for us to establish a rapport with our seniors, and gain adequate support in terms of mentorship and career advice. In fact, trainee doctors no longer feel that we ‘belong’ to a team, given the new shift patterns that have broken up teams of trainee doctors and their seniors. Morale is certainly lower and junior doctor sickness rates much higher. This is a negative spiral—more doctors off means that when you do turn up, your working day is more hectic and stressful, and you are much more likely to fall ill and take time off yourself.

Diary carding exercises (whereby doctors record the actual hours they work) have shown almost universally high rates of non-compliance with the working time directive. During my general medicine attachment in training, I ended up working 1.5 to to 2 extra hours (unpaid) per day and was consistently non-compliant…Doctors that do opt out of the 48-hour limit on the working week are sometimes not sure whether they will be remunerated appropriately for their time.”

That is interesting and highlights some of the problems faced by doctors who are trying to do the right thing by their patients. Of course, this is not only about doctors but about patients. My right hon. Friend the Minister will be aware of two recent cases where coroners have recorded problems associated with the working time directive. They said that it impacted on the ability of doctors to understand what was going on with patients, and that was one of the factors that caused the untimely death of a patient. The other case involved a patient undergoing a routine operation.

Let me quickly turn to the solutions.

--- Later in debate ---

[Chris Skidmore (Kingswood) (Con)]

As a member of the Select Committee on Health, I am very interested in this debate. I have learned a lot from the engaging contributions of all hon. Members who have spoken.

I want first to acknowledge the hard work of my hon. Friend the Member for Bristol North West (Charlotte Leslie), and not only for this debate. I want to put on the record the fact that she has campaigned on the matter for nearly two years. She has brought it up in recess Adjournment debates, Health questions, Prime Minister’s questions, and a ten-minute rule Bill—the NHS Acute Medical and Surgical Services (Working Time Directive) Bill. She has not let the issue go, and I think it is important to put that on the record because, without all her work over the past two years, we would not have achieved this Back-Bench debate today, which is extremely important, and the final Backbench Business Committee debate of the Session—and very apt it is too.

Following my hon. Friend’s two-year campaign, the exact financial cost and burden on the NHS caused by the directive is becoming clear. On 18 March, The Sunday Telegraph published a freedom of information request about the cost, and some of the figures have been read out, but I want to read out a few more to place them on the record. Of the hospital trusts that provided figures, 80% admitted spending more than £1,000 per shift on medical cover as a result of the EU working time directive. In total, £2 billion has been spent on that since 2009, which is roughly equivalent to the wages of 48,000 nurses or 33,000 junior doctors.

We have talked about inequalities. It is worrying that some trusts are clearly suffering more than others, and some are in extreme financial difficulties. Yet North Cumbria University Hospitals Trust spent £20,000 on hiring a surgeon for one single week. Mid Staffordshire NHS Foundation Trust—my hon. Friend the Member for Stafford (Jeremy Lefroy) referred to this—spent £5,667 for a doctor for just one 24-hour shift in a casualty unit. The Christie NHS Foundation Trust in Manchester spent £11,000 on six days’ cover for a haematology consultant. Scunthorpe general hospital offered £100 an hour for one month’s work in a temporary post. Princess Alexandra Hospital NHS Trust in Essex paid more than £2,000 for a locum doctor to work a 12.5 hour shift last October.

I could go on, but I want to come back to that £2 billion in two years, and to relate it to the Nicholson challenge, which is a cross-party issue, of saving £20 billion to reinvest back into front-line services. The challenge was set in 2009 by the previous Government to take place over three years. As a result of the comprehensive spending review, that has now been extended to four years. No MP can claim that that is a cut by one Government or another, although some MPs have tried to. It is a cross-party approach, and we in the Chamber are responsible and understand that if the NHS is to remain free at the point of use, regardless of ability to pay, we need to make savings and to reinvest them into front-line care.

The coalition Government have already done a fantastic job in making savings of about £7.5 billion on the way to the £20 billion figure. But the reality is that, if this £1 billion a year cost to the EU working time directive remains, that will be a £4 billion cost over the period of the comprehensive spending review. Therefore an extra £4 billion will need to be found in efficiency savings. We are moving from a 20% efficiency gain, therefore, to almost a 25% one. [Interruption.] It appears that the Minister disagrees, but it is just a back-of-an-envelope calculation.

[Charlotte Leslie]

My hon. Friend is contextualising this debate in an important way, in respect of wider finances and the Nicholson review. Reverting to the question of evidence, does he agree that simple figures, such as these, on the cost of a directive that has been introduced are also evidence? The first-hand reports of clinicians on the ground are perhaps more reliable than the evidence gathered from sources that might not always be willing to tell the truth about the situation, for fear of not meeting compliance targets.

[Chris Skidmore]

Absolutely. On the figures I mentioned, only 34 hospital trusts responded to the requests for information, so the data were incomplete. Only 83 out of 164 responded with any data at all.

--- Later in debate ---

[Andrew Gwynne]

The Labour party’s position is to support much of what the working time directive has brought about. Some real issues have been raised by Members of all parties in today’s debate. I recognise a lot of the issues and concerns, and it is incumbent on the Government of the day to resolve such matters to best suit the needs of the member state—in our case, the needs of the NHS throughout the United Kingdom. We support the working time directive, however, and its positive achievements, which have not been touched on to a great extent in today’s debate. There have been some positives.

We therefore have reservations about changes to the European working time directive. High-quality, safe patient care and the maintenance of further enhancement of the quality of training and education for junior doctors are important. I note the issues raised today, and specific areas must be looked at. We heard concerns about the maintenance of training standards, but patient safety must be paramount, and we should co-operate with all interested parties to develop sensible, workable and achievable solutions to the problems. If we allow a relaxation of the European working time directive for junior doctors, the danger is that we run the risk of a gradual return to their working dangerously long hours. I urge the Government to tread carefully because as the hon. Member for Bristol North West said, to be fair, some aspects of the working time directive had laudable aims. As was echoed in a number of contributions today, we do not want to see a return to the dangerous working hours worked by some doctors in the past.

[Charlotte Leslie]

Does the hon. Gentleman acknowledge that even if we relax the working time directive, with its detriments to the NHS, doctors would still be bound by the new deal and the 56-hour week? I see no return to the bad old days while the new deal is in place, although I think it, too, needs looking at again.

[Andrew Gwynne]

I shall come on to the new deal shortly, but no one would want to go back to the past with tired doctors working excessive hours. Many Members recall the very real horror stories that surfaced from time to time, in particular through the 1980s and early 1990s, when it was not uncommon for junior doctors to be working a 100-hour week, as we have heard in the debate. The hon. Member for Totnes called on her personal experience and the hon. Member for Stafford (Jeremy Lefroy) called on his domestic experiences from the past to make some reasonable points about the stress and strain that the old ways of working placed on doctors. I was reassured by their comments that they did not want to see a return to those days.

An article in the BMJ, the British medical journal magazine, looking at the effects of the working time directive, suggested that it was hard to draw firm conclusions. It also found that reducing working hours to fewer than 80 a week had not adversely affected outcomes for patients or in postgraduate training in the USA, where similar restrictions were introduced. As we heard from my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams), the systematic review found the same, and that cannot be discounted because it does not necessarily fit some arguments. I do, however, take full account of today’s anecdotal evidence from Members, although it might well be wise to look at the wider, long-term implications of relaxing some of the directive’s conditions.

If we go back a number of years, to the 1990s, the new deal tried to establish that full shift working should not exceed 56 hours. Through the 1990s, compliance with the new deal was poor, so a new contract was introduced in 2000. The implementation of the Working Time Regulations for employed doctors in the training grades has helped to protect doctors from working dangerously long hours, improving patient safety.

I accept, as we have heard from several hon. Members, that press reports of locum doctors costing hospitals and the NHS some quite extortionate amounts are concerning. Some reasonable points were made by the hon. Member for Central Suffolk and North Ipswich, who speaks with experience on these matters, about the clocking off and clocking on culture, which is certainly a concern. Clearly, questions must be raised about spending so much public money in these financially restricted times, and we need to know what will be the knock-on effect for the quality of patient care, especially if patients are continually seeing different doctors every time.

The Minister, in answer to the hon. Member for Kingswood (Chris Skidmore), mentioned the 11% drop in the use of locums since May 2010 and the increase in the number of doctors, which is welcome. I will just make the point that those extra doctors were trained and came through the system under the previous Labour Government. It would be churlish of the current Government not to recognise that as they take some political capital. May 2010 was not month zero; those doctors were coming through the system previous to that.

This debate has been a positive step. As we have heard, a number of issues surround health workers, especially junior doctors, and I agree that they should be further examined as we seek ways to resolve the problems. However, we should approach with some caution the idea of relaxing some of the directive’s conditions in relation to junior doctors as in the longer term it might cause more problems than it solves.

In closing, I refer to the opening comments of the hon. Member for Bristol North West in which she said that we all value the expertise and professionalism of NHS staff and that the aims of the working time directive were very reasonable. Long hours were dangerous for both doctor and patient and we do not want to return to those days. She is right. Although we recognise that there are issues to consider in relation to staffing implications and the cost to the NHS, we do not want to see the positives that have been secured disappear. I look forward to hearing from the Minister an indication of the current Government’s thinking on how to strike that important balance for those working in our medical and clinical professions in the NHS. I feel a bit like Daniel in the lion’s den. I urge the Minister to tread cautiously, and I mean that with all sincerity. Yes, there are some issues, but he really should resist the knee-jerk reaction of his party’s anti-EU wing, which is probably its mainstream. He needs to look holistically at the issues, the concerns and the benefits.

--- Later in debate ---

[Charlotte Leslie]

Thank you, Mr Howarth, for allowing me to speak.

I look forward to the Minister’s further reply in writing. I should like to take this brief opportunity to thank him and hon. Members for furnishing this debate with such insight and, in many cases, experience. The hon. Member for North Antrim (Ian Paisley) used the F-word and is a true advocate of Cillit Bang for the gold-plating that this country seems to put on every piece of legislation that we have.

I am particularly grateful to my hon. Friends the Members for Central Suffolk and North Ipswich (Dr Poulter) and for Totnes (Dr Wollaston) for sharing their first-hand experience and knowledge. They talked about vocation and the meaning of that word in terms of professionalism. My hon. Friend the Member for Totnes proposed some constructive solutions about how we can mitigate the effects of the European working time directive, right here and right now.

We heard an account of first-hand experience from the hon. Member for Vauxhall (Kate Hoey), who talked about the director of St Thomas’s hospital and warned that the formal view of events is often far better than the real situation, which is often a lot worse and not always represented in formal evidence that is given.

I also give many thanks to my hon. Friend the Member for Stafford (Jeremy Lefroy), who gave yet more first-hand evidence from his wife and talked cogently about the recruitment lag that we are facing. He also gave evidence from the Association of Surgeons in Training about the two years of surgical training time that is lost.

Many other Members made extremely valuable contributions. I fear that I cannot mention them all because of the limit on time, but I must mention my hon. Friend the Member for Kingswood (Chris Skidmore), who provided a great deal of experience from the Health Committee. I know that other Members would have contributed immensely if they had been able to make a speech today, particularly my hon. Friend the Member for Camborne and Redruth (George Eustice).

I was encouraged that the hon. Member for Denton and Reddish (Andrew Gwynne) acknowledged the challenges that we face, but I am slightly cautious about the fact that he did not acknowledge the urgency of the situation or the strength of doctors’ evidence. One of the reasons why the new deal failed is that it did not bring on board the views of doctors as a whole. It failed because it did not bring doctors with it. I warn against ignoring doctors’ evidence on this front. I am very encouraged by the Minister’s remarks, but I hope that he will forgive me and other Members if we carry on campaigning and do not let this issue drop.

NHS Risk Register

Charlotte Leslie Excerpts

Wednesday 22nd February 2012 Commons Chamber

[Grahame M. Morris]

A number of Members on the Government Benches have referred, in Health questions and at other times, to the huge support among clinicians and GPs in their area, but Clare Gerada, the chair of the Royal College of General Practitioners, has said that just because GPs are compelled to man the lifeboats does not mean they agree with the sinking of the ship. That sums things up.

Hon. Members on the Government Benches should be particularly concerned by some recent polling figures. According to a poll by ICM, the over-65s—the category of people who are most likely to use the NHS and most likely to vote—want to drop the Bill by a margin of 56% to 29%, or two to one, which is the largest such margin. Sadly, not one Conservative Member, as far as I am aware, has had the courage to sign the early-day motion or to call publicly on the Health Secretary to publish the risk assessment. I know that, privately at least, some of the more thoughtful Conservative Members have been advising the Secretary of State to publish, but he seems to be flatly ignoring them. The risk register contains an objective list of the Department’s view of the risks, an estimation of the likelihood of each specific risk occurring and an estimation of its severity if it did occur. To be clear, what the Health Secretary is determined to conceal are the severe and likely risks of his own reckless attack on the NHS.

The Prime Minister must also be held to account for his broken promises on the NHS, for allowing his Health Secretary to put the NHS at risk and for standing by him while he tries to cover up the mess that is the Health and Social Care Bill. I remind the House that the coalition agreement that was signed by the Government parties stated:

“The Government believes that we need to throw open the doors of public bodies, to enable the public to hold politicians and public bodies to account.”

How does that statement square with this decision? Where is the accountability now? No one in the country voted for these health reforms, the Health and Social Care Bill has no mandate and we in the House will be asked to vote on reforms in the knowledge that the Department of Health and the Health Secretary are complicit in hiding the associated risks.

[Charlotte Leslie (Bristol North West) (Con)]

Will the hon. Gentleman give way?

[Yasmin Qureshi]

Will my hon. Friend give way?

[Grahame M. Morris]

I am only going to give way twice, so I shall give way to the hon. Lady.

[Charlotte Leslie]

That is very kind; I thank the hon. Gentleman. Does he agree that if we want to debate the health reforms, this is not the place to do it because we are talking about the risk register? Also, does he agree that all this is slightly disingenuous because Governments do not publish risk registers for good reasons, in that it would be far more risky for patients, whom we should all be considering, if Government Departments could not have frank and open discussions? The risks we should really be looking at are those to patients.

[Grahame M. Morris]

I thank the hon. Lady for her intervention, but if she had been present for the whole debate, she would know that we have covered much of that in discussing the nature of a fundamental change—the biggest ever shake-up—in the national health service since it was established. We are not calling for the nationalisation of the railways or the abolition of the House of Lords. We are simply calling for the risk register to be published, in the interests of openness and transparency, to identify the risks associated with the changes proposed by the Government.

The changes are a matter of the most serious consequence. If the Health Secretary is suppressing a report that shows that the reforms could put patients at risk and worsen the functioning of the NHS—if that is in the report, which I do not know, as I have not seen the strategic risk register, at least the national one—he would be guilty of the biggest political cover-up in a generation.

As my right hon. Friend the Member for Leigh (Andy Burnham) mentioned, in his ruling back in November the Information Commissioner, Christopher Graham, said of the Secretary of State’s reasoning:

“Disclosure would significantly aid public understanding of risks related to the proposed reforms and it would also inform participation in the debate about the reforms.”

But almost three months on, we as parliamentarians are still being kept in the dark. We were told that releasing the risk register would jeopardise the success of the policy, but the Information Commissioner refuted that and said it would only enhance the quality of the debate and allow for greater scrutiny of the policy.

We were then told by Ministers that they had published the relevant risks associated with the reforms in the impact assessment. If that was the case, why would the Information Commissioner rule that they should be published to inform debate and why would the Health Secretary fight tooth and nail to prevent that?

Finally, we were told that publication would risk the frankness of future risk registers, another point that the Information Commissioner specifically ruled out. Before the general election, the Conservatives promised to “unleash an information revolution” in the NHS, yet in government they are giving us the biggest cover-up in the history of the NHS. The Prime Minister once described his priorities in three letters: NHS. So we should not be shocked by the professional and public outcry of “OMG!” since he has broken his promise of

“no more top-down reorganisation”

and deployed WMD—weapons of mass deception—to conceal the true nature of his reforms.

Opposition Members know the dangers for the future of the NHS with up to 49% of work carried out in NHS hospitals being done by the private sector, and every service provided by the NHS, whether it be radiotherapy or speech therapy, put out for competitive tender, making it vulnerable to private sector takeover. It is no wonder we are debating the threat to the NHS when so many pre-election promises have been broken.

I conclude by offering some advice to the Health Secretary. I leave him with this thought: history is littered with examples of people who have fallen from grace, not for their crimes, but for the cover-up. He should end his terrible attack on the NHS and have the courage to be open about his plans to fragment and privatise our beloved national health service.

--- Later in debate ---

[Mark Simmonds]

I am sure that the information centre in Leeds is working on that as we speak, because I know that it is important to the ministerial team.

[Charlotte Leslie]

Will my hon. Friend give way?

[Mark Simmonds]

I will not give way, because I have done so twice already.

Finally, it was made clear in an earlier intervention that the shadow Secretary of State, were he ever to be Health Secretary again, would not by necessity publish all risk registers, so it is nonsensical to suggest that this out-of-date risk register either informs debate or is necessary for discussing the future reforms of the NHS. Of course, that is not really what this debate is about. It is a cloak to try to put obstacles in the way of what I believe is necessary reform. We know why reform is necessary: a growing and ageing population; increasing levels of co-morbidities and long-term conditions; rising health care costs; and the impact of lifestyle choices. However, listening to the shadow Secretary of State, one would think that the NHS was falling apart. It absolutely is not. It is performing very well at the moment. We are reducing in-patient and out-patient waiting times. The backlog of patients waiting more than 18 weeks is going down, and the number of patients waiting more than a year is half what it was in May 2010.

--- Later in debate ---

[George Hollingbery]

I am grateful to the right hon. Gentleman for clearing up part of this, but I think that the decision that was made by the Information Commissioner was on the strategic risk register and its release. No doubt we can discuss that later, but I am grateful to him for his intervention and for clearing that up.

More generally, we must consider whether the Bill has been properly assessed both in the House and outside by many people. There are 443 pages of closely worded analysis on the impact of the Bill, and the impact assessments cover every possible aspect imaginable, including risk management and the risks associated with the new Bill. That information has been in the public domain for many months, and I do not honestly believe that there is anything to be gained by issuing further risk registers that may scare a number of people about the things that they have to consider. The risk register would add very little. The answer, basically, is that it is an expedient hook on which to hang a debate: to raise again in the House a topic that has been raised a great many times—quite rightly, in many ways, as many amendments have been made to the Bill. However, the quality of speeches from the Opposition demonstrates to me at least that the point of the debate was not to discuss the risk register but to use it as a hook on which to hang a particular viewpoint.

It is well known that when the right hon. Member for Leigh was Secretary of State he refused to release the risk register. I have examined that, and I was going to quote him further at length, but the House has heard that quote several times today, so I will not trouble hon. Members with it again. The argument that he made then was a sensible one, and it remains sensible now. Do we really believe that it is good for the Government to make public all their plans for the management of every conceivable risk that they might encounter? Some of those risks will scare people rigid, and I do not honestly believe that that is the right use for the strategic risk register.

[Charlotte Leslie]

Does my hon. Friend agree that the Opposition should be careful about what they wish for in setting a precedent of publishing every single risk register? It may seem unlikely at the moment, but one day, they might be in government.

[George Hollingbery]

That is a fair point. As we have heard again today, Tony Blair says that he very much regrets parts of the Freedom of Information Act. We have all come to regret parts of the Act, and setting such a precedent could be awkward for the Opposition. When, inevitably, they return to power, they will find that equally difficult to manage.

If officials are inhibited in any way from having full and frank discussions with Ministers on challenging issues for the Government, that is a retrograde step, and we cannot afford to take it. I have no argument with the Information Commissioner, as it is his job to make assessments based on rational arguments made to him in the light of documents under review and, as he explained in his judgment, on the timing of the initial request. It is germane, however, to point out that in paragraph 29, the judgment discusses exactly the issues to which I have referred, and cites

“the ‘safe space’ and ‘chilling effect’ arguments which are well understood and have been considered in a number of cases before the Information Tribunal.”

In paragraph 35 the commissioner makes his judgment and states:

“The Commissioner finds that the factors are finely balanced in this case”.

It was not an open and shut case; he had to make a fine judgment. The Information Commissioner himself clearly found that a difficult decision to make.

As I have said, it is entirely right and proper that the Information Commissioner should make his judgment as he sees fit. That is what he is there for, but for my part, I believe that that is a dangerous precedent to set. We have to wait for the result of the Government’s appeal and any further iterations of the statutory process before we receive the final answer. I recognise the shadow Secretary of State’s challenge, asking why the Secretary of State would not simply acquiesce and open up the information to all. The simple answer is that there are very good reasons for not doing so, and I have just talked about those.

What of the Opposition’s plans for the national health service? Will the shadow Secretary of State publish the likely contents of the NHS risk register for and the relevant impact assessments of his own plans for the service? That might be tricky because, other than the fact that they want to cut the NHS budget, we have absolutely no idea of the Opposition’s plans, and, as far as I can tell, neither do they. I trawled the party’s website today and I could find literally nothing about Labour’s plans for the future of the NHS; as is the case in a great many policy areas for the Labour party, confusion seems to reign on the Labour Benches. At a time when there is an exponential increase in demand on NHS services and a huge increase in available treatments, and when money is in very short supply for the Government, the Opposition’s response, judging by today’s debate, is nothing, except what seems to me to be naked opportunism.

I shall offer a final thought. Perhaps political parties should also be forced to publish impact assessments and maintain risk registers on their internal musings at election time, in the interests of transparency. Had Labour had to do that in 1997, it would have been extraordinarily unlikely that the party would ever have been elected.

Contaminated Blood

Charlotte Leslie Excerpts

Monday 10th January 2011 Commons Chamber

[Mr Lansley]

I regret that I cannot give such an estimate to my hon. Friend. The estimate that I have given is a range that extends from £100 million to £130 million during the life of this Parliament. If one were to go beyond that period, the parameters of the range would widen, not least because we do not, and cannot, know to what extent this infection is likely to progress to the second stage of these diseases.

[Charlotte Leslie (Bristol North West) (Con)]

I very much welcome much of what has been said in the statement, particularly the fact that the decision has been made to force closure on an issue that has been going on for so long. One of the things that has upset so many of the sufferers is not only that such a scandal happened but the subsequent failings, as they would see it, not of Government but of the Department of Health in being clear and transparent during those years in providing information on exactly what happened. Will the Secretary of State give an assurance that he will have to provide information to help those people who are still affected when they ask questions, perhaps through freedom of information requests, about what occurred in the past?

[Mr Lansley]

May I once more express my thanks to my hon. Friend for having been a forceful advocate in these matters? The answer to her question is yes, not least because my hon. Friend the Under-Secretary has been very open and willing to talk to everybody concerned, and she will continue to be so, because we are determined to give people confidence that we have not only exercised what we believe to be a responsible and reasonable judgment in these matters but are doing so in an open and transparent fashion.

Contaminated Blood and Blood Products

Charlotte Leslie Excerpts

Thursday 14th October 2010 Commons Chamber

[Mr Robinson]

My hon. Friend is, of course, absolutely right. I am very pleased to welcome the Secretary of State to the debate, because it gives it prominence and substance. The Backbench Business Committee has a real role to play—we have had a good debate on Afghanistan too. However, I saw the Secretary of State shake his head to say that the amendment is not a wrecking amendment. None the less, those of us who attended a meeting yesterday with the victims of blood contamination were hoping for an amendment that we could support, and he could have done something about that.

The Secretary of State bears no responsibility for what has happened. The NHS supplied contaminated blood. I will not go into individual cases, except for one in my own constituency, which I have been following ever since the victim first approached me many years ago. This goes back to the mid-1970s, to the Callaghan and Wilson Labour Governments and to the Thatcher Government, and, of course, to the subsequent response to those ill-advised, inadequate judgments, made mostly by officials or under their strong advice—clearly that is the case in these cases—from the last Government principally, although it even pre-dates them to some extent. We are not trying to blame the present coalition Government, but there are things that they could have done, the cost of which would have fallen well short of the £3 billion that will allegedly be the cost of implementing the Archer report.

As hon. Members will recall, the Archer report was set up under the Blair Government—in 1997-98, I think—at which time I was at the Treasury. People put it to me, “You were at the Treasury at the time. Why didn’t you do something?” We did not have the report then. We had made papers available. It was a privately funded and excellent report, which I commend to all Members, but we did not know what it was going to recommend. Unfortunately, I left the Treasury before I was confronted with the implications of the report. However, under the last two Labour Administrations, there were ample opportunities for us to respond more fully, generously and comprehensively, in human terms, to the suffering of the victims.

This was an unparalleled disaster in NHS treatment history involving thoroughly blameless individuals. I met one yesterday—a gentleman from Doncaster—who had been knifed, rushed to the accident and emergency department at Rotherham and given two pints of blood, from which he subsequently contracted HIV/AIDS and hepatitis C. He is now totally incapacitated, and has been asked to live, after capital payments of £25,000—of great value, of course, but not enormous—on £107 a week.

The Government could have said, “Well, we know there is a problem with, for example, the Skipton Fund, so we will take some steps to move that up towards the level of what the previous Administration made available—inadequate though it was—in respect of HIV/AIDS.”

[Charlotte Leslie (Bristol North West) (Con)]

Will the hon. Gentleman give way?

[Mr Robinson]

In a moment, yes.

The Government could have done that, but they did not. All we now have is their sad, tragic adoption of what previous Government’s did. That is a great pity, a great sadness, and does not reflect well on them. When they reflect on the matter, they will come to think that they should have handled the matter very differently.

Had the Government proposed what I have suggested, which would have cost a minimum amount—nothing like the sums talked about now—we could have voted for it and then, at 4.30 pm, when this debate ends, gone back to meet the victims in Committee Room 14 and told them that this Government have finally broken with the previous, inadequate and ill-judged consensus and reaction. We have never asked them to take responsibility. However, they could also have extended a gesture of an apology, which the victims are also looking for. Sadly, however, the Government have, in effect, done nothing but take on the same old weary mantle that we have seen for the last 20 years. They are already getting tired: they have lost their verve and the ability to respond energetically and imaginatively to situations. It is very sad.

[Mr Robinson]

I promised to give way first to the hon. Member for Bristol North West (Charlotte Leslie).

[Charlotte Leslie]

I appreciate the tone, spirit and intended outcome of what the hon. Gentleman is trying to do. As a newcomer to the House, however, may I ask what, over the past 13 years, he did to encourage the previous Government to deliver payments I believe should have been made? At that time, the public finances were not in such a diabolical state and compensation would have been much easier to give.

[Mr Robinson]

Unfortunately, the hon. Lady is trying to inject a party position into this debate, which those of us who have been involved in it have tried to exclude from it. We have said that past responses were inadequate and ill-judged—it says that in the motion. I regret that we did not deal with the matter, and I like to think that had I remained at the Treasury, I could have done something. I am open about that too; we all ought to be open here. However, those who say that I, as a former Treasury Minister, should appreciate our legacy are missing the central point: there will never be a good time to do something like this. There will always be bureaucratic arguments, and precedent arguments, and arguments we cannot foresee now but which will one day be made, for why we should do nothing, and the Government have caved into them. That is the reality.

--- Later in debate ---

[Paul Goggins]

I am aware of that. What I am trying to emphasise is that if my constituents, and indeed many others, had been given proper information, they would have been able to make a balanced decision about the risks that they faced.

We all have constituents who will have their own stories, and as a result of the Archer report we now have a definite analysis of what went wrong. The great thing about the report, however, is that it points the way forward. It is now a case of what we can do to support those who survive in the circumstances in which they find themselves, and I believe that we need to do at least four things.

First, there needs to be an apology. I know that some people feel that an apology is just words and is therefore meaningless, but in June this year the Prime Minister proved from the Dispatch Box that that is not the case when he gave an unequivocal apology to the families of Derry for what had occurred on 30 January 1972. That apology means a lot to those families, and it is enabling them to move forward. I believe that haemophiliacs infected with hepatitis C and HIV deserve no less.

Secondly, there must be proper financial recompense. There is a debate about that. Archer recommends equivalence with the Irish scheme, but the Government ruled that out today, and are to institute a review instead. Whatever the outcome of that review, it must be demonstrably fair to those who have been affected. There must be a level playing field between those infected with, respectively, hepatitis C and HIV. Thirdly, there must be no impact on benefit entitlement: any recompense must be over and above the benefit payments that people receive.

[Charlotte Leslie]

I want to pay tribute to my constituent Bob Purnell, who died, his son Edward, and his wife Gill. I also want to dispel any misunderstanding that there may have been about the debate’s being partisan. I welcome it very much.

I think we all appreciate that the Government are in a difficult position because of the financial situation. Does the right hon. Gentleman agree that if we cannot make the payments that I think we would all like to make to victims who have suffered greatly, it might be possible to increase payments in future as the economic situation becomes more viable?

[Paul Goggins]

I am pleased that the hon. Lady has had an opportunity to mention and pay tribute to her constituent. There may be an argument for staging payments over time, but the Government must be clear about the award and the level of compensation at the outset.

Finally, the whole social care and health system must become much more sensitive to the needs of those who were caught up in this tragedy. There must be more sympathetic treatment for those who have been infected and their carers.

I regret the fact that we were not able to do more over the past 13 years to support and assist this particular group. I want to compliment the Minister, because I know from conversations that I have had and from things that I have read that she has gained a fair amount of confidence from those who were caught up in the tragedy, and from members of the haemophiliac community. My guess is that her experience of the health service, along with her own personal qualities, has led her to want to deal with the situation and, in her own words, to get closure before the end of the year. Let me say to her that having come so far so quickly, she now carries a huge burden of responsibility to ensure that the solution that she comes up with retains that confidence, and does not further dash the hopes of a community who have been so badly let down in the past.

NHS White Paper

Charlotte Leslie Excerpts

Monday 12th July 2010 Commons Chamber

[Charlotte Leslie (Bristol North West) (Con)]

If hon. Members speak to GPs and professionals, who do not just sit here and talk about the NHS, but actually run it, day by day, they will find that it is not change or the White Paper that has caused demoralisation, but the machine-gun fire of targets and the monolith of management. The reason why that has caused so much demoralisation among the work force is that target box-ticking is so often different from the provision of quality care, as we have tragically seen in Staffordshire. Can my right hon. Friend reassure me that his reforms will mean that box-ticking is replaced by quality of care?

[Mr Lansley]

My hon. Friend is absolutely right and expresses her point superbly. The process is going to be about quality, not tick-box targets, and it is going to enable the front-line staff of the NHS to have not only access to the resources that they need, but the power to use them more effectively.

Child and Adolescent Mental Health Services

Charlotte Leslie Excerpts

Wednesday 7th July 2010 Westminster Hall

[Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op)]

I appreciate having been able to secure the debate. I thank the Minister and shadow Minister for their attendance, and am grateful to the other MPs present. A lot of people watching the debate on the Parliament website might not be aware that we all had a late night last night, debating the finer points of the Finance Bill, so I am grateful to hon. Members for turning up. I also thank the National Autistic Society for providing me with statistical information. I remind the Chamber that I have declared an interest in the subject of the debate, as the parent of a child with autism.

I want to discuss the experience of many families with autism; their feedback on the support provided by child and adolescent mental health services, or CAMHS; and problems of communication, misdiagnosis and the training of CAMHS professionals. I will then make the case for more specialist autism support and ask the Minister a number of questions.

Autism is a serious, lifelong, disabling condition that affects how a person communicates with and relates to other people. It is a spectrum disorder that affects each individual differently. Some people with autism can lead independent and fulfilling lives with little support, while others need specialist support throughout their lives.

People with autism have said that, to them, the world is a mass of people, places and events of which they struggle to make sense, and which can cause them considerable anxiety. In particular, understanding and relating to other people and taking part in everyday family and social life may be harder for them, while other people appear to know intuitively how to communicate and interact with each other. Approximately one child in 100 has autism.

Autism is not a mental health problem, but a recent study by Professors Simonoff and Charman found that 71% of children with autism have a co-occurring mental health problem, and 40% have two or more. Such problems include serious conditions such as depression, anxiety disorders and obsessive-compulsive disorder, which can be debilitating without the right support. Seven out of 10 children with autism develop such conditions, which is far too high a figure. However, with the right support from people who understand autism, such children can have mental health as good as any other child’s. Unfortunately, that support is often unavailable in our society.

Children with autism find it difficult to understand the world around them. They may not understand social cues and expectations or be able to identify patterns and routines in their lives. Help with understanding what to do in different situations or what happens next in a sequence of events, or with coping with changes in routine, can make a big difference, but without such support, children with autism can become anxious or frustrated.

Children with autism are also less likely than other children to have strong social relationships. One Office for National Statistics study found that 42% of children with autism had no friends, compared to 1% of other children. Children with autism may act in unusual ways, or may try to fit in with their peers in socially inappropriate ways. Other children may ridicule or bully them as a result.

Difficulties at school and elsewhere may affect the self-esteem of children with autism. An inability to express their feelings can lead to escalating emotions or leave them unable to deal with experiences such as loss or grief. A supportive educational setting that works for the child, in partnership with mental health services, can be crucial to maintaining emotional well-being and preventing mental health problems from developing, yet the NAS found that 34% of parents said that a delay in accessing the right support at school had had a negative impact on their child’s mental health, and that half of children with autism are not in the kind of school that their parents believe would best suit them. Awareness and consideration among the general public also play a part. Whether in shops and restaurants, on public transport or in the park, children with autism and their parents can face intolerance and lack of understanding that can cause considerable stress and anxiety.

It does not have to be like that. Most of those difficulties can be overcome with the right support for children with autism and their families. Children with autism can live happy, healthy, fulfilled lives, do well at school and reach their full potential. Everyone in society must take some responsibility for making that happen.

I intend to concentrate on the support that children with autism and their families receive when mental health problems develop. According to Government-commissioned research conducted by the university of Durham, one child in every 10 who accesses child and adolescent mental health services has an autism spectrum disorder. That amounts to more than 10,000 children a year. Such children are often extremely vulnerable and in dire need of support that works for them. Another ONS study for the Government found that 25% of children with autism either self-harm or have suicidal thoughts. Their families are desperate for skilled help that can improve their children’s mental health and quality of life.

The NAS has been carrying out in-depth research on the subject since last summer, as problems with CAMHS were being mentioned consistently through its helpline and regional offices. When NAS members were surveyed on the organisation’s campaigning priorities, 99% rated improving CAMHS as either important or very important. The NAS held focus groups with parents and one-to-one interviews with children who had experienced CAMHS, followed by a mass survey of parents. It also visited several CAMHS sites and spoke to professionals and clinical directors.

Through its research, the NAS has found that, sadly, most children with autism and mental health problems are not getting the service that they need from CAMHS. According to the NAS survey, CAMHS fails to improve the mental health of two thirds of children with autism. We must improve on that.

One young woman said of her experiences as a nine-year-old accessing CAMHS that

“when I went in to the meeting I was miserable and depressed. When I came out I was suicidal. I was trying to throw myself out of my windows and hang myself… It took me several years to recover and I didn’t ever want anything to do with them.”

The NAS consistently heard from professionals, parents and children that, despite the huge proportion of children with autism in the system, understanding of autism among professionals is generally poor. Only half of parents feel that CAMHS staff have a good understanding of autism, and fewer than half think that CAMHS staff know how to communicate properly with their child.

To work successfully with a child with autism, a CAMHS professional must have a good understanding of autism. Autism is a communication difficulty, so the professional must generally adapt how they communicate, which requires a good understanding of autism. With respect to some children, that involves speaking more clearly and directly, while others have limited or no verbal communication and may need visual cues to help them to make sense of and communicate their feelings. A child with autism is likely to take longer than other children to trust the professional and communicate openly.

Professionals may also have to adapt their explanations to be less abstract or hypothetical and relate more directly to the specifics of the child’s situation. For example, if a professional works with a child with autism to deal with a certain situation in a classroom setting, the child will usually struggle to generalise, applying the same techniques at home or on the school bus. The professional will have to work through each situation in turn, which is not necessary for other children.

Children with autism can also struggle to explain difficulties that they are not currently experiencing. One child said:

“They need to be there when things happen, because when I went to see the doctor at our local CAMHS I never felt bad and couldn’t talk about what had been hard because it wasn’t happening then”.

When professionals are given the time and training to get to know the child and their family, understand the child’s autism and how they communicate best, and adapt their approach accordingly, outcomes are greatly improved. However, a professional who does not understand autism is unlikely to make such adjustments, leading to a breakdown in communication and making effective intervention extremely difficult.

When a child with autism also has a mental health problem, it is crucial that the right support is provided for the right diagnosis. If a child is wrongly assessed, the wrong support will inevitably follow. Practitioners who do not have a good understanding of autism can misdiagnose children as a result, leading to inappropriate or unsuitable interventions. Without a sound working knowledge of autism, some behaviours that are common in children with autism can easily be interpreted as mental health problems. For example, autism-related personal obsessions, rituals and routines can lead to a false diagnosis of OCD. Peculiarities and fads about what a child eats can come across as an eating disorder. Sleeping difficulties or an aversion to human touch can wrongly lead to suspicions of abuse-related trauma.

The NAS found that some children who had been diagnosed with autism were wrongly undiagnosed by a professional who was convinced that their behaviour was symptomatic of a different condition. Other children’s mental health conditions were overshadowed by their autism, when professionals were unable to distinguish the symptoms of mental health problems from autism-related behaviours: if the CAMHS team focused on autism, mental health issues were ignored. Some parents said that the professionals they met considered conditions such as anxiety disorders inevitable and unavoidable side-effects of autism, rather than as the separate, treatable conditions that they are.

Many of the professionals told the NAS that they wanted more opportunities for professional training and development, so that they and their colleagues would be better able to work with children with autism and mental health problems. Many children with autism receive either inappropriate support or no support at all because the right support simply does not exist in their area. Some CAMHS professionals told the NAS that their waiting lists for children with autism were much longer than those for children without autism, and that, because so few staff had autism training, the vast majority lacked the skills to treat children with autism, so those children were left waiting for the handful of staff with sufficient autism expertise.

[Charlotte Leslie (Bristol North West) (Con)]

As chair of the all-party group on autism, I congratulate the hon. Gentleman on securing this debate on an immensely important subject. The NAS has done fantastic work raising these issues with colleagues. What training did CAMHS staff receive under the previous Government and does he think it was adequate? If not, what improvements might be made?

[Jonathan Reynolds]

I am grateful to the hon. Lady for her intervention, and I acknowledge her work and expertise in this field. I approach this subject primarily as a parent, so I am happy to say that more needs to be done. I am not making this a party political issue between this Government and the previous one. I am trying to highlight the issue and, I hope, move forward together, across the House.

I wish to identify some good practice relating to the hon. Lady’s question. Dudley primary care trust operates an autism clinic that focuses on diagnosis and assessment, and has the specialist expertise to assess complex autism cases. The clinic takes a “broad apprenticeship” approach to training new staff, which gives them the opportunity to observe specialists and more experienced clinicians assessing children from behind a one-way mirror.

After new staff have watched several assessments, they progress to shadowing colleagues and then to taking the lead with children with autism, with support from a specialist. Finally, they are able to work alone and train new starters themselves. They learn through practical experience, rather than theory. The clinic also shares its expertise more widely and trains external agencies. For instance, it trained a group of specialist autism teachers and key workers to provide social skills training to children, meaning that social skills training could continue once a child had left CAMHS, making it far more effective than if it had been delivered once and then discontinued.

There is clear evidence that a good understanding of autism is vital to delivering an effective service to the high number of children with autism in the CAMHS system. All professionals working in CAMHS must have their training needs relating to autism recognised and addressed. In “Fulfilling and rewarding lives”, the Government’s recently published strategy for adults with autism, there is a commitment for

“all NHS practitioners”

to

“be able to identify potential signs of autism, so they can refer for clinical diagnosis if necessary… but more importantly so they can understand how to adapt their behaviour, and particularly their communication, when a patient either has been diagnosed with autism or displays these signs.”

The same strategy commits the Government to working with the General Medical Council and various professional bodies

“to improve the quality of autism awareness training in their curricula.”

What action do the Government intend to take to ensure that the NHS training objectives made in the autism strategy, “Fulfilling and rewarding lives”, are met, so that all CAMHS practitioners receive some basic training in autism?